A Decade of JAMDA John E. Morley MB, BCh Journal of the American Medical Directors Association, 2017-12-01, Volume 18, Issue 12, P

“The afternoon knows what the morning never suspected”

Over the past decade we have seen tremendous growth in your Journal . This is objectively shown by an increase in the number of articles submitted from 157 in 2008 to 760 in 2016; and an increase in impact factor from 3.467 in 2008 to more than 5 in the past 2 years. These changes have led to JAMDA being recognized as one of the leading geriatric journals in the world. As I reach the end of my term as editor, I thought it would be appropriate to reflect on the most important articles that the Journal has published over the past decade and how these have changed the world view on geriatrics and long-term care medicine.

The International Association of Geriatrics and Gerontology (IAGG) Nursing Home Collaboration with JAMDA

One of the major roles of JAMDA has been to develop and publish a series of articles with IAGG setting forth an international viewpoint on the development of nursing home medicine. The first of these articles was a position paper 1 on the importance of the nursing home and the need to increase the quality of care for the most vulnerable of older persons and also to enhance the respect for health professionals who care for those persons living in nursing homes. 12 This led to a number of educational endeavors as well as the development of the International Nursing Home Research conferences. 3 An important early article in this collaboration led to the realization that dramatically different models of nursing home care existed in different countries and resulted in a general definition of a nursing home to encompass these different nursing home models 4 : “A nursing home is a facility with a domestic-styled environment that provides 24-hour functional support and care for persons who require assistance with ADLs and who often have complex health needs and increased vulnerability.”

An international panel prioritized the areas of research that needed to be developed in nursing homes.5 These included the following: Care of persons with cognitive impairment/dementia and the management of the behavioral and psychological symptoms of dementia, end-of-life care, nutrition, polypharmacy, meaningful activities, exercise, reduce hospital admissions (transitions), frailty, staff turnover, innovative educational approaches, and implementation of best practices. Rolland and de Souto Barreto 6 had pointed out that there is a paucity of high-quality research in the nursing home and the panel stressed the need for double-blind research studies in the nursing home.

A recent consensus conference also suggested that, around the world, nursing homes could provide support programs for older persons aging in place. 6

Finally, the last of these articles focused on the need to enhance the end-of-life care in nursing homes.7 This study recognized that there was a paucity of quality hospice programs in nursing homes. The need to improve end-of-life care in nursing homes had also been recognized in editorials in theJournal . 8910 Articles on improving the quality of advance directives 1112 and reducing the needless repeated end-of-life hospitalizations have further emphasized the importance of providing appropriate end-of-life care in nursing homes. 13141516

Frailty

The past decade could be considered the decade of “frailty in geriatric medicine.” The Journal played a key role in this area by publishing a major consensus paper pointing out the need for physicians to diagnose the frailty syndrome in older persons 1718 and, more recently, the Asian Pacific Consensus on the approach to the management of frailty. 19

The Journal published a number of early articles on different frailty diagnostic criteria, such as the Tilburg 2021 and the Groningen. 2223 While recognizing the variety of approaches to frailty, 2425the Journal has provided strong support for the physical frailty phenotype as originally propounded by Fried and her colleagues. 262728 The Journal has also drawn attention to the FRAIL screen used by family practitioners to rapidly diagnose frailty. 2930313233 The FRAIL has now been shown to be highly predictive of functional deterioration, hospitalization, and mortality in older persons. 343536373839 A computerized algorithm has been developed to allow primary care physicians to develop treatment programs for persons who are frail by using the FRAIL mnemonic as a guide. 4041Intervention programs have shown that exercise and protein supplementation can play important roles in reversing frailty. 424344 To enable physicians to be able to focus on frailty and develop treatment programs, there is a major need for a diagnosis code ( International Classification of Diseases, Tenth Revision, Clinical Modification [ICD-10]) to be created and accepted for frailty.

Sarcopenia

Loss of muscle mass and function (sarcopenia) is a major component of frailty. The Journal published 5 of the modern consensus definitions of sarcopenia. 4546474849 These all stress that cutpoints will be different for different populations. Sarcopenia is highly associated with increased mortality in nursing home residents. 50 The Journal published a number of validations for a rapid screening test for sarcopenia: the SARC-F. 515253545556 The SARC-F is highly predictive of which persons with poor muscle are liable to have poor outcomes. Resistance exercise and protein supplementation are the most successful approaches to manage sarcopenia. 5758596061 An ICD-10 code is now available to allow the diagnosis of sarcopenia and to charge for physical therapy to help with its reversal. 62

Nutrition

Over the decade, the Journal has highlighted the importance of weight loss as a sign of protein-energy malnutrition. 6364656667 Depression is the most common reversible cause of protein-energy undernutrition. 6869 It has highlighted that cachexia differs from malnutrition due to anorexia. 7071 Cachectic patients have an excess loss of muscle and usually low albumin and anemia. Cachexia is classically due to an illness producing an excess of cytokines. 7273 Early in the decade it was pointed out that feeding tubes are inappropriate in persons with dementia. 7475

At the beginning of the decade, there was still controversy about providing nursing home patients with vitamin D. A number of articles in the Journal clearly showed that vitamin D deficiency was common in older persons and nursing home residents. 7677 Nursing home residents need to receive between 800 and 1000 IU daily. 78 There is no evidence to support higher doses.

Dehydration is an important problem in nursing home residents that is often not recognized. 798081

Cognitive Impairment

The consensus on brain health pointed out that there are a number of treatable (reversible) causes of mild cognitive impairment, and, as such, it is important to detect cognitive impairment early. 82 One study showed that more than half of mild cognitive impairment could be reversed if the potential causes are treated. 83 Approaches to screening for cognitive impairment have been validated and screening for persons with vascular dementia exist. 848586 It is now accepted that amyloid-beta protein is a memory mnemonic and if it is blocked there is a loss of memory. 878889 For this reason, drugs such as antisenses to amyloid precursor protein, which downregulate amyloid-beta production, would appear more sensible to treat Alzheimer disease than antibodies that wipe out the production of amyloid-beta. 90919293 It is now clear that vascular dementia is almost as common as Alzheimer disease, requiring that vascular risk factors should be treated.

Improved outcomes are seen when persons with dementia have small-scale living facilities. 94cognitive stimulation therapy, 9596 SAIDO, 97 and sports (eg, soccer or baseball) reminiscence therapy 9899 all appear to be as effective as drugs for treatment of moderate dementia.

Studies have shown that exercise can improve memory and that, in persons with dementia and associated behavioral problems, regular exercise enhances the ability to manage patients with these behaviors. 100101102103 Exercise also maintains function in persons with dementia. 104

A number of studies explored the importance of early recognition and treatment of delirium. 105106107 In addition, the Journal published a scale to identify delirium and suggested that delirium should be considered as the sixth vital sign. 108109

Finally, several studies recognized that the combination of frailty and mild cognitive impairment is associated with poorer outcomes than either one alone. 110111 This syndrome is termed cognitive frailty or motoric cognitive risk syndrome. 112

Polypharmacy

Since I first was involved in geriatrics, it was recognized that polypharmacy is a major problem for older persons. 113114115 Together with polypharmacy, it is now recognized that there are a large number of potential inappropriate medications that increase the risk for adverse outcomes in older persons. 116 This has led to the development of lists of inappropriate drugs such as the Beers' list 117and the STOPP/START approach. 118 Over the past decade it has become clear that antipsychotic drugs are a major cause of harm in older people. 119120 Fitzgerald and Bean 121 showed that in older persons, adding 1 medicine over 5 has approximately the same chance of killing the person as it has for improving outcomes. Using a pharmacy review committee in nursing homes has been successful in reducing polypharmacy. 122

Diabetes Mellitus

Diabetes is recognized to accelerate the aging process and increase a variety of age-related complications. 123124 In particular, diabetes increases the risk of nursing home admission 125 and mortality. 126 Persons with diabetes are more likely to be frail than other older persons, and this is associated with increased hospitalizations and disability. 127128129 A major cause of frailty is secondary to the loss of muscle mass and function resulting in sarcopenia. 130131132133 Diabetes causes loss of muscle function through loss of motor nerve units, peripheral vascular disease, increased cytokines, low testosterone in men, and insulin resistance. Orthostasis and postprandial hypotension increase the possibility of developing frailty in older persons with diabetes. 134 Another problem is the acceleration of cognitive dysfunction due to multiple factors leading to the “diabetic brain.” 86135136

Perhaps most importantly, it has been recognized that overtreatment of older persons with diabetes leads to hypoglycemia and poor outcomes. This has led to the recommendations that in healthy older diabetics the HgbA 1 C should be between 7.0% and 7.5%, and in frail persons between 7.6% and 8.0%.137 Higher levels may be acceptable in some nursing home patients. Use of sliding scale insulin administration is no longer recommended in nursing homes. 138

Technology

Technological advances are on the verge of disrupting care of older persons in the nursing home. 139140 Marilyn Rantz and her colleagues 141142 have demonstrated that an intelligent sensor system can be used to give early illness alerts in senior housing. Technology has been developed to do a number of nursing tasks. 143 Numerous advances, such as the exoskeleton and those that improve physical and occupational therapy outcomes, have been developed and are being introduced to general usage. 143144 Use of robots as companions and monitors of older persons aging place has been successful. 145146147 Finally, telemedicine is beginning to become an important component of nursing home care. 148149150151

Conclusion

The past decade has been an exciting time in which there have been many developments to improve the care of older persons at home and in the nursing home. I trust our readership has enjoyed learning of these developments in the pages of JAMDA, as I have. I need to thank my associate editors, Barbara Resnick, David Thomas, Milta Little, and Julie Gammack, as well as our editorial board and all our reviewers for their support during this decade. I also need to thank our 2 publishing directors at Elsevier, Pamela Poppalardo and George Woodward, and their publications team for their consistent support. I thank the AMDA executive board and particularly Chris Laxton and Paul Katz for their support over the past decade. Valerie Tanner, our managing editor, has provided unbelievable support to allow the editorial office to work smoothly. Finally, I wish the best of luck to Philip Sloane and Sheryl Zimmerman as they assume the leadership of the Journal .