Faculty Bibliography

The objective of the study is to identify healthcare events leading to a diagnosis of dementia from a large real-world dataset. This study uses a data-driven approach to identify temporally ordered pairs and trajectories of healthcare codes in the electronic health record (EHR). This allows for discovery of novel temporal risk factors leading to an outcome of interest that may otherwise be unobvious. We identified several known (Down syndrome RR = 116.1, thiamine deficiency RR = 76.1, and Parkinson's disease RR = 41.1) and unknown (Brief psychotic disorder RR = 68.6, Toxic effect of metals RR = 40.4, and Schizoaffective disorders RR = 40.0) factors for a specific dementia diagnosis. The associations with the greatest risk for any dementia diagnosis were found to be primarily related to mental health (Brief psychotic disorder RR = 266.5, Dissociative and conversion disorders RR = 169.8), or neurologic conditions or procedures (Dystonia RR = 121.9, Lumbar Puncture RR = 119.0). Trajectory and clustering analysis identified factors related to cerebrovascular disorders, as well as diagnoses which increase the risk of toxic imbalances. The results of this study have the ability to provide valuable insights into potential patient progression towards dementia and improve recognition of patients at risk for developing dementia.

A 65-year-old woman with type II diabetes mellitus complicated by non-healing ulcers with recurrent osteomyelitis was admitted for progression of cellulitis after treatment failure with an outpatient course of amoxicillin-clavulanate. She was found to have persistent osteomyelitis and started on ceftazidime for a culture documented Pseudomonas aeruginosa infection. After two parenteral doses, she had a rapid rise in liver function tests (LFTs) in a hepatocellular pattern. Due to rapid identification, all medications with potential hepatotoxicity, including ceftazidime, were discontinued and the LFTs promptly returned to baseline over 3 days. Of note, the patient did not experience any symptoms of liver injury. Other causes of acute liver injury were effectively ruled out, but the case was confounded by usage of other potential hepatotoxic medications. Still, the most likely culprit was ceftazidime, a rare cause of drug induced liver injury with very few reports in the literature.

BACKGROUND:COVID-19 presents unique challenges to the care of hospitalized older adults, including fractured lines of communication and uncertainty surrounding long term trajectories in cognition and function. Geriatric medicine and palliative care clinicians bring specialized training in facilitating communication in the face of uncertainty. Insurance expansion of virtual visits enabled inpatient virtual consultation, which can preserve personal protective equipment and minimize exposure to clinicians. We examined changes in goals of care and code status following an inpatient virtual consultation with geriatric medicine and palliative care clinicians. METHODS:This was an observational case series study performed at a large tertiary Academic Hospital. The study population included 78 patients aged 65 years and older, hospitalized with COVID-19 who had an inpatient consultation completed by geriatric medicine or palliative care clinicians between April 9, 2020 through May 9, 2020. The intervention was targeted, virtual geriatric medicine or palliative care consultation. All patients admitted to a medical floor with COVID-19 were screened four days a week and if a patient was over the age of 65, the medical team was offered a consultation by geriatric medicine (ages 80 and above) or palliative care (ages 65-79). Consultation included medical record review, telephone conversations with clinicians and nurses, telephone or video conversations with patients and/or surrogate decision-makers and collaborative case review on daily virtual huddles with an interprofessional team of geriatric medicine and palliative care clinicians. Descriptive statistics were applied to categorize outcomes after chart abstraction. RESULTS:Following consultation, 24 patients (31%) patients changed their code status to less invasive interventions. Of patients who were FULL CODE at the time of consultation (n=42), 2 (4.8%) transitioned to DNR only and 16 (38.1%) transitioned to DNR/DNI after consultation. While 8 patients (10.3%) utilized intensive care unit (ICU) level of care prior to consultation, 6 (7.6%) patients utilized ICU after consultation. After consultation, 11 (14.1%) patients were referred to hospice. CONCLUSIONS:Given uncertain trajectories in older adults hospitalized with COVID-19 and variability in patient preferences, virtual goals of care geriatric medicine and palliative care consultations should be considered as a key component of COVID-19 hospital protocols.

BACKGROUND:The prevalence and degree of self-reported distress that patients with Alzheimer's disease (AD) experience after cognitive testing remain unknown. It is also unknown whether this level of distress is at all related to specific patient factors, test performance, or awareness of test performance. METHODS:In 154 mild-to-moderate AD patients and 62 cognitively intact patients, we measured self-reported distress, on a five-point Likert scale, after 45 minutes of cognitive testing. Using multivariate logistic regression, we then examined whether demographic factors, level of education, depressive symptoms, cognitive performance, perceived test difficulty, and perceived test performance compared to 10 years ago were predictive of self-reported distress. RESULTS:The prevalence of any self-reported distress in patients with AD was 70% compared to 47% in patients without AD (p <.001). Of persons with AD, bivariate analyses revealed that those who reported more difficulty with testing (relative risk [RR] 1.32; 95% confidence interval [CI], 1.25-1.37) and felt that they performed worse than 10 years ago (RR 1.21; 95% CI, 1.07-1.30) were at increased risk for reporting more distress. Paradoxically, cognitive performance was a weak predictor of distress, with only language performance demonstrating an association (RR 0.95; 95% CI, 0.89-0.99). Adjustments for demographic factors, education, dementia severity, or depressive symptoms in the multivariable analyses did not alter these relationships. CONCLUSION/CONCLUSIONS:Cognitive tasks provoke more distress in patients with mild-to-moderate AD compared with persons who do not have dementia. Predictors of distress are more closely related to patient awareness about test difficulty and performance, rather than actual test performance.

OBJECTIVE:To demonstrate the reliability and validity of the Assessment of Capacity for Everyday Decision-Making (ACED), an instrument to evaluate everyday decision-making. METHODS:The authors administered the ACED to 39 persons with very mild to moderate cognitive impairment and 13 cognitively intact caregivers. RESULTS:Intraclass correlation coefficients showed good reliability for the measures of understanding, appreciation and reasoning, and Cronbach's alpha coefficients were > or =0.84 for all three decision-making abilities. The ACED also had a moderate to strong correlation with the MacArthur Competency Assessment Tool for Treatment, a validated measure of decision-making capacity for medical treatment decisions, and measures of overall cognition. Associations with measures of executive function were mixed, with moderate correlations observed only with ACED understanding and reasoning performance. CONCLUSION/CONCLUSIONS:The ACED is a reliable and valid measure to assess decision-making capacity. It may serve as an important addition to current methods used to assess everyday decision-making.

Self-neglect is a serious and burgeoning public health challenge representing the most common problem faced by Adult Protective Services agencies. Among older adults who are vulnerable to self-neglect, the capacity to make decisions may remain intact. However, the capacity to identify and extract oneself from harmful situations, circumstances, or relationships may be diminished. A key ethical and clinical branch point in identifying older adults at risk for self-neglect involves determining whether the individual can both make and implement decisions regarding personal needs, health, and safety. The Articulate --> Demonstrate method is a practical and efficient way to screen capacity in the setting of suspected self-neglect. Once self-neglect has been identified, common clinical interventions can be targeted to the diagnosed deficits that foster vulnerability to neglect in older adults.

Assessing the capacity of patients to make decisions about their functional problems has substantial ethical, clinical, and financial implications. The growing population of older adults with cognitive impairment either in the community or in long-term care and medical facilities increase the importance of adequately assessing this capacity. This review examines the current approaches to making this assessment, demonstrates how they are incomplete, and considers potential approaches for improving these evaluations. Future research should develop and validate methods to identify patients with impaired capacity to make everyday decisions. These data will supplement functional, cognitive, and medical assessments.