Cathleen S. Colón-Emeric

Background: Deprescribing, a proactive systematic approach to reducing or stopping medications, may lower adverse outcomes in older adults receiving dialysis. We evaluated the feasibility of an intervention to deprescribe potentially inappropriate medications, defined as medications whose risks often outweigh the benefits in older adults. Methods: In this non-randomized feasibility study in Durham, NC, study personnel reviewed charts to identify potentially eligible patients (age ≥55, active potentially inappropriate medication prescription, and appropriate for deprescribing) and generated deprescribing recommendations. Clinicians at participating dialysis clinics received recommendations for each patient. When clinicians agreed, they or study staff engaged patients in shared decision-making. For deprescribing attempts, the study provided taper plans, guidance on alternatives, and adverse drug withdrawal event monitoring. Feasibility outcomes included demand, limited efficacy, acceptability, and practicality. To assess patient acceptability, eligible patients were invited to participate in semi-structured interviews. Results: Among 632 charts reviewed, 85 patients were potentially eligible for deprescribing. After confirming eligibility and obtaining clinician agreement, 41 of the 85 patients were approached about deprescribing; 17 (41%) agreed to attempt deprescribing. Gabapentin was the most commonly deprescribed medication (n=15; 88%). Among those who attempted deprescribing, 7 (41%) experienced symptom recurrence, but none required unplanned healthcare use. Clinician responses were mixed: five of seven reported the intervention met their approval or seemed doable, but only two reported it fit within their usual workflow. Qualitative interviews highlighted that patients generally viewed the deprescribing discussions favorably but desired clearer explanations of the deprescribing rationale. Conclusions: This feasibility study demonstrates that deprescribing potentially inappropriate medications in older adults receiving hemodialysis is achievable, with good patient engagement, and no significant adverse drug withdrawal events. Clinician support was variable, with workflow integration as a key barrier. Improved workflow integration and strengthened shared decision-making processes are needed to support implementation in a future clinical trial.

Background: We aimed to describe recovery trajectories over 6 months in pain intensity, pain interference, lower extremity disability, and physical activity in older adults undergoing elective total knee arthroplasty (TKA), and to identify clinically feasible measures predicting recovery. Methods: Prospective cohort study in a single academic medical center. Adults ≥60 years (n = 203) scheduled for elective TKA had preoperative assessments of physical reserve (3-min walk test, grip strength), psychological reserve (PHQ-9, Resilience Scale), social support (emotional support scale, financial resource sufficiency, education level), and cognitive reserve (3MS, Trail Making Test Part B, Digit Symbol Substitution Test, 15-item recall). Provocative tests with experimental stressors included dual-task gait speed, and functional near infrared spectroscopy (fNIRS). Outcomes were the PROMIS pain scales, the lower extremity gain scale, and average daily step counts measured at postoperative day 1-7 and months 1, 2, 4, and 6. Latent class trajectory analysis defined common recovery patterns for each outcome. Results: For each outcome, 3-4 recovery trajectory groups were defined. Overall, 7% of participants were in the highest recovery group in all 4 outcomes and 20% in the lowest for all outcomes. Preoperative depression score, cognitive tests, emotional support scale, 3-min walk distance, and grip strength were significantly different across resilience groups in multiple outcomes. Provocative tests were not predictive of recovery. Conclusions: Recovery trajectories after TKA are predicted by physical, cognitive, and psychological reserve measures. Results inform future resilience research and may allow for shared decision-making and targeted preoperative optimization.

Importance: Evidence supporting osteoporosis screening in men is limited. Efficient models that promote osteoporosis screening and adherence in primary care are needed.Objective: To test the impact of a centralized, remote bone health service (BHS) on screening, treatment, adherence, and bone density in older men with fracture risk factors.Design, Setting, and Participants: This cluster randomized clinical trial involved 39 primary care teams in 2 Veterans Affairs (VA) Health Systems that included 3112 male veterans aged 65 to 85 years who had at least 1 fracture risk factor but had no prior fractures. Data were analyzed from July through November 2025.Intervention: Eligible men in medical teams randomized to BHS were invited to undergo dual-energy x-ray absorptiometry (DXA) scan, followed by an electronic consult to their primary care clinician with additional recommendations. A nurse care manager entered orders, obtained test results, provided patient education, and monitored adherence over the phone. Primary care teams randomized to usual care received osteoporosis education and VA practice guidelines.Main Outcomes and Measures: DXA screening rates, osteoporosis treatment, persistence, and adherence were compared between patients in BHS and usual care. A random subset of patients in each team had a DXA 24 months after team enrollment, regardless of whether they had been screened during the intervention.Results: Of the 3112 randomized participants (mean [SD] age, 73.3 [5.3] years; 1260 [40.4%] were Black; and 1748 [56%] were White), 49.2% (830 of 1688) in the BHS group were screened vs 2.3% (33 of 1424) in the usual care group (P < .001). More than half of those screened (441 [51.1%]) had osteopenia or osteoporosis. One hundred fifty-seven patients (84.4%) in the BHS group initiated osteoporosis treatment and achieved high levels of adherence with a mean of 91.7% of subsequent days covered and a high persistence with a mean 657 (SD, 366) days over 2 years of follow-up. The mean femoral neck T-score 2 years after team initiation in a random subset favored BHS vs usual care (−0.55 vs −0.70, P = .04).Conclusions and Relevance: This cluster randomized clinical trial found that the BHS model was associated with significantly improved osteoporosis screening, treatment, and adherence compared with usual care, with high patient and clinician acceptance. Selecting men for osteoporosis screening based on clinical risk factors before a fracture has occurred has a high screening yield. This approach requires validation in other clinical settings and with longer follow-up to determine impact on fractures.Trial Registration: ClinicalTrials.gov Identifier: NCT04079868

Introduction: Low back pain (LBP) is a leading global factor in disability among older adults. Movement-evoked pain (MEP) is potentially an important mediator in the disability pathway but is predominantly tested in the laboratory. Objectives: We aimed to explore MEP in the natural environment (“daily” MEP) and its correlation with laboratory MEP, along with potential psychological and immunological influences. Method: Thirty-five older adults with persistent LBP attended a single laboratory session. Pain catastrophizing, pain-related fear of movement, and pain self-efficacy were measured by questionnaire. Resting inflammation and inflammatory reactivity to painful movement were evaluated using serum interleukin-6, tissue necrosis factor alpha, and C-reactive protein (CRP). Laboratory MEP was defined by aggregate pain intensity with a movement provocation test. Daily MEP was measured for the next 7 days using ecological momentary assessment. Results: Laboratory MEP was strongly correlated with daily MEP ( ρ = 0.780, P = g ] = 0.266) and interleukin-6 (g = 0.433) demonstrated small to moderate reactivity to painful movement. After controlling for age and multimorbidity, pain catastrophizing and pain self-efficacy explained 24% to 37% variance in laboratory and daily MEP. Resting inflammatory markers were not associated with MEP; however, C-reactive protein reactivity to painful movement explained 19% to 25% variance in laboratory and daily MEP. Conclusion: Preliminary indication is that laboratory and daily MEP may be proxy measures for one another, and that MEP is influenced by psychological and immunological factors. Future studies will aim to (1) validate findings among older adults with persistent LBP and (2) for clinical phenotyping, clarify complex relationships among psychological and immunological factors with disability pathway components like MEP.

In Reply We appreciate the comments of Dr Strandberg and of Dr Jones and colleagues, who noted that our recent review did not address alcohol and

Background: Central nervous system (CNS) medications are linked to higher morbidity and mortality in older adults. Hospitalization allows for deprescribing opportunities. This qualitative study investigates clinician and patient perspectives on CNS medication deprescribing during hospitalization using a behavioral change framework, aiming to inform interventions and identify recommendations to enhance hospital deprescribing processes. Methods: This qualitative study focused on hospitalists, primary care providers, pharmacists, and patients aged ≥60 years hospitalized on a general medicine service and prescribed ≥1 CNS medications. Using semi‐structured interviews and focus groups, we aimed to evaluate patient medication knowledge, prior deprescribing experiences, and decision‐making preferences, as well as provider processes and tools for medication evaluation and deprescribing. Rapid qualitative analysis applying the Capability, Opportunity, Motivation, and Behavior (COM‐B) framework revealed themes influencing deprescribing behavior in patients and providers. Results: A total of 52 participants (20 patients and 32 providers) identified facilitators and barriers across deprescribing steps and generated recommended strategies to address them. Clinicians and patients highlighted the opportunity for CNS medication deprescribing during hospitalizations, facilitated by multidisciplinary teams enhancing clinicians' capability to make medication changes. Both groups also stressed the importance of intensive patient engagement, education, and monitoring during hospitalizations, acknowledging challenges in timing and extent of deprescribing, with some patients preferring decisions deferred to outpatient clinicians. Hospitalist and pharmacist recommendations centered on early pharmacist involvement for medication reconciliation, expanding pharmacy consultation and clinician education on deprescribing, whereas patients recommended enhancing shared decision‐making through patient education on medication adverse effects, tapering plans, and alternatives. Hospitalists and PCPs also emphasized standardized discharge instructions and transitional care calls to improve medication review and feedback during care transitions. Conclusions: Clinicians and patients highlighted the potential advantages of hospital interventions for CNS medication deprescribing, emphasizing the necessity of addressing communication, education, and coordination challenges between inpatient and outpatient settings.

Importance: Falls are reported by more than 14 million US adults aged 65 years or older annually and can result in substantial morbidity, mortality, and health care expenditures.Observations: Falls result from age-related physiologic changes compounded by multiple intrinsic and extrinsic risk factors. Major modifiable risk factors among community-dwelling older adults include gait and balance disorders, orthostatic hypotension, sensory impairment, medications, and environmental hazards. Guidelines recommend that individuals who report a fall in the prior year, have concerns about falling, or have gait speed less than 0.8 to 1 m/s should receive fall prevention interventions. In a meta-analysis of 59 randomized clinical trials (RCTs) in average-risk to high-risk populations, exercise interventions to reduce falls were associated with 655 falls per 1000 patient-years in intervention groups vs 850 falls per 1000 patient-years in nonexercise control groups (rate ratio [RR] for falls, 0.77; 95% CI, 0.71-0.83; risk ratio for number of people who fall, 0.85; 95% CI, 0.81-0.89; risk difference, 7.2%; 95% CI, 5.2%-9.1%), with most trials assessing balance and functional exercises. In a meta-analysis of 43 RCTs of interventions that systematically assessed and addressed multiple risk factors among individuals at high risk, multifactorial interventions were associated with 1784 falls per 1000 patient-years in intervention groups vs 2317 falls per 1000 patient-years in control groups (RR, 0.77; 95% CI, 0.67-0.87) without a significant difference in the number of individuals who fell. Other interventions associated with decreased falls in meta-analysis of RCTs and quasi-randomized trials include surgery to remove cataracts (8 studies with 1834 patients; risk ratio [RR], 0.68; 95% CI, 0.48-0.96), multicomponent podiatry interventions (3 studies with 1358 patients; RR, 0.77; 95% CI, 0.61-0.99), and environmental modifications for individuals at high risk (12 studies with 5293 patients; RR, 0.74; 95% CI, 0.61-0.91). Meta-analysis of RCTs of programs to stop medications associated with falls have not found a significant reduction, although deprescribing is a component of many successful multifactorial interventions.Conclusions and Relevance: More than 25% of older adults fall each year, and falls are the leading cause of injury-related death in persons aged 65 years or older. Functional exercises to improve leg strength and balance are recommended for fall prevention in average-risk to high-risk populations. Multifactorial risk reduction based on a systematic clinical assessment for modifiable risk factors may reduce fall rates among those at high risk.