Influence of Studies Published by the <i>Journal of the American Geriatrics Society</i> : Top 20 Articles from 2000–2015

As the tenure of Dr. Thomas T. Yoshikawa comes to a close on July 1, 2016, after 16 years as editor in chief of the Journal of the American Geriatrics Society (JAGS), the editorial board members (which includes the editors) felt it would be valuable to determine which of the published manuscripts would be rated as the most important articles in terms of clinical influence on patient care and improving the health and quality of life of older adults from 2000 to 2015. In addition, such information would provide some level of perspective on how the field of aging (geriatrics, gerontology, and long-term care) has evolved over 15 years and how that progress continues to affect our focus and priorities for the present and future of care for older adults. The process of determining which of the articles published from 2000 to 2015 would be worthy of consideration involved objective and subjective assessments. JAGS publisher, Wiley-Blackwell, provided a spreadsheet of the 10 published JAGS articles that other journals cited most for each year between 2000 and 2015, which yielded 155 articles for consideration. (There were more than 150 articles because a few articles had the same rating scores.) This information was organized according to year and included the title, authors, publication date, volume, and total citations for each article. The data were then shared with 96 JAGS editorial board members. Editorial board members were asked to vote on their top two articles for each year based on what they believed the article's influence has been on clinical care, research and education. The editorial board members were also invited to recommend any additional articles that they felt should be considered but were not included in the spreadsheet data. From the votes obtained on the 155 articles, a rank order of articles from the most to fewest votes was generated. Thirty-six editors submitted their votes. These votes were tallied and shared with the selection committee: Thomas T. Yoshikawa, MD (outgoing JAGS editor in chief), William B. Applegate, MD (incoming JAGS editor in chief), and Joseph G. Ouslander, MD (JAGS executive editor). The selection committee met in a conference call to determine the final list of top articles for 2000 to 2015 from the ranking of the 155 articles. A cutoff of the top 20 articles was arbitrarily agreed upon. Each of the selection committee members was assigned an equal number of articles to review and provide a brief summary (100 words or fewer) that included study objective, relevance of the findings, and effect on current practice. Selection committee members were also allowed to contact experts in the field to obtain their opinions on the merits and influence of the articles assigned to them. The following are the summaries of the top 20 articles listed according to rank order of votes received, beginning with the articles with the highest votes and in decreasing order. Many articles received the same number of votes. The articles will be listed by title, first author's name, year, volume, and pages. (See Reference section for complete citations.) The Montreal Cognitive Assessment, MoCA: A Brief Screening Tool for Mild Cognitive Impairment. Nasreddine ZS et al. 2005;53:695–699.1 Study Objective: To report on a new screening test to detect mild cognitive impairment (MCI). Relevance: The MoCA is an excellent bedside measure that performs well in discriminating MCI from normal cognition as an initial test. Effect on Current Practice: MCI is more common than dementia in older adults, and the MoCA's more-challenging tasks, all of which are directly related to clinical cognitive status, produce greater sensitivity for MCI than other screening tests, making the MoCA an attractive measure for use in clinical and research settings where detection of MCI is desired and use of longer neuropsychological batteries is not feasible. American Geriatrics Society Updated Beers Criteria for Potentially Inappropriate Medication Use in Older Adults. American Geriatrics Society. 2012;60:616–631. 2 Study Objective: To update the previous Beers Criteria using a comprehensive, systematic review and grading of the evidence on drug-related problems and adverse drug events. Relevance: Fifty-three medications or medication classes were divided into three categories: potentially inappropriate medications or medication classes to avoid in older adults, potentially inappropriate medications or medication classes to avoid in older adults with certain diseases and syndromes that the drugs listed can exacerbate, and medications or medication classes to be used with caution in older adults. Effect on Current Practice: In recent years, the Beers Criteria has been one of the most widely used clinical tools for determining medications that could be harmful to older persons. Transitional Care of Older Adults Hospitalized with Heart Failure: A Randomized, Controlled Trial. Naylor MD et al. 2004;52:675–684. 3 Study Objective: To examine the effectiveness of a transitional care intervention delivered by advanced practice nurses to older adults hospitalized with heart failure. Relevance: The study involved 259 participants (mean age 76, 43% male, 36% African American) in six academic and community hospitals followed for 52 weeks after index hospital discharge. Time to first admission or death was longer in intervention participants (P = .026). At 52 weeks, intervention group participants had fewer admissions than controls (104 vs 162, P = .047) and lower mean total costs ($7,363 vs $12,481, P = .002). For intervention participants, only short-term improvements were demonstrated in overall quality of life, physical dimension of quality of life, and participant satisfaction. It was concluded that a comprehensive transitional care intervention for older adults hospitalized with heart failure increased the length of time between hospital discharge and readmission or death, reduced total number of rehospitalizations, and decreased healthcare costs. Effect on Current Practice: This study formed the basis of Dr. Mary Naylor's Transitional Care Model, which is being disseminated widely throughout the United States as a result of evolving Medicare payment models. Potentially Avoidable Hospitalizations of Nursing Home Residents: Frequency, Causes and Costs. Ouslander JG et al. 2010;58:627–635. 4 Study Objective: To examine the frequency of and reasons for potentially avoidable hospitalizations (PAHs) of nursing home (NH) residents. Relevance: Ten hospitalizations each per NH of long- and short-stay residents were randomly selected—10 from Georgia NHs with high and 10 with low hospitalization rates. Expert clinicians performed ratings of avoidability using a structured review. Of the 200 hospitalizations, 134 (67%) were rated as potentially avoidable. The expert clinicians cited lack of on-site availability of primary care clinicians, inability to obtain timely laboratory tests and intravenous fluids, problems with quality of care in assessing acute changes, and uncertain benefits of hospitalization as causes of these potentially avoidable hospitalizations. Results suggested that support for NH infrastructure, attention to reducing the frequency of medically futile care, and financial and other incentives for NHs and their affiliated hospitals are needed to improve care, reduce PAHs, and avoid unnecessary healthcare expenditures in this population. Effect on Current Practice: This study provided the data for an expert panel to make recommendations that evolved into the Interventions to Reduce Acute Care Transfers quality improvement program, which is being widely used in many NHs in the United States, as well as in several other countries. Ten-Year Effects of the Advanced Cognitive Training for Independent and Vital Elderly Cognitive Training Trial on Cognition and Everyday Functioning in Older Adults. Rebok GW et al. 2014;62:16–24. 5 Study Objective: To assess the effect of 10 cognitive training sessions with or without two later booster sessions on cognitive performance and self-reported function at 10 years compared to controls. Relevance: This is the seminal randomized clinical trial of cognitive training for older adults. Effects were specific to the domain trained (memory, speed of processing, reasoning), and gains in speed and reasoning were still evident after 10 years relative to controls, when participants' average age was 82. Training was associated with small to moderate benefits in long-term maintenance of self-reported activities of daily living. Effect on Current Practice: This study confirmed that cognitive performance of older adults can improve with structured training and hinted at possible transfer of training benefits to everyday function. The results seeded commercialization and expansion of cognitive training tools and new studies demonstrating important practical benefits, such as better driving performance in older adults. Geriatric Syndromes: Clinical, Research, and Policy Implications of a Core Geriatric Concept. Inouye SK et al. 2007;55:780–791. 6 Study Objective: To review criteria for defining geriatric syndromes and propose a balanced approach of developing preliminary criteria based on peer-reviewed evidence. Relevance: Based on a review of the literature, four shared risk factors (old age, baseline cognitive impairment, baseline functional impairment, impaired mobility) were identified for five common geriatric syndromes (pressure ulcers, incontinence, falls, functional decline, delirium). It was asserted that understanding basic mechanisms involved in geriatric syndromes will be critical to advancing research and developing targeted therapeutic options and that, given the complexity of these multifactorial conditions, attempts to define relevant mechanisms will need to incorporate more-complex models, including a focus on synergistic interactions between risk factors. There was a call for national strategic initiatives to overcome barriers and to achieve clinical, research, and policy advances that will improve quality of life for older adults. Effect on Current Practice: This is a seminal article that has formed the basis of many current clinical care and research initiatives on multimorbidity. Guideline for the Prevention of Falls in Older Persons. American Geriatrics Society et al. 2001;49:664–672. 7 Study Objective: To provide a guideline for clinicians for prevention of falls in older adults. Relevance: This guideline was a collaborative effort between the American Geriatrics Society, British Geriatrics Society, and American Academy of Orthopaedic Surgeons. It includes a review of the literature on risk factors for falls, general recommendations for the assessment of individuals who have fallen, and an evidence-based review of multiple types of interventions for fall prevention. The guideline also outlines an ambitious research agenda for the future. Effect on Current Practice: This guideline formed the basis for current fall prevention guidelines and provided a research agenda, some elements of which have been accomplished, and much of which is still ongoing. The Hospital Elder Life Program: A Model of Care to Prevent Cognitive and Functional Decline in Hospitalized Older Patients. Inouye SK et al. 2000;48:1697–1706. 8 Study Objective: To describe the Hospital Elder Life Program (HELP), a new model of care designed to prevent delirium. Relevance: In 1,507 participants, HELP substantially decreased rates of cognitive and functional decline. HELP was the first in-hospital delirium-prevention model and has subsequently been demonstrated to be clinically effective and cost-effective through reductions in delirium, falls, sitter use, hospital length of stay, institutionalization, and readmission. Effect on Current Practice: The program has been implemented in more than 200 hospitals in the United States and other countries. HELP interventions and protocols have also had widespread influence on many adaptations, guidelines, pathways, and standing order sets for delirium worldwide. Reducing Delirium After Hip Fracture: A Randomized Trial. Marcantonio ER et al. 2001;49:516–522. 9 Study Objective: To conduct a randomized trial of a proactive geriatrics consultation to reduce delirium after hip fracture surgery. Relevance: One hundred twenty-six participants were randomized. All proactive consultation participants were seen within 24 hours of admission and had good adherence to recommendations. The incidence of delirium in the proactive consultation group was two-thirds that of the usual care group, and the incidence of severe delirium was half that of the usual care group. Effect on Current Practice: This study provided a model for improving outcomes of a vulnerable hospitalized population and has led to the widespread adoption of geriatrics–orthopedics co-management services in many medical centers today. Pharmacological Management of Persistent Pain in Older Persons. American Geriatrics Society. 2009;57:1331–1346. 10 Study Objective: To update the 2002 American Geriatrics Society pain guideline and provide recommendations regarding use of newer pharmacological approaches to managing persistent pain in older adults. Relevance: This guideline provided general principles on the assessment and management of persistent pain, principles of pharmacological management, and a summary of nonopioid and opioid analgesics with an emphasis on recommending acetaminophen as initial and ongoing pharmacotherapy for most cases of persistent pain. Effect on Current Practice: The guideline continues to remain an important management tool for treating older adults with persistent pain. Physical Performance Measures in the Clinical Setting. Studenski S et al. 2003;51:314–322. 11 Study Objective: To assess the ability of gait speed alone and a three-item lower extremity performance battery to predict 12-month rates of hospitalization, decline in health, and decline in function in primary care settings serving older adults. Relevance: Gait speed alone and the Established Populations for Epidemiological Study of the Elderly (EPESE) battery predicted hospitalizations; 41% (21/51) of slow walkers (gait speed <0.6 m/sec), 26% (70/266) of intermediate walkers (0.6–1.0 m/sec) and 11% (15/136) of fast walkers (>1.0 m/sec) were hospitalized at least once (P < .001). It was concluded that gait speed and a physical performance battery are brief, quantitative estimates of future risk of hospitalization and decline in health and might serve as easily accessible “vital signs” to screen older adults in clinical settings. Effect on Current Practice: In the years since this article was published, gait speed and physical performance have been shown to have clinical utility in risk stratifying older adults. Effective Exercise for the Prevention of Falls: A Systematic Review and Meta-Analysis. Sherrington C et al. 2008;56:2234–2243. 12 Study Objective: To determine the effects of exercise on fall prevention. Relevance: Randomized controlled trials were included that compared fall rates in older adults who undertook exercise programs with fall rates in older adults who did not exercise in the general community and residential care. The pooled estimate of the effect of exercise was that it reduced the rate of falling by 17% (44 trials with 9,603 participants; rate ratio = 0.83, 95% confidence interval = 0.75–0.91, P < .001). The greatest relative effects of exercise on fall rates were seen in programs that had a combination of a higher total dose of exercise (450 hours over the trial period) and challenging balance exercises (exercises conducted while standing in which people aimed to stand with their feet closer together or on one leg, minimize use of their hands to assist, and practice controlled movements of the center of mass) and did not include a walking program. It was concluded that exercise can prevent falls in older adults, with greater relative effects seen in programs that include exercises that challenge balance, use a higher dose of exercise, and do not include a walking program. Effect on Current Practice: This study reinforces the use of tai chi and similar balance training that is commonly used in fall prevention today. Summary of the Updated American Geriatrics Society/British Geriatrics Society Clinical Practice Guideline for Prevention of Falls in Older Persons. American Geriatrics Society and British Geriatrics Society. 2011;59:148–157. 13 Study Objective: To provide a summary of the updated American Geriatrics Society/British Geriatrics fall guideline, the guideline process, and the differences between the updated guideline and the 2001 version of fall guideline. Relevance: The algorithm is clear and simple to follow, and the text of the article highlights a comprehensive set of recommendations on screening and assessment and interventions for falls, with ratings of the evidence supporting them. Separate sections are included on managing falls in long-term care facilities and in older persons with cognitive impairment. Updates of the 2001 guideline include more-specific recommendations on fall risk assessment and the circumstances of the fall and new recommendations on a variety of interventions studied since the older guideline was published. Effect on Current Practice: This guideline should form the basis of all initiatives to manage fall risk and prevent falls in older adults. Low Relative Skeletal Mass (Sarcopenia) in Older Persons Is Associated with Functional Impairment and Physical Disability. Jansen I et al. 2002;58:889–896. 14 Study Objective: To establish the prevalence of sarcopenia in older Americans and to test the hypothesis that sarcopenia is related to functional impairment and physical disability in older adults. Relevance: The prevalence of Class I (59% vs 45%) and Class II (10% vs 7%) sarcopenia was greater in older (≥60) women than older men (P < .001). The likelihood of functional impairment and disability was approximately two times as great in older men and three times as great in older women with Class II sarcopenia than in those with Class I sarcopenia. Some of the associations between Class II sarcopenia and functional impairment remained significant after adjustment for age, race, body mass index, health behaviors, and comorbidity. Effect on Current Practice: This study demonstrates the independent association between sarcopenia and functional impairment and disability and hypothesizes that sarcopenia may be a potentially reversible cause of disability, particularly in older women. The Mini-Cog as a Screen for Dementia: Validation in a Population-Based Sample. Borson S et al. 2003;51:1451–1454. 15 Study Objective: To compare performance of a 2–3-minute screen for dementia, the Mini-Cog, compared with that of the Mini-Mental State Examination and a research neuropsychological battery in a population with low rates of dementia. Relevance: The Mini-Cog was as effective as longer tests in detecting dementia diagnosed by research criteria, making dementia detection simple and feasible in primary care settings. Effect on Current Practice: This study provided evidence to support adoption of the Mini-Cog in healthcare and clinical training settings and electronic medical record systems, its endorsement in evidence reviews and best practice statements, and its use to evaluate the combined effects of cognitive impairment and comorbid chronic conditions on healthcare outcomes. Effects of Exercise Training on Frailty in Community-Dwelling Older Adults: Results of a Randomized, Controlled Trial. Binder EF et al. 2002;50:1921–1928. 16 Study Objective: To determine the effects of intensive exercise training (ET) on measures of physical frailty in older community-dwelling men and women. Relevance: One hundred fifteen sedentary men and women (mean age 83) with mild to moderate physical were randomized to an exercise intervention (ET) or home exercise for 9 with 3 of and balance the 3 training was and the 3 training was in greater improvements than home exercise in three of the four primary a physical performance a functional and Effect on Current Practice: This may be the first study to provide evidence of the of a training in reducing frailty and improving in community-dwelling for Frailty in Older Adults: a of and Summary from the American Geriatrics on on Frailty in Older Adults. et al. Study Objective: To report on the results of the American Geriatrics on conference on a research agenda on frailty in older adults. Relevance: The conference on evolving and of of including the of and and and approaches that may to specific recommendations as to future were also including recommendations on and to clinical studies of and to of and models, of studies to frailty research, and of collaborative in which and can be Effect on Current Practice: Many of the conference recommendations and have led to the of research studies that have better frailty and its and into in clinical practice. article summary on frailty by et of Frailty and of to et al. Study Objective: To evaluate frailty and compare their prevalence estimates of and ability to predict Relevance: Frailty were the Frailty Frailty Frailty based on a Geriatric Clinical Frailty Frailty and and the differences were between in their and ability to predict The is that these frailty related but of older persons. Effect on Current Practice: frailty are being used in clinical research and at times in clinical practice to define which older persons are most at risk of adverse clinical outcomes and Delirium Is Associated with Functional After Hip Marcantonio ER et al. Study Objective: To define the of delirium in functional outcomes. Relevance: After for age, cognitive and functional impairment, and delirium remained an independent risk for decline in activities of daily decline, and death or new nursing home at participants with persistent delirium at had outcomes than those delirium Effect on Current Practice: This was one of the first studies to the of delirium in functional after Screening for delirium after in older adults is common practice. The and Care from the of a for Medicare and Nursing et al. 20 Study Objective: To describe a preliminary report on the and Care Relevance: This is one of that the for Medicare and has to test interventions to reduce avoidable hospitalizations of nursing residents. The study a in each to an evidence-based quality improvement program with clinical support from elements include better medical care through of the Interventions to Reduce Acute Care Transfers tools and chronic care management, transitional care, and better care with a focus on systematic care were performed for acute The as avoidable and for quality improvement were identified in included defining new clinical quality improvement principles into managing with multiple and developing a for and managing data. Effect on Current Practice: The of and other similar interventions in the has in a of to on these interventions that will improve care and of over the the 15 years progress has been improving the health and quality of life of older adults, through designed and implemented research In through this exercise of to the studies published in JAGS that have the greatest influence on improving clinical care and health outcomes in older adults, it is that the field of aging (geriatrics, gerontology, long-term care) has and a in the and health of older adults. The not health of older adults, particularly as they age into their and of life, are cognitive impairment, physical and functional and to and and their effects on health outcomes. In this of the top 20 JAGS articles, five articles were on of cognition cognitive assessment and five were physical three two were and two hospitalization and transitional care. these top 20 research studies the of our older population. these in health therapeutic and measures for the health the field of aging still has in the of health of older adults. have to causes and how to prevent diseases and other cognitive manage and a variety of and drug reduce falls and hospitalizations; and the prevalence and of diseases such as heart chronic and health such as As the field of aging has JAGS has through its publication improving the health and of older adults these 15 the 15 years will be as and of healthcare models, and of care to achieve our The opinions by the are not those of the of of All three a from the American Geriatrics Society in their as editors of The have other of to relevant to this article. All three to this The of for the spreadsheet data of the top 10 published JAGS articles as cited by other journals from 2000 to 2015. also Mary of the American Geriatrics Society for and the spreadsheet data for each year, the JAGS editors for their specific ranking of the articles, and the ranking of articles based on the votes submitted by the The American Geriatrics Society and had in the determining the final outcomes and relevant to this

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