W. John Boscardin

Objective: To test the accuracy of existing traumatic brain injury (TBI) outcome prediction models in older adults with TBI (oaTBI), to determine the independent association of 5 different measures of preinjury health with 6-month outcome, and to investigate whether these preinjury health measures improve outcome prediction. Setting: Two level 1 trauma centers. Participants: A total of 112 adults aged ≥65 years who underwent head computed tomography after acute TBI (95% with Glasgow Coma Scale (GCS) score 13–15, 66% with acute intracranial trauma on head CT). Design: Prospective cohort study. Main Measures: Preinjury health was characterized using activities of daily living (ADL), Functional Activities Questionnaire (FAQ), Clinical Dementia Rating (CDR), Charlson Comorbidity Index (CCI), and Groningen Frailty Index (GFI). The primary outcome was poor recovery (Glasgow Outcome Scale–Extended 0.05). Conclusions: Among older adults with mainly mild TBI, preinjury frailty and cognitive-mediated function were independently associated with poor 6-month outcome, yet these preinjury measures did not significantly improve prediction accuracy. Instruments such as the FAQ and GFI capture clinically meaningful preinjury heterogeneity and may inform the development of more precise oaTBI prognostic models.

Background: Distressing symptoms are common in the last year of life and contribute substantially to suffering for older adults and their families. While psychological resilience has been linked to better aging outcomes, its association with end‐of‐life symptom burden is not well characterized. Methods: We conducted a retrospective cohort study using nationally representative data from the Health and Retirement Study (2006–2022). The cohort included 4466 decedents aged ≥ 50 years with next‐of‐kin–reported symptoms in the last year of life and psychological resilience assessed on average 2 years before death. Psychological resilience was measured using a validated 12‐item scale and categorized into quartiles. Outcomes included 12 end‐of‐life symptoms grouped into physical, neuropsychiatric, and functional domains. The primary outcome was high symptom burden, defined as seven or more symptoms. Associations were estimated using survey‐weighted Poisson regression with robust standard errors, adjusting for sociodemographic, clinical, and functional covariates. Results: Decedents were on average 76 years old, 50% female, and 16% non‐White. Resilience scores averaged 8.4 (SD, 1.91; median, 8.5). Higher resilience was associated with lower prevalence of end‐of‐life symptom burden. In adjusted models, high symptom burden was present in 31.1% (95% CI, 28.0–34.2) of those in the lowest resilience quartile and 19.6% (95% CI, 16.8–22.4) of those in the highest ( P for trend < 0.001). Predicted probabilities demonstrated notable gradients of symptom prevalence across quartiles for depression (57.9% vs. 36.5%), severe fatigue (66.1% vs. 56.7%), incontinence (45.0% vs. 35.0%), and pain (56.1% vs. 47.4%). Associations were absent for symptoms such as appetite loss and vomiting. Conclusions: In this nationally representative cohort, high psychological resilience measured before death was associated with lower symptom burden across multiple domains in the last year of life. Resilience assessment may help identify individuals at risk for distressing end‐of‐life experiences and inform interventions to bolster late‐life resilience.

Background: Social vulnerability index (SVI) has been used as a surrogate measure to assess social determinants of health (SDOH) when conducting health disparities research, but the impact of SVI on the timing, receipt, and outcomes of cataract care in a nationally representative population of patients is unknown. Methods: A retrospective observational cohort study of Medicare fee-for-service beneficiaries aged 66 + in 2014 without a prior diagnosis of cataract disease was conducted to determine who went on to develop cataract disease and undergo cataract surgery between 2014 and 2021. A Fine and Gray sub-distribution hazard model was used to determine the association between SVI quartile, time to diagnosis and time to cataract surgery. Logistic regression was used to assess the association between SVI quartile and the incidence of ophthalmic complications. Results: Among 170,778 Medicare beneficiaries aged 66 + years of age at the start of the study period, 50.2% identified as female, 7.0% Black, 4.4% Hispanic, and 80.9% White. Fewer beneficiaries residing in high SVI (higher vulnerability) regions were diagnosed with cataracts (Quartile 4 55.9% vs. Q1 67.1%, p < 0.001) and underwent cataract surgery (Q4 19.4% vs. Q1 21.1%, p < 0.001) compared to beneficiaries in low SVI regions. After adjusting for patient demographics, overall health and frailty status, and health systemic characteristics including region, urban/rural location and number of ophthalmologists per capita, patients residing in higher SVI areas had lower rates of diagnosis (Q2 HR: 0.92 95% CI (0.91, 0.94); Q3 0.86 (0.84, 0.87); Q4: 0.78 (0.77, 0.80), reference=Q1) and cataract surgery (Q3 HR: 0.95, 95% CI (0.92, 0.98) and Q4: 0.90 (0.87, 0.93), respectively, reference=Q1). However, once a diagnosis was made, patients residing in higher SVI regions had higher rates of cataract surgery (Q2 HR: 1.04 (1.01, 1.07); Q3: 1.06 (1.03, 1.09); and Q4: 1.08 (1.05, 1.12), respectively, reference=Q1). There was no association between SVI and ophthalmic complications. Conclusions: Higher SVI is associated with disparities in receipt of cataract surgery among Medicare beneficiaries, which may be mediated by delays in cataract diagnosis. Reducing SDOH-related barriers to timely diagnosis in under-resourced areas could shorten the overall time to cataract surgery in this population.

Introduction: Understanding the concordance between incident cognitive impairment status and the diagnosis of Alzheimer disease and related dementias (ADRD) is clinically important, as a diagnosis serves as the gateway for treatment, care planning, and supportive services. Methods: Using the REGARDS cohort (2006 to 2021) linked to Medicare claims, we examined the discordance between incident cognitive impairment and claims-based ADRD diagnoses. Directly standardized diagnosis rates were estimated by year, overall, and race, and stratified by cognitive impairment status. Logistic regression models were used to examine sociodemographic correlates of diagnosis. Results: The sample included 45,191 observations (23% Black) of 8368 participants. Among those with incident cognitive impairment, 30.8% received a claim-based diagnosis, and while 8.9% of those without incident cognitive impairment received a claim-based diagnosis. ADRD diagnosis rates remained stable, whereas rates among observations with incident cognitive impairment rose through the early 2010s, then plateaued and declined. The black race and education below the college level were associated with lower odds of diagnosis in this group; female sex was associated with higher odds. Among observations without cognitive impairment, older age and female sex were associated with higher odds; Midwest or West/Northeast residence and less than high school education were associated with lower odds. Discussion: Differences observed in the study may potentially represent underlying disparities in access to care and dementia diagnosis in clinical practice.

Older adults, women, and minorities are under‐represented in clinical trials. Our objective was to identify characteristics predicting participation in clinical trials of medications in a diverse sample of older adults; and, secondarily, identify current participation motivators and barriers and trial preferences. A cross‐sectional U.S. community convenience sample survey of adults > 65 years with > 3 chronic medical conditions querying attitudes about participation in clinical trials was conducted from March 2023–October 2024 in English and Spanish. Formats were yes/no or three‐point Likert scale answers. Multivariable logistic regression identified characteristics with higher likelihood of trial participation. Surveys were from 2176 older adults (White (50.3%), Black/African American (18.5%), Hispanic/Latino (17.7%), Asian (13.5%) aged 73.1 ± 6.1 years (mean, SD), 52% women,one 4.1 ± 1.9 medical conditions; taking 7.4 ± 3.2 medications. Characteristics with higher likelihood of trial participation were higher income (1.36, 0.93–1.99; Odds Ratio, 95% Confidence Interval), educational status (1.88, 1.12–3.0), greater health literacy (2.07, 1.29–3.3), having cancer (1.49, 1.11–1.99) or chronic pain (1.55, 1.17–2.06), Black/African American race (1.44, 1.02–2.02) or Hispanic/Latino race/ethnicity (1.55, 1.11–2.16). Females had lower likelihood of participation (0.66, 1.29–3.32) as did age 75 and above (0.67, 0.50–0.92). Disincentives in women were potential side effects, placeboes, visit travel > 1 h, and video visits. Prior participants and nonparticipants were more likely to consider participation after physician recommendation (92% and 76.4%, respectively). Better care would motivate the highest percentage of all respondents. Education about trials including possible benefits, addressing concerns of women, physician involvement during recruitment and trials with in‐person visits may increase representative enrollment.

Purpose: The Nepal Turnaway Study was designed to understand abortion care experiences and the longitudinal wellbeing of abortion-seekers and their families. Participants: The Nepal Turnaway Study is a nation-wide cohort of abortion seekers recruited from public and private facilities across all seven provinces between April 2019 and December 2020. It contains 1,832 abortion seekers followed for up to five years. Repeated measures of socioeconomic status, health and wellbeing—including maternal physical and mental health and child health (under age three)—were collected every six months or annually, alongside detailed pregnancy and abortion-seeking histories. Findings to date: Abortion seekers in this context can be recruited at health facilities (96% participation) and successfully followed for up to five years (85% retention). Nearly half (49%, n=856) of abortion seekers were initially denied their abortion, and 16% (n=275) ultimately carried the pregnancy to term and gave birth. Those who were denied were more likely to be socioeconomically disadvantaged prior to abortion seeking. Future plans: The Nepal Turnaway Study will be used to understand the longitudinal health and socioeconomic effects of receiving a wanted abortion in this setting. Exposure-balancing weights can be applied to ensure rigorous estimation of the effects of abortion denial on longitudinal outcomes. This cohort can also be used more broadly to examine the trajectories of women and their families in the years following abortion-seeking. Registration: This study has been registered at clinicaltrials.gov ( NCT03930576 )

The timing of the biological onset of multiple sclerosis (MS) is unclear. We used high-throughput discovery proteomics and samples from presymptomatic patients with MS and matched healthy controls to define the biological neurological onset and characterize the mechanisms involved. Remarkably, evidence of myelin injury was seen ~7 years before the symptomatic onset and preceded evidence of axonal injury by ~1 year. By contrast, astrocyte involvement became evident only at clinical onset. Numerous changes in the serum proteome indicate the involvement of interleukin 3 and nuclear factor kappa B pathways during the presymptomatic stage. Furthermore, people with MS with a previously reported distinct autoantibody signature showed increased immune cell activity compared to those without. We propose a protein biomarker panel that may help distinguish presymptomatic patients with MS from healthy controls, pending validation in future studies. Our findings can help understand the pathophysiology of MS as well as the cascade of central nervous system injury and might facilitate early detection of MS in high-risk people.

Traumatic brain injury (TBI) is associated with increased risk of both death and dementia in older adults, but no prognostic models currently exist to help identify which individuals are at greatest risk of long-term adverse outcomes. Our primary objective was to develop a single prognostic model that uses electronic health record (EHR) data to predict 5-year risk of dementia or death in older veterans who have experienced TBI. We performed a retrospective cohort study using EHR data from the US Department of Veterans Affairs Health Care System. Participants were US veterans aged 55 years or older without dementia who had a TBI diagnosis and received care between 2002 and 2019. Potential predictor variables included demographics, medical comorbidities, mental health conditions, and health care utilization factors. We used multinomial logistic regression with least absolute shrinkage and selection operator to develop a prognostic model for 5-year risk of dementia or death. Cohort members (N = 113,779) had a mean ± SD age of 68 ± 10 years; 6% were female, and 20% were non-White or Hispanic. The key predictors of dementia or death included older age; male sex; number of inpatient visits; and comorbidities such as Parkinson disease, diabetes, weight loss, epilepsy, substance use disorder, and psychosis. The c-statistics were 0.756 (95% CI 0.751-0.761) for dementia and 0.783 (0.779-0.786) for death. Among those in the lowest predicted decile of dementia risk, 3% developed dementia within 5 years, compared with 43% of those in the highest predicted decile of risk. Similarly, the proportion of participants who died without dementia was 4% among those in the lowest predicted decile of risk compared with 64% in the highest predicted decile of risk. A single prognostic model that includes demographics, comorbidities, and utilization variables can predict risk of dementia or death in older veterans who have experienced TBI with good accuracy. Additional studies are needed to determine how this information might be best used to support better care.

Background: Older adults with multimorbidity have been under‐represented in clinical drug trials. We sought to determine willingness to enroll in trials and preferences of older adults for learning about clinical trials, visit frequency, travel, locations, and testing. Methods: Cross‐sectional internet and telephone survey of a nationally representative sample of adults ≥ 65 years with ≥ 3 chronic conditions ( NORC University of Chicago Foresight 50+ panel) from March–April 2023 to determine acceptability of aspects of clinical trials. Results: Surveyed 1318 (1142 Internet, 176 phone), mean age 72.3 ± 6.3 ( SD ), 52% women; race: 83% White, 10% Black or African American ( BLAfrAm ), 5% Hispanic or Latino, 1.1% Asian; 4.4 ± 1.9 chronic conditions (of 16 queried), taking 7.5 ± 3.3 medications. Almost half would consider trials of medications for memory problems, hypertension, cancer, chronic pain, diabetes, or high cholesterol. Men and BLAfrAm respondents were the most willing to consider hypertension or diabetes trials. Preferences for where to learn about trials were physician offices (87% overall, 85% of BLAfrAm , 94% of Hispanic); 10% of White respondents considered senior centers versus 30% of BLAfrAm and 20% of Hispanics ( p < 0.001). Two‐thirds wanted written materials and question and answer sessions (no significant sex or racial differences). Respondents anticipated no difficulty with measuring blood pressure at home, and only respondents > 80 years anticipated difficulty wearing activity monitoring devices. All groups preferred monthly or every 3–4 month visits for physical exams, blood or urine tests vs. less frequently and were willing to travel half an hour in each direction for visits. Conclusions: Efforts to increase enrollment of older adults and older adults from previously under‐represented racial populations will need increased physician engagement. Pragmatic trials with infrequent participant contact are not likely to increase participation of older adults with multimorbidity.