Older Veterans Research Articles

Central Nervous System-Active Prescriptions in Older Veterans: Trends in Prevalence, Prescribers, and High-risk Populations.

Little is known about the prevalence or chronicity of prescriptions of central nervous system-active (CNS-active) medications in older Veterans. We sought to describe (1) the prevalence and trends in prescription of CNS-active medications in older Veterans over time; (2) variation in prescriptions across high-risk groups; and (3) where the prescription originated (VA or Medicare Part D). Retrospective cohort study from 2015 to 2019. Veterans age ≥ 65 enrolled in the Medicare and the VA residing in Veterans Integrated Service Network 4 (incorporating Pennsylvania and parts of surrounding states). Drug classes included antipsychotics, gabapentinoids, muscle relaxants, opioids, sedative-hypnotics, and anticholinergics. We described prescribing patterns overall and in three subgroups: Veterans with a diagnosis of dementia, Veterans with high predicted utilization, and frail Veterans. We calculated both prevalence (any fill) and percent of days covered (chronicity) for each drug class, and CNS-active polypharmacy (≥ 2 CNS-active medications) rates in each year in these groups. The sample included 460,142 Veterans and 1,862,544 person-years. While opioid and sedative-hypnotic prevalence decreased, gabapentinoids exhibited the largest increase in both prevalence and percent of days covered. Each subgroup exhibited different patterns of prescribing, but all had double the rates of CNS-active polypharmacy compared to the overall study population. Opioid and sedative-hypnotic prevalence was higher in Medicare Part D prescriptions, but the percent of days covered of nearly all drug classes was higher in VA prescriptions. The concurrent increase of gabapentinoid prescribing paralleling a decrease in opioid and sedative-hypnotics is a new phenomenon that merits further evaluation of patient safety outcomes. In addition, we found substantial potential opportunities for deprescribing CNS-active medications in high-risk groups. Finally, the increased chronicity of VA prescriptions versus Medicare Part D is novel and should be further evaluated in terms of its mechanism and impact on Medicare-VA dual users.

Retention of older veterans with serious mental illness in a clinical exercise program.

Older adults with serious mental illness (SMI) have compromised physical function that could be improved with exercise; however, retention in exercise programs is a challenge. This study was a retrospective analysis of retention for the 150 older veterans with SMI that enrolled in Gerofit, a clinical exercise program offered in the Veterans Health Administration. Chi-square and t-tests were conducted to evaluate baseline differences between those that were and were not retained at six and 12 months. Retention was 33% and better health-related quality of life and endurance were related to retention. Future work is needed to improve exercise program retention in this population.

645-P: Experiences of Managing Comorbid Obstructive Sleep Apnea and Type 2 Diabetes among Veterans

Obstructive sleep apnea (OSA) is highly prevalent in patients with type 2 diabetes (T2DM), more so in veterans compared to non-veterans. Positive airway pressure (PAP) is the recommended first-line treatment for OSA. However, adherence to both PAP and to diabetes management regimens can be challenging to older adults. This study describes older veterans’ experiences managing comorbid OSA and T2DM, and the types of support they receive from family and friends. Methods: We conducted a postal survey of 900 randomly selected veterans (aged ≥50 years with medical diagnoses of OSA and T2DM) from one VA healthcare system. Questions included the Diabetes Patient Behavior Checklist and perceived benefits of and assistance with PAP use. Results: Of the 145 respondents (97% men, 51% White, 21% Black, mean age 72 years), 43% received help for diabetes from family or a friend, including preparing healthy food (91%), providing encouragement for diabetes self-care (89%), and eating at the same time (89%). Almost two thirds of the respondents were current PAP users. Among the respondents, 27% received help using PAP from a household member, including putting on the mask (68%), filling the water reservoir (59%), and cleaning the device (59%). Current PAP users had significantly lower levels of hemoglobin A1c than nonusers (6.7 ± 1.1 vs. 7.3± 1.6 %, respectively, p=0.008). Current PAP users also reported significantly higher perceived benefits of PAP use on improving sleep quality, sleep apnea, diabetes, and general health than nonusers. Married or non-White respondents thought it would be more helpful for a family member or friend to receive education on treatment of both OSA and T2DM. Conclusion: Future studies should investigate feasible strategies for addressing adherence to PAP use as part of diabetes self-management to improve glycemic control and overall health outcomes among patients with T2DM and comorbid OSA. Family support and social/demographic factors should be considered. Disclosure Y.Song: None. S.E.Choi: None. A.Papazyan: None. P.M.Macey: None. C.Alessi: None. C.H.Fung: None. J.Martin: None. Funding National Institutes of Health (K23AG055668); University of California, Los Angeles Clinical and Translational Science Institute School of Nursing

Prevalence and risk factors of suicide and suicidal ideation in veterans who served in the British Armed Forces: a systematic review

IntroductionResearch into the factors resulting in suicide in the military veteran population has yet to reach a consensus. Available research is concentrated on a small number of countries, and there...

Peer-to-Patient-Aligned Care Team (Peer-to-PACT; P2P), a Peer-Led Home Visit Intervention Program for Targeting and Improving Long-term Care Services and Support for Veterans With High Needs and High Risk: Protocol for a Mixed Methods Feasibility Study.

Keeping older veterans with high needs and high risk (HNHR) who are at risk of long-term institutional care safely in their homes for as long as possible is a Department of Veterans Affairs priority. Older veterans with HNHR face disproportionate barriers and disparities to engaging in their care, including accessing care and services. Veterans with HNHR often have poor ability to maintain health owing to complicated unmet health and social needs. The use of peer support specialists (peers) is a promising approach to improving patient engagement and addressing unmet needs. The Peer-to-Patient-Aligned Care Team (Peer-to-PACT; P2P) intervention is a multicomponential home visit intervention designed to support older veterans with HNHR to age in place. Participants receive a peer-led home visit to identify unmet needs and home safety risks aligned with the age-friendly health system model; care coordination, health care system navigation, and linking to needed services and resources in collaboration with their PACT; and patient empowerment and coaching using Department of Veterans Affairs whole health principles. The primary aim of this study is to evaluate the preliminary effect of the P2P intervention on patient health care engagement. The second aim is to identify the number and types of needs and unmet needs as well as needs addressed using the P2P needs identification tool. The third aim is to evaluate the feasibility and acceptability of the P2P intervention delivered over 6 months. We will use a quantitative-qualitative convergent mixed methods approach to evaluate the P2P intervention outcomes. For our primary outcome, we will conduct an independent, 2-tailed, 2-sample t test to compare the means of the 6-month pre-post differences in the number of outpatient PACT encounters between the intervention and matched comparison groups. Qualitative data analysis will follow a structured rapid approach using deductive coding as well as the Consolidated Framework for Implementation Research. Study enrollment began in July 2020 and was completed in March 2022. Our sample size consists of 114 veterans: 38 (33.3%) P2P intervention participants and 76 (66.7%) matched comparison group participants. Study findings are expected to be published in late 2023. Peers may help bridge the gap between PACT providers and veterans with HNHR by evaluating veterans' needs outside of the clinic, summarizing identified unmet needs, and developing team-based solutions in partnership with the PACT. The home visit component of the intervention provides eyes in the home and may be a promising and innovative tool to improve patient engagement. DERR1-10.2196/46156.

Characteristics and Correlates of Ten-Year Trajectories of Posttraumatic Stress Symptoms in Older U.S. Military Veterans

ObjectivesTo examine the nature and correlates of 10-year trajectories of posttraumatic stress disorder (PTSD) symptoms in older U.S. military Veterans. Design and SettingA nationally representative web-based survey of older U.S. Veterans who participated in the National Health and Resilience in Veterans Study over 5 waves between 2011 and 2021. ParticipantsA total of 1,843 U.S. Veterans aged 50 and older (mean age = 67). MeasurementsPTSD symptoms were assessed using the PTSD Checklist. Self-report measures at baseline assessed sociodemographic characteristics; trauma exposures; psychiatric and substance use disorders; mental, cognitive, and physical functioning; and psychosocial factors including expectations of aging. Latent growth mixture modeling identified the nature and correlates of 10-year PTSD symptom trajectories. ResultsMost of the sample had no/low PTSD symptoms (88.7%), while 6.0% had consistently subthreshold symptoms, 2.7% consistently high symptoms, and 2.6% increasing symptoms. Relative to the no/low symptom group, the subthreshold and high symptom groups reported more medical conditions and cognitive difficulties, with younger age and more lifetime traumatic events additionally linked to the high symptom trajectory. Relative to the no/low symptom group, Veterans with increasing symptoms were more likely to report functional disability and lifetime nicotine use disorder, cognitive difficulties, negative expectations regarding physical and emotional aging, and traumatic events over the study period. ConclusionsDespite high rates of trauma exposure, most older Veterans do not evidence symptomatic PTSD trajectories; however, about 11% do. Results underscore the importance of assessing PTSD symptoms in this population and considering longitudinal trajectories as well as associated risk and protective factors.

Clinicopathologic features and outcomes associated with induction regimen intensity among older veterans with myeloma.

e20054 Background: More than one third of patients diagnosed with multiple myeloma (MM) are 75 years or older. Though registries and clinical trials have conveyed the disease features across myeloma patients and have confirmed improvement in outcomes with increasing number of frontline induction agents, older patients are disproportionately excluded from these studies. We sought to evaluate the disease characteristics and frontline (FL) induction treatment patterns among older Veterans. Methods: The VA’s Corporate Data Warehouse was queried to identify patients who (1) were diagnosed with MM between January 1, 2016 and December 31, 2019, (2) were 75 years or older at the time of diagnosis, and (3) received at least 1 induction regimen within the VA. Each unique record was reviewed in the VA’s Joint Legacy Viewer, an online platform collectivizing Veteran electronic charts nationwide. Data abstraction was performed to ascertain disease type, cytogenetics, stage, and characteristics of treatment regimen(s) by reviewing provider progress notes and treatment notes. Presence of del(17p), t(4;14), t(14;16), t(14;20), or gain 1q by FISH defined high-risk cytogenetics. Median composite progression-free survival (PFS), defined as the interval between date of FL induction initiation and the earliest date of second induction or death, was computed for Veterans based upon number of drugs in their FL induction regimens. Results: A total of 199 Veterans met selection criteria, with a mean age of 83.0 (SD 4.8) years at start of treatment. Of the 84 patients with documented cytogenetics, 44 (52.3%) had high-risk disease, and 6 (7.1%) had 2 or more deleterious cytogenetic findings. The majority (52.8%) of patients received only 1 induction regimen, and only 44 (22.1%) patients received maintenance therapy following frontline induction. 1 patient underwent autologous stem cell transplant, and 1 was referred for chimeric antigen receptor T-cell therapy. Within FL induction regimen, 104 (52.3%) received 2 drugs and 88 (44.2%) received 3 drugs. Induction therapy selection was unrelated to disease stage (p = 0.556) or cytogenetic risk (p = 0.335), but patients 80 years or older were more likely to receive 2-drug therapy (p = 0.012) than those between 75 and 79 years. No difference in median composite PFS was observed between patients receiving 2 drugs (10.1 [4.5 – 21.7] months) and those receiving 3 drugs (10.7 [5.0 – 20.3] months) (p = 0.733) in FL induction regimen. Conclusions: In a real-world study of older Veterans with MM bearing a high rate of high-risk cytogenetics, the median PFS with FL induction is only 10 months, but a more intensive FL 3-drug induction regimen is not more beneficial than a 2-drug. Less intense treatment planning is most reasonable for geriatric patients. Larger investigations evaluating cytogenetic results across Veterans with MM should be considered.

Frailty Trends in an Older Veteran Subpopulation 1 Year Prior and Into the COVID-19 Pandemic Using CAN Scores.

We studied the effects of the first year of the COVID-19 pandemic on frailty trends in a subset of older veterans at the Phoenix Veterans Affairs Health Care System. We identified 3538 and 6103 veterans aged 70 to 75 years as of February 8, 2019, with a calculated Care Assessment Need (CAN) score of ≥ 75 for 1-year mortality and hospitalization, respectively. After excluding veterans with insufficient 2020 and 2021 data, we compared the difference in 1-year mortality and hospitalization CAN scores from 2019 to 2020 with 2020 to 2021 using a paired t test. The difference in mean (SD) 1-year mortality CAN scores from 2020 to 2021 was 0.2 (13.4) when compared with the previous year's -4.9 (12.5) (P < .0001), indicating increased frailty. The difference in 1-year hospitalization CAN scores from 2020 to 2021 was -1.5 (12.0) when compared with the previous year's -2.8 (9.9) (P < .0001). Frailty in our veteran subpopulation as calculated by 1-year mortality CAN scores increased in the first year of the COVID-19 pandemic when compared with a recovering trend the previous year.

Association of frailty index of laboratory tests (FI-LAB) and COVID-19 clinical outcomes in veterans with cancer.

e24023 Background: Veterans with cancer have high COVID-19-attributable mortality. Frailty, a multisystem syndrome characterized by vulnerability to stressors from loss of physiological reserve, is common in cancer patients and confers worse clinical outcomes. In hospitalized cancer patients with COVID-19 infection, the role of frailty remains unclear. Our study aim was to compare clinical and utilization outcomes of cancer patients hospitalized with COVID-19 according to frailty status. Methods: The retrospective cohort study included hospitalized veterans with cancer and acute COVID-19 infection at 7 VA facilities in Florida and Puerto Rico from March-August 2020. Frailty was assessed using a 31-item frailty index of laboratory tests and vital signs (FI-LAB) with scores grouped by tertiles. We chart reviewed VA databases to collect Veterans’ socio-demographics, COVID-19 Polymerase Chain Reaction (PCR) results, and clinical and utilization outcomes. We ran binomial logistic regression analyses to calculate the odds of inpatient death, ICU admission, ICU transfer, prolonged length of stay, new nursing home placement, 30-day readmission, 30-day mortality, 6-month,1-year, and 2-year mortality according to the tertiles, adjusted for age, BMI, sex, race, ethnicity, and other conditions with greater risk for poor COVID-19 outcomes. Patients were followed until death or August 13, 2022. Results: 143 older Veterans with cancer were hospitalized with a mean age of 74.4 years (SD = 11.5) years, 95.9% (n = 117) male, 66.4% white (n = 81), and 9.8% (n = 12) Hispanic. 122 (85.3%) met the inclusion criteria. There were no differences in baseline sociodemographic or clinical characteristics except for a higher prevalence of congestive heart failure. The upper FI-LAB tertile had a higher risk of inpatient death, OR 12.47 (95%CI:1.3-121.4), p = 0.03, 30-day post-discharge mortality, OR 9.78 (95%CI:.21-79.4), p = .03 and 2-yr post-discharge mortality OR 4.9 (1.2-19.6) p &lt; 0.03. There were no differences in other clinical and utilization outcomes. Conclusions: In hospitalized Veterans with cancer and coexistent COVID-19 infection, patients with higher levels of frailty have a greater risk of inpatient death, 30-day post-discharge mortality, and 2-year post-discharge mortality. More studies are needed to confirm the utility of FI-LAB in hospitalized patients with COVID-19 and cancer.

The association between electrophysiological and neuropsychological measures and cardiovascular disease in patients with Alzheimer’s Disease dementia

AbstractBackgroundElectrophysiological and neuropsychological measures are useful markers of Alzheimer’s Disease (AD); however, it is still unclear how these measures relate to the cardiovascular profile of AD patients, and their influence on disease progression and management. Our study examined how electrophysiological and neuropsychological measures are associated with cardiovascular risk factors and the severity of small vessel disease among patients with AD dementia.MethodData were collected using a seven‐electrode COGNISION™ rig in 185 older veterans from the VA Boston Healthcare system memory disorders clinic. EEG/ERP data were recorded while participants completed a three‐tone auditory oddball task. All subjects were administered a neuropsychological battery composed of 8 subtests. Through review of medical history, we selected a subset of patients (N = 46) that met the following criteria: core clinical criteria for probable AD dementia, ≥ 65 years of age, and MMSE score between 20 and 26. We categorized these patients based on their number of cardiovascular risk factors—among hypertension, type 2 diabetes or prediabetes, hypercholesterolemia, and body mass index (BMI) ≥ 25 kg/m2 —and their small vessel disease severity (absent, mild, moderate, or severe). Spearman correlations were computed to assess the association of electrophysiological and neuropsychological measures with the number of cardiovascular risk factors and the severity of small vessel disease.ResultAlpha peak frequency was positively correlated with the number of cardiovascular risk factors (p = .011) and was inversely correlated with small vessel disease severity (p = .029). N100 standard latency was inversely correlated with small vessel disease severity (p = .018). Scores on the verbal phonemic fluency test were inversely correlated with the number of cardiovascular risk factors (p = .014), while scores on the verbal category fluency test were inversely correlated with small vessel disease severity (p = .023).ConclusionAlpha peak frequency, N100, and verbal fluency scores are associated with the number of cardiovascular risk factors and small vessel disease severity in AD patients. Overall, these electrophysiological and neuropsychological measures represent a clinical tool to help characterize the cardiovascular profile of patients with AD dementia, and its contribution to overall disease progression.

Exacerbated PTSD symptoms among older U.S. military veterans during the COVID-19 pandemic: Results from the national health and resilience in veterans study

Research has demonstrated that the impact of the coronavirus 2019 (COVID-19) pandemic on the mental health of United States (U.S.) veterans was less negative than originally anticipated. However, U.S. veterans are susceptible to exacerbation of post-traumatic stress disorder (PTSD) symptomology in late life. The aims of this study were to examine the extent to which older U.S. veterans experienced an exacerbation of PTSD symptoms during the COVID-19 pandemic, and to identify pre- and peri-pandemic factors that conferred risk for symptom exacerbation. Participants were U.S. military veterans aged 60 and older who completed three waves of the 2019–2022 National Health and Resilience in Veterans Study (NHRVS) (n=1858). PTSD symptoms were measured at all waves using the PTSD Checklist for DSM-5, and a latent growth mixture model was conducted to compute latent slopes of change of PTSD symptoms over the 3-year period. 159 (8.3%) participants experienced a worsening of PTSD symptomology over the pandemic period. Factors related to PTSD exacerbation were incident trauma exposure between Waves 1 and 2, more medical conditions with onset prior to the pandemic, and peri-pandemic social restriction stress. Number of incident traumas moderated the relationship between both number of pre-pandemic medical conditions and pre-pandemic social connectedness, and exacerbated PTSD symptoms. These results suggest that the pandemic did not confer additional risk for PTSD exacerbation than would be expected over a 3-year period for older veterans. Those who experience incident trauma exposure should be monitored for symptom exacerbation.

0096 Short sleep duration and poor sleep quality associated with elevated serum NfL and mild cognitive impairment in older Veterans

Abstract Introduction Ten percent of adults aged ≥ 65 and 50% of adults ≥ 85 years exhibit cognitive impairment. In addition, 50% of older adults experience poor sleep quality. Veterans are more vulnerable to sleep disturbances and potential cognitive impairment as long-term consequences of on-duty responsibilities, co-morbidities, and conditions such as post-traumatic stress disorder. Previous studies demonstrated a relationship between sleep and cognitive impairment through impaired glymphatic function and neurodegeneration. Biomarkers such as neurofilament light (NfL) are elevated in neurodegeneration and dementia. Here, we sought to investigate NfL levels in cognitive-intact older Veterans exhibiting poor sleep quality. Methods A cross-sectional study with eighteen Veterans aged 65-86 without a clinical diagnosis of dementia. Self-reported sleep quality was assessed with the Pittsburgh Sleep Quality Index (PSQI), while time in bed (TIB), and total sleep time (TST) were retrieved from Fitbit Charge. Cognitive function was evaluated with the St. Louis University Mental Status Exam (VA-SLUMS). We used an automated multiplex immunoassay system to identify dementia biomarkers using an enzyme-linked lectin assay. T-tests, one-way or two-way ANOVAs with Tukey’s post-hoc (with or without repeated measures) were used for the analysis. Results Participants were classified as good sleepers (PSQI&amp;gt;5) and poor sleepers (PSQI&amp;lt; 5). Poor sleepers spent less TIB (Fitbit 5.3h vs. 7.7h, p =0.001) and slept fewer hours (Fitbit 4.7h vs. 7.2h, p =0.001) when compared to good sleepers. Additionally, poor sleepers exhibited mild cognitive impairment (VA SLUMS 26.9, p, =0.01). Lastly, poor sleepers exhibited higher serum NfL (mean 66.7, p=0.04). Conclusion Poor sleep quality was associated with short sleep duration, mild cognitive impairment, and higher serum levels of NfL in older Veterans without a dementia diagnosis. Results may contribute to the early identification of dementia and sleep-centered treatment guidance. Further studies with more extensive and diverse samples are warranted before clinical recommendations. Support (if any) Carleara Weiss, Ph.D., MS, RN. 1K99AG079117-01 (PI), National Institute on Aging.

0536 Impact of Positive Airway Pressure Therapy on Clinical Outcomes in Older Veterans with Comorbid COPD and OSA: An Update

Abstract Introduction Cognitive impairment in older Veterans is an independent predictor of subsequent mortality and disability. Pilot data indicate that patients with OSA-COPD Overlap Syndrome (OVS) may have reduced sleep quality, cognitive function and quality of life (QoL). However, there are no prior systematic studies evaluating treatment paradigms in patients with OVS. Our ongoing clinical trial is investigating whether positive airway pressure (PAP) therapy alleviates sleep disturbances, sleepiness, and improves cognitive function and QoL in older adults with OVS. Methods The design is a prospective parallel group randomized controlled trial in Veterans 60 years and older, with moderate-to-severe OSA with concomitant COPD (OVS). 225 eligible participants will be randomized to two treatment groups (PAP and conservative care) in 2:1 ratio for a duration of 6 months. Participants on the conservative care arm are required to follow good sleep habits and sleep hygiene, and on the PAP arm, in addition, are required to be adherent to PAP treatment (CPAP or Bilevel PAP, as required). Sleep questionnaires are administered to evaluate sleepiness, sleep quality, and general and disease specific QoL. Cognitive function is evaluated using Trail Making Test Part A and B, Paced Auditory Serial Addition Test, Stroop Task, Digit Coding, Hopkins Verbal Learning Test-R, Weschler Abbreviated Scale Intelligence II, Weschler Memory Scale IV, and Psychomotor Vigilance Test, respectively. All tests are administered at baseline visit, 3 months, and 6 months. Results In year-2 of the study, we have screened 7878 Veterans, enrolled 137 participants, randomized 34 participants (31 males, 3 females; age: 70.7±6.6 years, BMI: 29.6±6.7 kg/m2, AHI: 47±22 events/hr, spirometry FEV1: 60.8±11.7% predicted, arterial blood gas (n=22) pCO2:41.2 ±3.6 mmHg, ESS: 1.9 ±2.4); 15 have completed the study per the protocol. Analysis of data will be completed at the end of the RCT. Conclusion Our research seeks to systematically study the effects of treating a novel target (OVS) to maximize daytime function and QoL, while also providing a framework for early treatment of mild cognitive impairment in vulnerable older Veterans. Support (if any) VHA RR&amp;D Merit Award # 1I01RX003124-01

Study protocol: Type III hybrid effectiveness-implementation study implementing Age-Friendly evidence-based practices in the VA to improve outcomes in older adults

BackgroundUnmet care needs among older adults accelerate cognitive and functional decline and increase medical harms, leading to poorer quality of life, more frequent hospitalizations, and premature nursing home admission. The Department of Veterans Affairs (VA) is invested in becoming an “Age-Friendly Health System” to better address four tenets associated with reduced harm and improved outcomes among the 4 million Veterans aged 65 and over receiving VA care. These four tenets focus on “4Ms” that are fundamental to the care of older adults, including (1) what Matters (ensuring that care is consistent with each person’s goals and preferences); (2) Medications (only using necessary medications and ensuring that they do not interfere with what matters, mobility, or mentation); (3) Mentation (preventing, identifying, treating, and managing dementia, depression, and delirium); and (4) Mobility (promoting safe movement to maintain function and independence). The Safer Aging through Geriatrics-Informed Evidence-Based Practices (SAGE) Quality Enhancement Research Initiative (QUERI) seeks to implement four evidence-based practices (EBPs) that have shown efficacy in addressing these core tenets of an “Age-Friendly Health System,” leading to reduced harm and improved outcomes in older adults.MethodsWe will implement four EBPs in 9 VA medical centers and associated outpatient clinics using a type III hybrid effectiveness-implementation stepped-wedge trial design. We selected four EBPs that align with Age-Friendly Health System principles: Surgical Pause, EMPOWER (Eliminating Medications Through Patient Ownership of End Results), TAP (Tailored Activities Program), and CAPABLE (Community Aging in Place – Advancing Better Living for Elders). Guided by the Pragmatic Robust Implementation and Sustainability Model (PRISM), we are comparing implementation as usual vs. active facilitation. Reach is our primary implementation outcome, while “facility-free days” is our primary effectiveness outcome across evidence-based practice interventions.DiscussionTo our knowledge, this is the first large-scale randomized effort to implement “Age-Friendly” aligned evidence-based practices. Understanding the barriers and facilitators to implementing these evidence-based practices is essential to successfully help shift current healthcare systems to become Age-Friendly. Effective implementation of this project will improve the care and outcomes of older Veterans and help them age safely within their communities.Trial registrationRegistered 05 May 2021, at ISRCTN #60,657,985.Reporting guidelinesStandards for Reporting Implementation Studies (see attached).

The Etiology of Abnormal TSH in Veterans Cared by a VA Medical Center – One High Serum Thyrotropin is Associated with Higher 5-Years Mortality

Objective: By analyzing the etiology of abnormal TSH in randomly selected veteran patients, we set our heart on improving future clinical care/management of the clinical/subclinical hyper- and hypothyroidism in the aging veteran population. Methods: A total of 1100 patients’ charts in alphabetical order were selected. Excluded cases of insufficient information, 897 patients’ charts were reviewed and analyzed for causes of abnormal TSH. Among them, 602 for the cause of low TSH (below 0.55 uU/mL) and 295 for high TSH (above 4.78 uU/mL) were reviewed retrospectively. Findings: Among the 1100 patients selected, 680 (61.8%) were 60 y or older (female=44, 6.8%); 420 were under 60 y (female=80, 19.0%); significantly more female patients were found in the younger age group (P&lt;0.001). After excluding patients with insufficient data, the most common cause of suppressed TSH is iodine-induced, CT iodinated contrast and betadine use caused 35.0% in the older group (n=126) compared to 23.6% in the younger group(n=57) (P = 0.027). The significant difference is that older veterans received more contrast CTs (P &lt; 0.05 compared to the younger group). In both age groups with concurrent FT4 study, we found four high FT4 among 90 studies, 4.4% overt hyperthyroidism. The second most common cause of suppressed TSH is due to thyroid hormone (TH) replacement in the older group (119 patients, 33.1%) with age &gt; 60y, significantly more frequent compared to the younger group, P&lt;0.001. There is significantly more overt hyperthyroidism, 27.8/%, than the iodine-load induced suppression of TSH, P&lt;0.001, due to 17 patients on TSH suppression therapy after total thyroidectomy for thyroid cancer. Among the 295 patients with elevated TSH, the most common cause of high TSH was due to hypothyroidism on T4 replacement: a total of 128 (59.3%) in the older group (N=216) is, similar to 47 (59.5%) in the younger group (N=79). In both age groups, there were 139 patients with concomitant FT4 measurement; 17 overt hypothyroidism were found, 12.2%. No significant difference is seen in the two age groups. The next most common causes of elevated TSH are CT contrast infusion, 23 (10.6%) in the older group and 7 (8.9%) in the younger group. We find high TSH is associated with a higher death rate of 101/238 (42.4%) in a 5-year follow-up (from 2016 to 2021), as compared to low TSH of 68/238 (28.6%), in the older age group, p&lt;0.03； both were significantly higher than the age- and sex-matched general US population, 19.7%, P&lt;0.01. Conclusion: Even though most, ~ 90%, were subclinical, the suppressed and elevated TSH are associated with severe consequences in CV/CNS and immune-suppression complications in aging veterans. Therefore, cautious use (and more frequent check of TSH) of TH replacement and CT contrast in aging veterans is recommended. The alarming increase in the 5-year death rate in older patients with elevated TSH deserves further study.

Co-occurring Medical Multimorbidity, Mental Illness, and Substance Use Disorders Among Older Criminal Legal System-Involved Veterans.

Older veterans involved in the criminal legal system (CLS) may have patterns of multimorbidity that place them at risk for poor health outcomes. To estimate the prevalence of medical multimorbidity (≥2 chronic medical diseases), substance use disorders (SUDs), and mental illness among CLS-involved veterans aged 50 and older. Using Veterans Health Administration health records, we estimated the prevalence of mental illness, SUD, medical multimorbidity, and the co-occurrence of these conditions among veterans by CLS involvement as indicated by Veterans Justice Programs encounters. Multivariable logistic regression models assessed the association between CLS involvement, the odds for each condition, and the co-occurrence of conditions. Veterans aged 50 and older who received services at Veterans Health Administration facilities in 2019 (n=4,669,447). Mental illness, SUD, medical multimorbidity. An estimated 0.5% (n=24,973) of veterans aged 50 and older had CLS involvement. For individual conditions, veterans with CLS involvement had a lower prevalence of medical multimorbidity compared with veterans without but had a higher prevalence of all mental illnesses and SUDs. After adjusting for demographic factors, CLS involvement remained associated with concurrent mental illness and SUD (adjusted odds ratio [aOR] 5.52, 95% CI=5.35-5.69), SUD and medical multimorbidity (aOR=2.09, 95% CI=2.04-2.15), mental illness and medical multimorbidity (aOR=1.04, 95% CI=1.01-1.06), and having all 3 simultaneously (aOR=2.42, 95% CI=2.35-2.49). Older veterans involved in the CLS are at high risk for co-occurring mental illness, SUDs, and medical multimorbidity, all of which require appropriate care and treatment. Integrated care rather than disease-specific care is imperative for this population.

Veterans' Experiences of Support in Managing Comorbid Sleep Apnea and Type 2 Diabetes.

Obstructive sleep apnea (OSA) is highly prevalent in patients with Type 2 diabetes, more so in veterans compared with nonveterans. Positive airway pressure is the recommended first-line treatment for OSA. However, adherence to both positive airway pressure and diabetes management regimens can be challenging for older adults. Support from family or friends may improve glucose control or sleep-apnea-related symptoms, yet the evidence is limited when both conditions coexist. This study aimed to describe veterans' experiences of support from family and friends with managing comorbid sleep apnea and Type 2 diabetes. We conducted a postal survey of older veterans with OSA and Type 2 diabetes from one healthcare system. Questions include demographic and health-related information, information about sleep apnea and diabetes treatment and education received, related support from family or a friend, perceived benefits of regular positive airway pressure device use on improving sleep health, and perceived benefits of education for family or a friend on sleep apnea and diabetes. Descriptive and bivariate analyses were performed. Of 145 respondents (mean age = 72 years), 43% reported receiving help for Type 2 diabetes from family or a friend. Almost two thirds of the respondents were currently using a positive airway pressure device, of whom 27% received support with device use from family or friends. About one third of veterans perceived family and friends receiving education on treating sleep apnea and diabetes to be very or extremely helpful. Such perceived benefit was higher among those who were married or identified as non-White. Veterans using a positive airway pressure device had lower hemoglobin A1c levels than nonusers. Veterans perceived that additional education for the individuals providing support would be beneficial. Future studies could address interventions to increase sleep apnea and Type 2 diabetes knowledge among families and friends of veterans with these comorbid conditions. In addition, patients' adherence to positive airway pressure may be enhanced by support from family and friends.

Meaningful Occupation and Resilience among Older U.S. Veterans: A Mixed Methods Study

Background Research on the factors that promote the health of older veterans is limited. Purpose To explore the relationships between military service, occupational participation, resilience and successful aging for older U.S. military veterans. Method A sequential explanatory mixed methods design was used, a survey (n = 41) and follow-up interviews (n = 9). Findings Occupational participation was associated with resilience (r = 0.60, p < .01). Three integrated themes emerged: (1) staying engaged & connected, (2) relationship between occupation and resilience, and (3) positive impact of military service. Conclusion Findings help fill the gap in research identifying intervention targets for older veterans. KEY MESSAGES The meaningful occupational participation of older veterans has received little attention in previous literature and is an important area of focus with strong relevance for occupational therapy Occupational therapy practitioners can play an important role in promoting the healthy aging and resilience of this population through occupation-based interventions

Caregiver Experience of Tele-dementia Care for Older Veterans.

For the 5 million persons living with dementia (PLWD) in the USA, telemedicine may improve access to specialty care from their homes. To elicit informal caregiver perceptions of tele-dementia care provided during COVID-19. Qualitative, observational study using grounded theory. Informal caregivers aged 18 + who cared for an older adult who received tele-dementia services at two major VA healthcare systems participated in 30-60-min semi-structured telephone interviews. Interviews were designed using Fortney's Access to Care model. Thirty caregivers (mean age = 67, SD = 12, 87% women) were interviewed. Five major themes were (1) Tele-dementia care avoids routine disruption and pre-visit stress; (2) Transportation barriers to in-person visits include not only travel logistics but navigating the sequelae of dementia and comorbid medical conditions. These include cognitive, behavioral, physical, and emotional challenges such as balance issues, incontinence, and agitation in traffic; (3) Tele-dementia care saves time and money and improves access to specialists; (4) Tele-dementia facilitated communication between caregiver and provider without hindering communication between PLWD and provider; and (5) Caregivers described ideal future dementia care as a combination of virtual and in-person modalities with in-home help, financial and medical support, and dementia-sensitive caregiver access. Caregivers interviewed saved 2.6h ± 1.5h (range: 0.5 to 6h) of travel time. Multiple caregivers described disruption of routines as difficult in PLWD and appreciated the limited preparation and immediate return to routine post telemedicine visit as positives. Caregivers found tele-dementia care convenient, comfortable, stress reducing, timesaving, and highly satisfactory. Caregivers would prefer a combination of in-person and telemedicine visits, with an opportunity to communicate with providers privately. This intervention prioritizes care for older Veterans with dementia who have high care needs and are at higher risk for hospitalization than their same age counterparts without dementia.

Suicidal Thoughts and Behaviors in Older U.S. Military Veterans: Results From the National Health and Resilience in Veterans Study

To identify the prevalence and correlates associated with suicidal thoughts and behaviors (STBs) in a nationally representative sample of older (55+) US military veterans. Data were analyzed from the 2019-2020 National Health and Resilience in Veterans Study (N=3,356; mean age=70.6). Self-report measures of past-year suicidal ideation (SI), lifetime suicide plan, lifetime suicide attempt(s), and future suicide intent were examined in relation to sociodemographic, neuropsychiatric, trauma, physical health, and protective factors. A total of 6.6% (95% CI=5.7%-7.8%) of the sample endorsed past-year SI, 4.1% (CI=3.3%-5.1%) a lifetime suicide plan, 1.8% (CI=1.4%-2.3%) a lifetime suicide attempt, and 0.9% (CI=0.5%-1.3%) future suicide intent. Higher levels of loneliness and lower levels of purpose in life were most strongly associated with past-year SI; lifetime history of major depressive disorder with suicide plan and suicide attempt; and frequency of past-year SI and more negative expectations regarding emotional aging with future suicide intent. These findings provide the most up-to-date nationally representative prevalence estimates of STBs among older military veterans in the United States. Several modifiable vulnerability factors were found to be associated with suicide risk in older US military veterans, suggesting that these factors may be targets for intervention in this population.