Same Patients, Different Health Care Systems—Revisited. Geriatric Care Models in the U.S., Canada, and Europe

Journal of the American Geriatrics Society · 2026-05-12

Health care systems differ worldwide, allowing learning from each other and improving care for older adults with similar clinical profiles. In the early 1990s, Dr. Howard Bergman and Dr. Mark Clarfield from Canada and Dr. Joseph Ouslander from the United States described the approach to care for the same patient in their respective health care systems. Yet, challenges identified then, such as limited access to geriatric medicine care, as well as multimorbidity and system constraints, remain relevant to the care of older adults today. This article revisits the original exercise summarizing the joint symposium of the America, Canadian, and European geriatric medicine societies, held at the 2025 European Geriatric Medicine Society (EuGMS) Congress in Iceland. Using the case of an 82-year-old woman with multimorbidity, frailty, and social vulnerability, experts examined how three systems would manage key aspects of care for this patient: Delirium prevention (U.S.), falls and rehabilitation (Canada), and medication optimization (Europe). Each presentation situated clinical priorities within broader systemic realities, including workforce shortages, care fragmentation, and policy challenges. Emerging models, such as Age-Friendly Health Systems and the Hospital Elder Life Program in the U.S., Acute Care for the Elderly units and Geriatric Rehabilitation Units in Canada and structured medication review initiatives in Europe, illustrate innovations and persistent gaps. By contrasting clinical strategies and organizational structures, this analysis identifies transferable best practices and policy levers to improve geriatric medicine care globally. Recommendations emphasize harmonizing geriatric expertise, embedding evidence-based interventions, and fostering cross-system learning to optimize outcomes for older adults.

Robust immune cell infiltration and macrophage senescence occur within a week of recovery after limb immobilization in older adult skeletal muscle

The Journal of Physiology · 2026-03-27

Abstract Immune cells are critical for modulating inflammation and extracellular matrix remodelling for effective muscle regrowth following disuse atrophy. However, disrupted macrophage function and accumulation of cellular senescence may limit muscle recovery in ageing. The present study aimed to compare changes in the cellular dynamics of muscle macrophages, cellular senescence and collagen content during early recovery following 14 days of unilateral limb immobilization in young ( n = 18; ∼24 years) and older male and female adults ( n = 18; ∼69 years). Participants underwent 14 days of immobilization followed by 7 days of re‐ambulation. Muscle biopsies were collected at baseline, post‐immobilization, and at 2 and 7 days of recovery. During re‐ambulation, older adults exhibited elevated immune cell infiltration (haematoxylin and eosin, CD45 + ), higher CD68 + CD206 + macrophage content and greater muscle collagen deposition (Sirius Red) compared to their young counterpart. Furthermore, cellular senescence (SA‐β‐galactosidase + ) was elevated, including a high number of macrophages co‐labelled with p21 in older skeletal muscle during recovery. At 7 days of recovery, the amount of macrophage infiltration was positively associated with cellular senescence, whereas the senescent macrophage cell population was significantly correlated to the Sirius Red percent area. Our findings suggest that an age‐altered immune cell response and the accumulation of senescent macrophages may disrupt collagen remodelling during early muscle recovery following disuse. image Key points Age‐related impairments in muscle recovery following disuse remain a significant challenge. Immune cells, particularly macrophages, play critical role in muscle remodelling. Muscle macrophage characteristics during the early phase of recovery following disuse in older adults remain unclear. We compared changes in immune cell content, cellular dynamics, cellular senescence, and collagen content during recovery (2 days and 7 days) following 14 days unilateral limb immobilization in young (18–35 years) and older male and female adults (≥60 years). During muscle recovery, older adults ( vs . young), increased muscle collagen content concurrent with an infiltration of macrophages. This response was characterized by a distinct predominance of CD68 + CD206 + macrophages and a parallel increase in senescent macrophages. Our findings suggest that an altered immune cell response and accumulation of senescent macrophages may disrupt tissue remodelling during muscle recovery in aged muscle.

Arterial Stiffness Mechanisms and Orthostatic Hypotension in SPRINT

JACC Advances · 2026-04-11

BACKGROUND: Hypertension is a leading cardiovascular disease risk factor. Intensive blood pressure (BP) control reduces cardiovascular disease events but may be limited by treatment-related serious adverse events (SAEs). OBJECTIVES: The purpose of this study was to determine if baseline carotid to femoral pulse wave velocity (PWV)-including the component of structural stiffening, due to remodeling of the vessel wall, and load-dependent stiffening, due to the BP load on the arterial wall-is independently associated with orthostatic hypotension (OH) and SAEs in the SPRINT (Systolic Blood Pressure Intervention Trial). METHODS: SPRINT compared intensive (<120 mm Hg) vs standard (<140 mm Hg) systolic BP goals. Carotid-femoral PWV was measured in 642 participants at baseline. Structural stiffening and load-dependent stiffening were calculated by adjusting PWV to a 120/80 mm Hg reference BP with participant-specific models. The association of PWV with OH and with other SAEs was assessed using negative binomial regression. RESULTS: Over a 3.0-year median follow-up, the cumulative SAE incidence was 38.7% in the intensive group and 35.1% in the standard group. OH was the most frequent event (27.0% standard; 24.4% intensive). Higher load-dependent PWV was associated with greater numbers of OH events (P = 0.005) regardless of treatment group. Higher total PWV was associated with greater rates of SAEs (P = 0.001) and this was largely driven by the association with load-dependent PWV (P < 0.001). CONCLUSIONS: Load-dependent stiffness is associated with SAEs, including OH, regardless of BP treatment intensity. Load-dependent PWV may serve as a valuable clinical tool to identify patients who require enhanced surveillance before initiating intensive BP treatment. (Systolic Blood Pressure Intervention Trial SPRINT]; NCT01206062).

Targeted Nrf2 activation improves vascular endothelial function with aging and prevents vascular dysfunction following disuse in younger and older adults

Free Radical Biology and Medicine · 2026-05-01

Aging and physical inactivity/disuse contribute to cardiovascular disease, which is attributable, in part, to vascular endothelial dysfunction associated with impaired nuclear-factor erythroid 2-related factor 2 (Nrf2) signaling. However, the ability to augment Nrf2 activation and its effects on age- and disuse-related vascular dysfunction in humans remains limited. In a double-blind, randomized, placebo-controlled study design 20 younger adults (8M/12F, age 27±7 y) and 24 older adults (12M/12F, age 67±8 y) were randomized to receive either placebo or PB125 (200 mg/day, Nrf2 activator) across three visits: baseline, 2 weeks of supplementation, and following either 5 days of bed rest (old) or 2 weeks of limb immobilization (young). Brachial and popliteal artery flow-mediated dilation (FMD), passive leg movement-induced (PLM) leg blood flow (LBF) and vascular conductance (LVC) and serum antioxidant status (superoxide dismutase, SOD) were assessed at each timepoint. Compared to placebo, 2 weeks of PB125 increased brachial (PB125: 2.8±1.5 to 3.8±1.3%, p<0.0001) and popliteal FMD (PB125: 1.5±1.5 to 2.3±1.4%, p=0.033) in older, but not younger adults (both, p>0.27). During bed rest, PB125 preserved brachial (3.8±1.3 to 3.6±1.4%, p=0.543) and popliteal FMD (2.3±1.4 to 2.7±1.4%, p=0.269), LVC (1.1±0.8 to 1.1±1.5 AUC, p=0.530) and circulating SOD concentrations (28.3±7.2 to 28.6±8.6 U/mL, p=0.888) in older adults compared to placebo (all, p<0.05). Following limb immobilization, PB125 preserved popliteal FMD (4.4±2.8 to 3.4±1.8%, p=0.302) in younger adults compared to placebo (p<0.05). These findings demonstrate targeted Nrf2 activation with PB125 improves age-related vascular endothelial dysfunction while preserving vascular function and antioxidant capacity following periods of disuse.

The surgeon's role in optimizing elective surgical care for older adults: Perspectives of outpatient geriatricians

Current Problems in Surgery · 2025-04-08

Effects of Blood Pressure Control on Arterial Stiffness Mechanisms in SPRINT: A Randomized Controlled Trial

Hypertension · 2025-04-22 · 10 citations

BACKGROUND: The longitudinal impact of blood pressure (BP) control on the components of arterial stiffness has not been studied. METHODS: The SPRINT (Systolic BP Intervention Trial) compared an intensive systolic BP goal (&lt;120 mm Hg) to a standard goal (&lt;140 mm Hg). Carotid-femoral pulse wave velocity (PWV) was measured in a subset of participants (n=605) at 0, 1, 2, and 3 years after randomization. Structural stiffening due to remodeling of the vessel wall and load‐dependent stiffening, from changes in BP, were calculated by adjusting PWV to a 120/80 mm Hg reference BP with participant‐specific models. The effect of intensive BP control on BP and arterial stiffness components over time was evaluated using generalized least squares regression. RESULTS: Intensive BP control slowed the progression of PWV (total stiffness) compared with standard BP control at 3-year follow-up (−0.49 [−0.02 to −0.96] m/s, P =0.042). Differences in total stiffness between treatment groups over 3 years of follow-up were driven by intensive BP control reducing load-dependent PWV (−0.71 [−0.58 to −0.85] m/s, P &lt;0.001), not structural PWV (+0.20 [−0.26 to +0.66], P =0.40). Load-dependent PWV was lower in the intensive treatment group at 1 year and remained lower throughout the follow-up. In contrast, structural PWV was similar between the 2 groups and increased throughout the follow-up period. CONCLUSIONS: Intensive BP control slowed the progression of total arterial stiffness by decreasing load-dependent stiffness, but not through reduced structural stiffness. Future investigations are needed to determine if load-dependent PWV may have potential utility as a biomarker to monitor the efficacy of treatment and guide BP management strategies. REGISTRATION: URL: https://www.clinicaltrials.gov ; Unique identifier: NCT01206062.

Abstract 4369002: Blood Pressure Variability and Implications for Trial Screening

Circulation · 2025-11-03

Background: Blood pressure (BP) is a dynamic measure influenced by contextual and behavioral factors, with well-established evidence showing notable differences between office (OBP) and home (HBP) measurements . While OBP is often used to diagnose and manage hypertension and can be also used to identify eligible patients for clinical trials to enhance trial pragmatism through efficient use of electronic health records, caution is warranted against relying on a single OBP measurement for participant screening. In this study, we explored explanatory factors that associated with BP variability. Hypothesis: We hypothesize that OBP and HBP will vary, and that variability cannot be explained by change in anti-hypertensives alone. Methods: We compared OBP and HBP for 1000 patients above age 65 from two health systems participating in an NIH funded pragmatic, hybrid effectiveness implementation study. Patients were identified using a pragmatic recruitment strategy based on OBP. BP variability was defined as the SBP difference (i.e. SBP between qualifying OBP and baseline HBP) and further grouped into low (SBP less than 10 mmHg), moderate (SBP between 10 - 20 mmHg), and high (SBP more than 20 mmHg). We also examined changes in anti-hypertensives or their doses that could contribute to the BP variability. Results: The study cohort had a mean (SD) age of 73.3 (5.6), with 61% female, 88% White, 10% Black and 2% Hispanic participants. The mean (sd) baseline DBP and SBP was 135 (17) mmHg, and 70 (16) bpm, respectively. The median (Q1, Q3) run-in period was 13 (8, 20) days between eligibility OBP and baseline visit with an HBP. 285, 292, 423 participants had low (0 – 10), moderate (10 – 20), and high (&gt; 20) BP variability. Among those with moderate to high BP variability, 54 (8%) increased the use of antihypertensives (AHT) during the run-in period. In addition, female sex [1.62 (1.23 – 2.12)], low OBP [1.07 (1.05 – 1.08)], vision deficit [1.35 (1.01 – 1.81)], valvular disease [1.51 (1.03 – 2.21)] and smoking [0.50 (0.28 – 0.87)] are shown to be significantly associated with high BP variability. Conclusion: These analyses highlight the substantial variability in BP readings in the same person and offers critical insights to inform the design of robust pragmatic trials in hypertension research. For screening for enrollment in clinical trials, multiple HBP readings, may be better than a single OBP reading.

Diverticulitis in Older Adults: A Review of Etiology, Diagnosis, and Management

Journal of the American Geriatrics Society · 2025-02-08 · 6 citations

BACKGROUND: Diverticulitis accounts for over 300,000 hospitalizations annually in the United States and its incidence increases with age. Among older adults, diverticulitis is the fourth leading cause for emergency surgery. Older adults with multimorbidity and geriatric syndromes are often excluded from clinical studies, leaving a gap in the evidence needed to guide management. Here, we provide a clinically oriented review of the diagnosis and management of older adults with diverticulitis through the lens of age-friendly care. METHODS AND RESULTS: We reviewed the literature describing the epidemiology, diagnosis, management, and prevention of diverticulitis in older adults. Due to age-related physiologic changes, the presence of geriatric syndromes, and multimorbidity, older adults with diverticulitis often present with atypical symptoms, variable laboratory findings, and are at higher risk for complications than younger patients. Guidelines support a more aggressive approach to diagnosis in this population, with lower threshold for obtaining diagnostic imaging. Antibiotics remain a mainstay of treatment for uncomplicated disease, and surgical management should be focused on severity of disease and the balance between the likelihood of improving quality of life and risks and burden of treatment. CONCLUSIONS: Diverticulitis is a common disease that has a unique presentation among older individuals with limited evidence to guide management. Diagnosis and treatment should focus on what matters most to the patient, providing the most meaningful outcome possible within the context of multimorbidity, patient goals, symptom burden, and anticipated treatment outcomes.

Changes in Arterial Stiffness Under Blood Pressure Control are Independently Associated with Cognitive Impairment: The Systolic Blood Pressure Intervention Trial (SPRINT)

Alzheimer s & Dementia · 2025-12-01

BACKGROUND: Arterial stiffness is implicated in the development of Alzheimer's disease and related dementias. The effect of intensive blood pressure control on changing arterial stiffness parameters and their associations with cognitive impairment remains unclear. METHOD: SPRINT evaluated the effect of intensive versus standard blood pressure control (SBP<120mmHg versus SBP<140 mmHg) on time to cognitive impairment. Arterial stiffness was assessed in a subset of participants by total carotid-femoral pulse wave velocity (T-PWV, in m/s) at baseline and years 1-3. Age-related structural stiffening (S-PWV, due to vessel wall remodeling) and load-dependent stiffening (LD-PWV, due to changes in BP over the cardiac cycle) were calculated by adjusting T-PWV to a 120/80 mmHg reference with participant-specific models. Cognitive impairment was assessed by repeated testing over 10 years with adjudication of Mild Cognitive Impairment (MCI) or Probable Dementia (PD) as a composite outcome. Time to incident cognitive impairment was estimated as hazard ratios (HR) and 95% Confidence Intervals (95%CI) using Cox proportional hazards for baseline stiffness and Joint Longitudinal Survival Models for changes in stiffness over time adjusted for treatment arm, demographics (age, race, sex, education), baseline mean arterial pressure, and heterogeneous effects of intensive BP control. RESULT: A total of 611 participants (72±9 years old, 40% women, 70% White) had T-PWV and time to event data resulting in 90 composite MCI (n = 62) and PD (n = 28) events over a median follow-up of 6.2 years. Each m/s higher baseline T-PWV and S-PWV was significantly associated with a 10% increase in the hazards for developing incident cognitive impairment independent of treatment arm but was attenuated by adjustment for demographics (Table 1). LD-PWV declined with intensive SBP control, while T-PWV and S-PWV increased over the 3-year study treatment period (Figure 1). Intensive treatment-related declines in LD-PWV were associated a 21% reduction [HR(95%CI) = 0.79(0.61-1.00] in the risk for cognitive impairment adjusted for demographics (Table 2). No heterogeneous treatment effects based on T-PWV, S-PWV, or LD-PWV were detected. CONCLUSION: Components of arterial stiffness are associated with incident cognitive impairment independent of BP control. Arterial stiffness remains an unaddressed risk factor for cognitive impairment and potential target for dementia prevention.

Rates of new indication for antithrombotic drugs in people with cognitive impairment: implications for anti‐amyloid monoclonal antibody treatment

Alzheimer s & Dementia · 2025-12-01

BACKGROUND: Anti-amyloid monoclonal antibody treatments may interact with anticoagulants and thrombolytics to increase the risk of intracranial hemorrhage (ICH). Expert guidance advises against co-prescribing antithrombotic drugs due to increased ICH risk. However, because new cardiovascular diagnoses are common in older adults, some people may develop an indication for anticoagulant or thrombolytic therapy during an anti-amyloid treatment course. Our goal was to estimate how many people with mild cognitive impairment (MCI) or dementia develop a new condition for which antithrombotic therapy is indicated. METHOD: We conducted a longitudinal cohort study using the nationally representative Health and Retirement Study (HRS) data (2010-2020). We included adults aged ≥65 years who consented to Medicare claims linkage and had no indication for anticoagulants in the 12 months prior to a baseline interview. Participants' cognition was categorized as normal, MCI (defined in HRS as mild or moderate cognitive impairment without dementia), or dementia. We fit Fine-Gray survival models accounting for competing risk of death to estimate the 1-year incidence of atrial fibrillation (AF), deep vein thrombosis (DVT) or pulmonary embolism (PE), acute myocardial infarction (MI), stroke, and new anticoagulant prescriptions. Separate models were fit for each outcome, and models used a robust sandwich estimator to account for repeated observations. RESULT: The study included 22,373 participants (Table; median age 71 years, 59% female). Among participants with MCI, the 1-year incidence was 1.7% for AF, 1.2% for DVT, 0.4% for PE, 1.2% for AMI, 2.0% for stroke, and 2.2% for new anticoagulant prescription (Figure). Overall, the 1-year likelihood of developing a new indication for anticoagulants or thrombolytics for any reason was 6.9%. Among participants with dementia, 1-year rates were 1.7% for AF, 1.8% for DVT, 0.3% for PE, 1.0% for AMI, 2.4% for stroke, 1.9% for new anticoagulant prescription, and 7.6% for any indication. CONCLUSION: In this national sample of people with MCI or dementia, over 1 year, 7-8% of people were newly diagnosed with a cardiovascular disease requiring antithrombotic therapy. The risk of developing a condition for which anticoagulants or thrombolytics are indicated should be incorporated into discussions about anti-amyloid treatment to enhance shared decision-making.