Fred C. Ko

Background: As the population ages, kidney transplantation ( KT ) is increasingly considered for older adults with advanced chronic kidney disease ( CKD ). However, frailty, cognitive impairment, and malnutrition complicate transplant decision‐making. A Comprehensive Geriatric Assessment ( CGA ) offers a multidimensional approach, but the relative contribution of individual CGA domains to transplant eligibility and receipt remains unclear. Methods: We conducted a retrospective observational study of 164 older adults with advanced CKD seeking KT and underwent CGA by a geriatrician at an urban academic center from September 2021 to July 2024. Associations between CGA domains and KT listing and receipt were evaluated using logistic regression analyses, adjusting for age and other clinical covariates. Results: Of the 164 participants, 139 (84.8%) were listed, and 24 (17.3%) received KT among them. While higher levels of functional status, as measured by activities of daily living ( ADL ), were associated with KT listing, instrumental ADL and gait speed were significantly associated with transplantation. Even after adjusting for age, better cognitive function, as assessed through clinical evaluation and Montreal Cognitive Assessment ( MoCA ), was also positively associated with both outcomes. Age‐adjusted nutritional status was independently associated with transplant listing eligibility. Conclusions: Individual domains of CGA , particularly physical function, cognition, and nutrition, are independently associated with KT decision‐making among older adults. Incorporating focused geriatric assessments into kidney transplant evaluation may improve risk stratification and reduce disparities in transplant access.

The Aging, Life Innovations, Goals and Needs-Collaboration Achieving Readiness and Empowerment (ALIGN-CARE) ambulatory geriatric surgery co-management is an interdisciplinary program to better prepare frail older patients for surgery. We examined the development and implementation of this complex clinical program using the Medical Research Council (MRC) evaluative framework, document review, and analysis of program meetings. We analyzed 84 meetings (81.5 hours) generated at four recurring meeting types (advisory, interdisciplinary, surgeon, and research) between January 2020 and January 2022. Documents were coded and thematically analyzed to develop the implementation timeline, evolving program components, and implementation processes supporting program development. ALIGN-CARE evolved and stabilized four distinct components (referral, scheduling, assessment, and plan), drawing upon several implementation strategies. Each meeting drove the process in unique ways. Program flexibility and responsiveness were key ingredients driving implementation. ALIGN-CARE has matured through the adaptation of program components, with stakeholder meetings supporting these objectives. The document analysis method identified processes key to developing geriatric surgical co-management and advancing complex interdisciplinary programs for older adults.

This study aimed to characterize the effects of laparotomy on postoperative physical function and skeletal muscle gene expression in male C57BL/6N mice at 3, 20, and 24 months of age to investigate late-life vulnerability and resiliency to acute surgical stress. Pre and postoperative physical functioning was assessed by forelimb grip strength on postoperative day (POD) 1 and 3 and motor coordination on POD 2 and 4. Laparotomy-induced an age-associated postoperative decline in forelimb grip strength that was the greatest in the oldest mice. While motor coordination declined with increasing age at baseline, it was unaffected by laparotomy. Baseline physical function as stratified by motor coordination performance (low functioning vs high functioning) in 24-month-old mice did not differentially affect postlaparotomy reduction in grip strength. RNA sequencing of soleus muscles showed that laparotomy-induced age-associated differential gene expression and canonical pathway activation with the greatest effects in the youngest mice. Examples of such age-associated, metabolically important pathways that were only activated in the youngest mice after laparotomy included oxidative phosphorylation and NRF2-mediated oxidative stress response. Analysis of lipid mediators in serum and gastrocnemius muscle showed alterations in profiles during aging and confirmed an association between such changes and functional status in gastrocnemius muscle. These findings demonstrate a mouse model of laparotomy which recapitulated some features of postoperative skeletal muscle decline in older adults, and identified age-associated, laparotomy-induced molecular signatures in skeletal muscles. Future research can build upon this model to study molecular mechanisms of late-life vulnerability and resiliency to acute surgical stress.

With advances in antiretroviral therapy and subsequent increase in life expectancy, People with HIV (PWH) now experience multiple geriatric syndromes in the setting of advanced aging and increased multimorbidity. HIV clinicians bear the responsibility of delivering geriatric care to this vulnerable population, despite limited geriatric medicine training and limited support from HIV service networks that were not traditionally designed to care for an aging population. Although HIV clinicians reported formal guidelines specific to older PWH to be among the most helpful interventions, current HIV guidelines present multiple issues in their applicability to the care of older PWH, including multifactorial nature of conditions in older adults, difficulty measuring patient-centered outcomes, lack of representation of older PWH in clinical trials, limited guidelines addressing geriatric syndromes, and the use of chronological age as criteria for inclusion despite advanced aging in PWH. Understanding that updated guidelines addressing above challenges may take many years to develop, we offer strategies on the application of current guidelines, including using baseline attributes, time to benefit, and the Geriatrics 5M model to aid in shared decision making and improve outcomes among older PWH.

This study aimed to characterize the effects of laparotomy on post-operative physical function and skeletal muscle gene expression in C57BL/6N mice at 3, 20 and 24 months of age to investigate late-life vulnerability and resiliency to acute surgical stress. Pre- and post-operative physical functioning were assessed by forelimb grip strength and motor coordination. Laparotomy induced an age-associated post-operative decline in forelimb grip strength that was greatest in the oldest mice. In contrast, while motor coordination declined with increasing age at baseline, it was unaffected by laparotomy. Moreover, baseline physical function as stratified by motor coordination performance (low vs. high functioning) in 24-month-old mice did not differentially affect post-laparotomy reduction in grip strength. RNA sequencing of soleus muscles showed that laparotomy induced age-associated differential gene expression and canonical pathway activation with the greatest effects in the youngest mice. Examples of such age-associated, metabolically important pathways that were only activated in the youngest mice after laparotomy included oxidative phosphorylation and NRF2-mediated oxidative stress response. Analysis of lipid mediators in serum and gastrocnemius muscle showed alterations in profiles of these mediators during aging and confirmed an association between such changes and functional status in gastrocnemius muscle. These findings demonstrate a mouse model of laparotomy which recapitulated some features of post-operative skeletal muscle decline in older adults following surgery, and identified age-associated, laparotomy-induced molecular signatures in skeletal muscles. Future research can build upon this mouse model to study molecular mechanisms of late-life vulnerability to acute surgical stress and resiliency to counter surgery-induced physical decline.

Older adults are the fastest growing segment of the population and surgical procedures in this group increase each year. Chronic post-surgical pain is an important consideration in the older adult as it affects recovery, physical functioning, and overall quality of life. It is increasingly recognized as a public health issue but there is a need to improve our understanding of the disease process as well as the appropriate treatment and prevention. Frailty, delirium, and cognition influence post-operative outcomes in older adults and have been implicated in the development of chronic post-surgical pain. Further research must be conducted to fully understand the role they play in the occurrence of chronic post-surgical pain in the older adult. Additionally, careful attention must be given to the physiologic, cognitive, and comorbidity differences between the older adult and the general population. This is critical for elucidating the proper chronic post-surgical pain treatment and prevention strategies to ensure that the older adult undergoing surgical intervention will have an appropriate and desirable post-operative outcome.