Faculty Bibliography

BACKGROUND:Although studies to date have broadly shown that cardiovascular disease (CVD) increases cognitive and physical impairment risk, there is still limited understanding of the magnitude of this risk among relevant CVD subtypes or age cohorts. METHODS:We analyzed longitudinal data from 16 679 U.S. Health and Retirement Study participants who were aged ≥65 years at study entry. Primary endpoints were physical impairment (activities of daily living impairment) or cognitive impairment (Langa-Weir Classification of dementia). We compared these endpoints among participants who developed incident CVD versus those who were CVD free, both in the short term (<2-year postdiagnosis) and long term (>5 years), controlling for sociodemographic and health characteristics. We then analyzed the effects by CVD subtype (atrial fibrillation, congestive heart failure, ischemic heart disease, and stroke) and age-at-diagnosis (65-74, 75-84, and ≥85). RESULTS:Over a median follow-up of 10 years, 8 750 participants (52%) developed incident CVD. Incident CVD was associated with significantly higher adjusted odds (aOR) of short-term and long-term physical and cognitive impairment. The oldest (≥85) age-at-diagnosis subgroup had the highest risk of short-term physical (aOR 3.01, 95% confidence interval [CI]: 2.40-3.77) and cognitive impairment (aOR 1.96, 95% CI: 1.55-2.48), as well as long-term impairment. All CVD subtypes were associated with higher odds of physical and cognitive impairment, with the highest risk for patients with incident stroke. CONCLUSIONS:Incident CVD was associated with an increased risk of physical and cognitive impairment across CVD subtypes. Impairment risk after CVD was highest among the oldest patients (≥85 years) who should therefore remain a target for prevention efforts.

Given the growth of the older adult population in the United States, there is a greater need for tools to enable students, trainees, and clinicians to master the comprehensive geriatric assessment. Our goal was to develop a mobile phone application (app) to assist in performing this assessment. We performed a market survey of 45 apps that related to geriatrics and health screening. We evaluated for usability, target audience, and instruments used. Deficiencies included: (1) focusing on a single domain; (2) being time-intensive; and (3) having components behind a paywall. We then designed an app that incorporates instruments that are well-validated, available at no cost, and brief in length. GeriKit includes eight domains: cognition, depression, function, strength, medications, falls, and advance care planning. Each instrument requires fewer than 5 minutes, and once it is completed and scored, the user can access relevant educational materials. GeriKit was launched for Apple users in December 2020, and for Android in August 2021. There have been over 3,400 downloads to date. The GeriKit app makes the comprehensive geriatric assessment accessible to a wide audience, improving the ability to for learners to perform geriatric assessments.

Background: As the number of older adults in the US grows, there is a pressing need to teach medical trainees how to conduct geriatric assessments. GeriKit, a free mobile health (mHealth) app (available for iOS and Android) was designed to guide learners in conducting these assessments. The aim of this study was to understand the app's usability in early adopters.
Method(s): A 9-question validated survey of mHealth app usability was embedded within GeriKit and, through a 7-point Likert scale for each question, measured features of the user experience. A 10th question invited users to offer feedback. All users were eligible to take the survey anonymously. Survey data was analyzed from 12/2020-11/2021.
Result(s): 56 survey responses were received, which were categorized as positive (strongly agree/agree/somewhat agree; like a great deal/like a moderate amount/like a little) and negative/neutral (neither agree nor disagree/somewhat disagree/disagree/strongly disagree; neither like nor dislike/dislike a little/dislike a moderate amount/ dislike a great deal). Notably 53/56 (95%) would use the app again, 55/56 (98%) thought the app was easy to use, and 53/56 (95%) liked the interface (Figure). As feedback, respondents suggested adding a screening tool for medications on the Beer's List and an e-mail feature for assessment results.
Conclusion(s): Data from early adopters of GeriKit demonstrate that that the app was effective in assisting users with performing geriatric assessments

Background: Delirium affects 14-56% of hospitalized older adults, and leads to higher morbidity and increased healthcare costs. At NYULH we implemented the EmpoweRing elder Novel Interventions (ERNI) program in 2017, modeled after Hospital Elder Life Program (HELP), but we utilize trained pre-med and pre-nursing volunteers to prevent delirium. We have shown reduced length of stay and a decreased incidence of delirium with ERNI. Here we report on ERNI as a novel method to grow the geriatrics workforce.
Method(s): Patients 65 years or older admitted to ICU, ED observation, neurology, cardiology, and general medicine units determined to be at high risk for delirium were visited by trained pre-med/ nursing volunteers who engaged them in conversations, listened to music, reoriented them, worked on puzzles, and advocated for patients' needs. We assessed nursing and volunteer satisfaction, and patient/family satisfaction using Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) data from April 2017- July 2019.
Result(s): 26/31 (84%) nurses rated volunteers 7 or higher on a scale of 1-10, and 84% of nurses felt volunteers helped prevent delirium. The volunteers expressed satisfaction with the program, 17/18 (94%), and felt appreciated by patients and families[BC1]. 16/18 (89%) volunteers plan to pursue a career in healthcare, and 17/18 volunteers (94%) plan to work with older adults. 12/18 (67%) volunteers were the first in their families to work in healthcare. Although not directly related to ERNI, patient HCAHPS scores in the Observation Unit (measured by the hospital), improved after ERNI implementation, with nursing communication increasing from 70.5% to 77% and pain communication from 34.1% to 45.6%.
Conclusion(s): Our ERNI program demonstrated high rates of nursing and volunteer satisfaction, and patients in ED Observation had increased satisfaction. Exposing pre-med/nursing volunteers to older patients in a modified HELP program may be an important step toward increasing recruitment to the geriatrics workforce. For those already considering this career, the ERNI experience might solidify those intentions. Future plans are to expand this program by recruiting more college students as volunteers

Background: Approximately half of patients with HIV in the US are over age 50, but older adults are not commonly screened for HIV despite having known risk factors. Evidence for routine HIV screening in the geriatric population is limited, and the USPSTF only recommends HIV screening in those age 15-65. The aim of this quality improvement project was to measure the rate of HIV screening among older patients as well as assess provider knowledge for HIV testing guidelines in an urban safety net geriatrics clinic.
Method(s): Patient visits between 7/1/2019 - 9/30/2019 in the Bellevue Hospital geriatrics clinic were reviewed for HIV testing and sexual health assessment. In addition, we conducted a brief survey designed to assess how providers (n=14) handle HIV screening in geriatric patients.
Result(s): Of the 1259 patients seen in the geriatrics clinic in a 3 month period, 31 (2.5%) of which were tested for HIV during this time. Of those, 26 (84%) were tested based on a known risk factor. The mean age of the 31 tested was 81.64, and 14 (45%) of the patients were male. Only 7 (22.5%) patients had documentation of their sexual activity. In the provider survey, most providers (10/14) reported knowledge of USPSTF HIV screening guidelines and ordered HIV screening tests if there was a risk factor. Providers responded that they did not order annual HIV screening either because there was "not enough time to discuss" (3/14), or "patient refused to discuss" (3/14). Providers reported discussing patients' sexual practices less than once a year. Of those who did discuss sexual practices, 79% (12/14) assessed condom use.
Conclusion(s): This study showed low rates of HIV screening among geriatric patients, and minimal sexual health documentation. The provider survey demonstrated that clinicians do not assess their patients' sex lives, but order an HIV test if there is a risk factor for HIV. Given this data, we plan to pursue a provider education intervention to increase rates of HIV screening in our older adults

Background: Although medical schools use behavioral based interviews, most residencies and fellowships use unstructured interviews. The literature suggests that structured interviews help in reducing bias and selecting the best fit applicants, but most faculty lack formal interview training. We created a faculty development workshop to teach GME faculty how to conduct interviews more effectively.
Method(s): 15 GME faculty participated in an interviewing workshop with a group OSCE where they reviewed an applicant's CV and letter of recommendation, and then observed an unstructured interview followed by a structured interview utilizing behavioral based questions. After each simulation, faculty rated the applicant. We discussed the literature on different styles of interviewing including how to evaluate behavioral based questions. We reviewed the prevalence of unconscious bias and illegal questions. Participants worked together to create behavioral based questions tied to the particular needs of their own programs.
Result(s): Faculty rated the candidate in the unstructured interview favorably with 87% responding that the candidate was above average or excellent. Following the structured interview, 78% of faculty rated the candidate average or below average, and were concerned about behavioral issues including applicant's lack of empathy toward a difficult patient and limited insight. In a post-workshop survey, only 50% of faculty reported that their department provides training for interviews, and 50% thought they should have detected a problematic trainee in their interview. 100% of faculty reported motivation to change their interviewing style, and 92% of faculty reported the workshop was moderately, very, or extremely effective in providing tools for interviews.
Conclusion(s): This workshop enabled GME faculty to reflect on their ability to tailor questions to their program's needs. We successfully taught faculty how to utilize structured interviews to choose optimal candidates for their programs. These structured questions, created with the ACGME milestones, were designed to improve the interview reliability and validity by increasing standardization. We believe faculty who improve their interviewing skills will decrease bias, have better match outcomes, and will reduce the likelihood of their trainees requiring remediation for non-cognitive issues