Journal of the American Geriatrics Society (JAGS):
ARTICLES PUBLISHED (between 2000 & 2015)WHICH ARE OF GRET IMPORTANCE TO SENIORS
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Online Version of Record published before inclusion in an issue
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.)
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. 
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. 
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
Potentially Avoidable Hospitalizations of Nursing Home Residents: Frequency, Causes and Costs. Ouslander JG et al. 2010;58:627–635. 
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
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. 
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.
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. 
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
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.
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
Reducing Delirium After Hip Fracture: A Randomized Trial. Marcantonio ER et al. 2001;49:516–522. 
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. 
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. 
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. 
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. 
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. 
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. 
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. 
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 frailty1 were randomized to an exercise intervention (ET) or low-intensity home exercise (control group) for 9 months. ET began with 3 months of flexibility, light-resistance, and balance training. During the next 3 months, resistance training was added, and during the last 3 months, endurance training was added. ET resulted in significantly greater improvements than home exercise in three of the four primary outcome measures: a physical performance battery, a functional status questionnaire, and peak oxygen intake.
Effect on Current Practice: This may be the first study to provide evidence of the efficacy of a multidimensional high-intensity training regimen in reducing frailty and improving oxygen uptake in frail community-dwelling people.
Research Agenda for Frailty in Older Adults: Toward a Better Understanding of Physiology and Etiology: Summary from the American Geriatrics Society/National Institute on Aging Research Conference on Frailty in Older Adults. Walston J et al. 2006;54:991–1001. 
Study Objective: To report on the results of the 2004 American Geriatrics Society/National Institute on Aging conference on a research agenda on frailty in older adults.
Relevance: The conference focused on evolving conceptualizations and definitions of frailty; physiological underpinnings of frailty, including the potential contributions of inflammatory, endocrine, skeletal muscle, and neurological system changes; potential molecular and genetic contributors; proposed animal models; and integrative, system biology approaches that may help to facilitate research. Several specific recommendations as to future directions were also developed, including recommendations on definition and phenotype development, methodological development to perform clinical studies of individual-system and multiple-system vulnerability to stressors, development of animal and cellular models, application of population-based studies to frailty research, and development of large collaborative networks in which populations and resources can be shared.
Effect on Current Practice: Many of the conference recommendations and concepts have led to the multitude of research studies that have better defined frailty and its consequences and translated into implementation (although limited) in clinical practice. (For example, see next article summary on frailty by Theou O et al.)
Operationalization of Frailty Using Eight Commonly Used Scales and Comparison of Their Ability to Predict All-Cause Mortality. Theou O et al. 2013;61:1537–1551. 
Study Objective: To evaluate eight frailty scales and compare their validity, feasibility, prevalence estimates of frailty, and ability to predict all-cause mortality.
Relevance: Frailty scales were the Groningen Frailty Indicator, Tilburg Frailty Indicator, 70-item Frailty Index (FI), 44-item FI based on a Comprehensive Geriatric Assessment (FI-CGA), Clinical Frailty Scale, Frailty Phenotype (weighted and unweighted versions), Edmonton Frail Scale, and the FRAIL scale. Substantive differences were found between scales in their content validity, feasibility, and ability to predict all-cause mortality. The major finding is that these frailty scales capture related but distinct groups of older persons.
Effect on Current Practice: Over time, frailty scales are increasingly 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 disability.
Delirium Is Independently Associated with Poor Functional Recovery After Hip Fracture. Marcantonio ER et al. 2000;48:618–624. 
Study Objective: To define the role of delirium in poor functional outcomes.
Relevance: After adjusting for age, preexisting cognitive and functional impairment, and comorbidity, delirium remained an independent risk factor for decline in activities of daily living, ambulatory decline, and death or new nursing home placement at 1 month. Moreover, participants with persistent delirium at 1 month had worse outcomes than those whose delirium resolved.
Effect on Current Practice: This was one of the first studies to demonstrate the importance of delirium in functional recovery after hospitalization. Screening for delirium after surgery in older adults is now common practice.
The Optimizing Patient Transfers, Impacting Medical Quality, and Improving Symptoms: Transforming Institutional Care Approach: Preliminary Data from the Implementation of a Centers for Medicare and Medicaid Services Nursing Facility Demonstration Project. Unroe KT et al. 2015;63:165–169. 
Study Objective: To describe a preliminary report on the Optimizing Patient Transfers, Impacting Medical Quality, and Improving Symptoms: Transforming Institutional Care (OPTIMISTIC) project.
Relevance: This is one of seven projects that the Centers for Medicare and Medicaid Services (CMS) has funded to test interventions to reduce avoidable hospitalizations of long-stay nursing facility residents. The study places a registered nurse in each facility to implement an evidence-based quality improvement program with clinical support from nurse practitioners. Important elements include better medical care through implementation of the Interventions to Reduce Acute Care Transfers tools and chronic care management, enhanced transitional care, and better palliative care with a focus on systematic advance care planning. Root-cause analyses were performed for 910 acute transfers. The project registered nurse evaluated 29% as avoidable transfers, and opportunities for quality improvement were identified in 54%. Lessons learned included defining new clinical roles, integrating quality improvement principles into facility culture, managing competing priorities, communicating with multiple stakeholders, and developing a system for collecting and managing data.
Effect on Current Practice: The success of OPTIMISTIC and other similar interventions in the CMS initiative has resulted in a second round of funding to build on these interventions that will improve care and save billions of dollars over the next decade.
During the past 15 years (2000–2015), remarkable progress has been made toward improving the health and quality of life of older adults, largely through carefully designed and implemented research studies. In going through this exercise of attempting to identify the studies published in JAGS that have the greatest influence on improving clinical care delivery and achieving desirable health outcomes in older adults, it is apparent that the field of aging (geriatrics, gerontology, long-term care) has rapidly matured and become a major discipline in the public and personal health of older adults. The major (but not only) health concerns of older adults, particularly as they age into their eighth and ninth decades of life, are concerns about cognitive impairment, physical disabilities and functional incapacity, medications, and increasing vulnerability to aging-related and disease-related disorders and their effects on health outcomes.
In this review, of the top 20 JAGS articles, five articles were focused on various aspects of cognition (delirium, cognitive assessment and training), five were about physical disabilities (function, performance, falls), three discussed frailty, two were about medications, and two discussed hospitalization and transitional care. Not surprisingly, these top 20 research studies address the major concerns of our older population.
Despite these successes in addressing health concerns, finding therapeutic interventions, and implementing potential preventive measures for the above major health concerns, the field of aging still has monumental challenges in the area of health of older adults. We have yet to identify causes of, treatments for, and how to prevent dementing diseases and other cognitive disorders; adequately manage multimorbidity, frailty, and a variety of infectious diseases; decrease polypharmacy and drug interactions; reduce falls and unnecessary, repeated, lengthy hospitalizations; and mitigate the prevalence and complications of age-related diseases such as heart disease, stroke, cancer, diabetes mellitus, chronic obstructive lung disease, arthritis, hypertension, osteoporosis, kidney failure, and mental health disorders such as depression.
As the field of aging has matured, JAGS has gained successes through its publication toward improving the health and well-being of older adults these past 15 years. We certainly hope the next 15 years will be as productive and yielding of improved healthcare practices, models, and systems of care to achieve our stated goals.
The opinions expressed by the authors are not necessarily those of the U.S. Department of Veterans Affairs.
Conflicts of Interest: All three authors receive a stipend from the American Geriatrics Society in their role as editors of JAGS. The authors have no other conflicts of interest to disclose relevant to this article.
Authors Contributions: All three authors contributed equally to this manuscript. The authors thank Ms. Jennifer English of Wiley-Blackwell for providing the spreadsheet data of the top 10 published JAGS articles as cited by other journals from 2000 to 2015. We also thank Ms. Mary Jordan Samuel of the American Geriatrics Society for collating and organizing the spreadsheet data for each year, contacting the JAGS editors for their specific ranking of the articles, and tabulating the ranking of articles based on the votes submitted by the editors.
Sponsor's Role: The American Geriatrics Society and Wiley-Blackwell had no role in the determining the final outcomes and decisions relevant to this manuscript.
Criteria for physical frailty: presence of two of three of the following parameters: 1) Modified Physical Performance Test score between 18 and 32, 2) Peak oxygen uptake between 10 and 18 mL/kg per min, or 3) Self-report of difficulty or assistance with one activity of daily living or two instrumental activities of daily living.