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AGS 2021 Offers a Chance for Reflection

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The American Geriatrics Society (AGS) 2021 Annual Meeting took place virtually from May 12–15. Dr. Joseph Shega, MD, program chair, framed the meeting’s objective in his introduction as an opportunity to reflect on how COVID-19, structural racism, and ageism have impacted the care of older adults. He also championed the importance of interdisciplinary teams, eliciting personal care goals, and treating older people as whole persons.

In a session entitled “Lessons from a Pandemic,” Dr. Jasmine L. Travers, Assistant Professor of nursing at NYU Rory Meyers College Nursing, described how we could and should work to dismantle the structural inequities that led to aging-related disparities from COVID-19. She outlined how to detect and address inequities at the system, community, institutional, inter-and intra-personal level. She highlighted in a powerful illustration the nine-year difference in life expectancy between neighborhoods in Manhattan 4.5 miles apart. Dr. Timothy W. Farrell, Associate Professor at the University of Utah School of Medicine, outlined how structural inequities at national, state, and local levels, are impacting the national effort to vaccinate 2 million homebound older adults. In contrast to these challenges, these speakers both hope for and create a future roadmap by highlighting examples of local communities that have successfully addressed and overcome structural inequities. Common themes in these success stories included: acknowledging inequities, directing investment to underserved communities, building trust through the engagement of local leaders, and fostering a culture of transparency, communication, and accountability. Dr. Travers shared a quote from Dr. Maureen Bell of Howard University Hospital that summarized the goal of such endeavors; “As a country, as a community, we are only as healthy as the most vulnerable among us.”

A popular session each year is the Geriatrics Literature Update led by Drs. Eric Widera, Kenneth Covinsky, and Alexander Smith, all from the University of California at San Francisco. They reviewed journal articles from January 2019 to December 2020 and discussed each article in an amusing and theatrical yet scientific manner. The AGS attendee carefully pays attention to these articles as they are selected based on their potential for impacting and altering the clinical care of older adults. In our opinion, two themes were particularly notable. The first was the push to move away from age-based decision-making to using functional status and frailty assessments to decide the appropriateness of specific interventions. Panagiotou et al., 2020 evaluated the risk factors associated with all-cause, 30-day mortality in nursing home residents with symptomatic COVID-19. The findings in a cohort of 5,256 individuals found that persons with minimal functional impairment had a 5% risk of death at 30 days, while those with severe functional impairment had a 44% risk of death in the same time period. A secondary analysis of a large-scale hypertension trial, the SPRINT MIND trial, evaluated the effect of intensive vs. standard blood pressure control on the risk of developing probable dementia. Treating to a systolic blood pressure goal of < 120 mmHg compared to a goal of <140 mmHg did not result in a significant reduction in the risk of probable dementia (7.2 vs. 8.6 cases per 1000 person-year; hazard ratio [HR], 0.83; 95% CI, 0.67-1.04). In a secondary analysis of the same study that was limited to adults aged 80+ years, intensive BP control (target SBP < 120) lowered the risk of major adverse cardiovascular events, mild cognitive impairment, and death. There were limitations in both of these studies, but the combination suggested that while older adults may benefit from more intensive BP control, decisions should be made based on baseline functional status and patient priorities rather than age alone. Finally, Kim et al., 2019 evaluated changes in functional status in patients one year after aortic valve replacement (AVR) and found that AVR seldom restores independent function. The functional status at one year post-procedure was determined primarily by the pre-procedure function.

Aligned with the importance of person-centered care, this session, along with others presentations during the conference, strongly urged attendees to push back against the oft-repeated dogma that there are no effective treatments available for patients with dementia. Two key studies focused on the high cost countered by the equivocal results of using a PET scan to aid in the diagnosis and management in patients with dementia of unclear etiology, and Aducanumb, an anti-amyloid drug for patients with Alzheimer’s. In contrast, The Care Ecosystem Randomized Clinical Trial and The Capable Study both demonstrated the positive impact of team-based supportive interventions on the quality of life of patients with dementia and their caregivers. These non-pharmacological interventions also demonstrated reductions in emergency room use, caregiver depression, and functional decline. Relative to diagnostics and therapeutics that are being studied in recent trials, these interventions are cheap and remarkably effective. The reviewers posited, if these interventions were a drug, would they have more extensive uptake?

There were many other highlights that are too numerous to mention here but, we would be remiss if we did not mention two more high points. In the “Yoshikawa outstanding scientific achievement for clinical investigation award lecture,” Dr. Alexander Smith of UCSF outlined the benefits of focusing on multiple distinct areas throughout an academic career as opposed to a narrow focus promoted by the “inch-wide, mile-deep” approach and finally, despite the virtual format there were many networking opportunities, particularly during the interactive poster sessions and the special interest virtual meetings.

Image by Victoria Sergeeva / Shutterstock

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