Faculty Bibliography

Background: Older adults are at increased risk for respiratory failure due to anatomic age-related changes, reduction of muscle mass, and comorbid conditions. Mechanical ventilation increases the risk of inpatient mortality; thus, non-invasive modalities are preferred where clinically feasible. Advanced modalities of non-invasive ventilation support patients with acute and/or chronic respiratory failure. Case report: I evaluated a 95-year-old male with hypothyroidism, atrial fibrillation, seizure disorder, obstructive sleep apnea (OSA) on nightly BiPAP, and restrictive lung disease who presented to the hospital with lethargy. He was hypoxic with acute-on-chronic hypoxic, hypercarbic respiratory failure requiring intubation. Antibiotics were initiated due to radiographic consolidation. This was the third episode of hypercarbic respiratory failure requiring intubation in the prior 2 months. As geriatric consultants, we were asked to determine what future invasive measures might be appropriate and within goals of care. At baseline, he was cognitively intact and lived with his son and caregiver. His functional status had declined and he was not able to stand at bedside. His goal was to be able to move across the country with his son, and to maintain close relationships with his family. Pulmonary service determined respiratory failure was likely persistent hypoventilation due to deconditioning and neuromuscular weakness, with supporting features of normal A-a gradient and hypercapnia. Average volume-assured pressure support ventilation (AVAPS) was initiated one hour pre-lunch, three hours in the afternoon pre-dinner, and overnight. Physical therapy provided support to avoid kyphotic positioning. He transitioned to a long-term acute care hospital for respiratory therapy with the goal of returning home.
Discussion(s): Respiratory failure in older adults is often multifactorial and the treatment plan should address the underlying condition along with factors such as psychosocial, functional, and cognitive needs. In this case, the patient desired interactive time with family and was willing to spend more time on non-invasive ventilation to avoid recurrent hospitalizations and intubation. The interdisciplinary approach of geriatrics and pulmonary medicine allowed for a treatment plan that focused on what mattered, rather than limiting the discussion to consideration for future intubation

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: Delirium occurs commonly in hospitalized older adults. Clinicians investigate frequent causes of delirium such as infection, metabolic derangement, intracranial disorders, urinary and fecal disorders, and medication. The complexity in treating the underlying cause of delirium is the treatment of one contributing factor (e.g. infection), may in fact be the source of the confusion. Case report: We evaluated a 95 year old woman with atrial fibrillation, severe aortic stenosis, chronic kidney disease, heart failure, and clostridium difficile who presented to the hospital with shortness of breath. White blood cell count was elevated and CT chest revealed moderate patchy consolidation in the lung. The patient was started on Vancomycin, Aztreonam, and Cefepime for multidrug resistant pneumonia. At baseline she has no dementia and there was no concern for delirium on presentation. Hospital days 4-6 she became lethargic but remained clinically stable without a change in infectious markers. By hospital day 8 she completed the course of Cefepime but was nonverbal and opened her eyes only when directly stimulated. The only notable lab change was an uptrend of creatinine from 1.09 to 1.70 in the setting of diuresis for fluid overload. Mental status remained poor through hospital day 10. CT brain revealed moderate global volume loss. There was no evidence of a new infection, hypercarbia, or other metabolic derangements. EEG was not completed per family preference. By hospital day 12, 4 days after the cessation of Cefepime, her mental status began to improve and returned almost back to baseline before discharge.
Discussion(s): Cefepime is known to have neurotoxic effects that may include depressed consciousness, encephalopathy, aphasia, myoclonus, seizures, and coma. The primary risk factors for Cefepime neurotoxicity are renal impairment and blood-brain barrier dysfunction from systemic inflammation. Older age is a commonly reported clinical risk factor. Neurotoxic effects are noted a median of 4 days after initiation with reduced consciousness most commonly seen. The neurotoxic symptoms may resolve a median of 2 days after discontinuation. The literature findings mimic what was seen in this case. This case reinforces the need to consider the multifactorial contribution to delirium etiology. Cefepime induced neurotoxicity should be considered for infected patients with persistent hypoactive delirium

Background Up to fifty percent of geriatric patients are taking five or more prescription medications. Hospital admission is a vulnerable time for geriatric patients as most are cared for by physicians who do not follow them in the community. Though previous studies have shown success with deprescribing practices in the community, there is little data on the success of deprescribing that is initiated in the hospital. Methods Inpatients with a Geriatric consult from September 2019-November 2019 with recommendations per the consult service for deprescribing were included. Follow-up phone calls were completed at 30-days post discharge to determine success of deprescribing. Patients, care givers, or patient's pharmacies were contacted for follow-up. Results Twenty-two patients met inclusion criteria. One patient had no clear recommendation and was excluded. Four patients were deceased at 30-days. Four patients were unable to be reached. Fourteen patients were included in analysis. In total, 26 medications were recommended for deprescribing. Nine (34.6%) were successfully deprescribed. All antipsychotics and 50% of benzodiazepines were successfully deprescribed. Anticholinergics and H2 blockers were most present at 30-days despite recommendations for deprescribing. Five of 14 (35%) of after visit summaries listed medications on discharge that were recommended for deprescribing. Conclusions Recommendations for deprecribing are an important aspect of geriatric care. Our data demonstrates success in deprescribing certain classes of medications, though frequently recommendations were not followed. At discharge patients were provided instructions to continue medications recommended for deprescribing. This creates care discontinuity and miscommunication to outpatient providers

Background: Hospital readmissions put older adults at risk for health complications and increase health system costs. Research shows post-discharge calls to patients and caregivers help improve transitional care and reduce readmission risk. The NYU inpatient geri-atric consult service provides post-discharge calls, but a triage method was needed to target patients at greatest risk for readmission. The HOSPITAL score is a validated prediction model to identify patients at risk for potentially avoidable 30-day readmissions. We present the first known application of the HOSPITAL score to risk stratify patients for post-discharge calls and review its feasibility.
Method(s): The HOSPITAL score was calculated for patients 65 years and older admitted to a medicine team with a geriatrics consult starting October 2018. The HOSPITAL score stands for Hemoglobin, Oncology service, Sodium level, Procedure, Index Type, Admissions in the past year, and Length of stay. HOSPITAL score 0-4 is low risk (5.8%), 5-6 is intermediate risk (11.9%), and >= 7 is high risk (22.8%) for potentially avoidable 30-day readmissions. A post-discharge call within 1 week of discharge was provided to patients with a HOSPITAL score >= 5 deemed intermediate or high risk to address their current condition, care plan, and medication adherence.
Result(s): Preliminary data showed a total of 50 patients on the inpatient geriatric consult service with a HOSPITAL score calculated in October 2018 and 64% meeting criteria for post-discharge calls. The average age was 86 and the average HOSPITAL score was 5 with a range from 1-11. The total all-cause 30-day readmission rate to NYU was 14%. The low risk HOSPITAL score group included 18 patients with a 2% readmission rate while the intermediate or high risk HOSPITAL score group included 32 patients with a 12% readmission rate.
Conclusion(s): The HOSPITAL score was a feasible tool to risk stratify patients for post-discharge calls given its use of readily avail-able data and quick calculation. The HOSPITAL score provided an effective triage method for post-discharge calls on the inpatient geriat-ric consult service and may be applicable to other medical teams who seek to allocate their transitional care services

Background: The surprise question (SQ) is an assessment tool used to iden-tify hospitalized patients with poor prognoses by asking providers the following question: "Would you be surprised if this patient died within the next 6 months?" We sought to describe the prognostic utility of the SQ as well as the impact of age and gender on the accuracy of the SQ in elderly patients.
Method(s): We identified patients hospitalized between March and April of 2018 seen by the geriatric consultation service at our hospital. Responses to the SQ on admission and patient demographic data were recorded. We queried the New York State death registry and the hospi-tal's internal medical record 6 months after each SQ response was filed. This data was then used to assess the accuracy of providers' responses. The accuracy of the SQ was compared across gender and age groups using chi-square tests with statistical significance defined as p<0.05.
Result(s): A total of 163 cases were studied. The mean age of the patients analyzed was 85.7 years. 55.8% of the patients were female. The overall accuracy of the SQ was 54.6% (95% CI 46.6%-62.4%). The sensi-tivity and specificity of the SQ for death within 6 months were 66.7% (95% CI 44.7%-84.4%) and 53% (95% CI 43.9%-61.1%), respec-tively. The positive predictive value and negative predictive value of the SQ for death within 6 months were 19.5% (95% CI 14.8%-25.3%) and 90.1% (95% CI 83.5%-94.3%), respectively. There was no significant difference in the accuracy of the SQ between male and female patients (56.3% vs. 53.3%, p = 0.70). The SQ was more accurate in patients under 90 years of age compared to patients 90 years of age and older (60.6% vs. 44.1%, p = 0.04)
Conclusion(s): In this single institution study, we found the SQ to be neither sensitive nor specific for predicting death within 6 months of hospi-tal admission. The SQ is more accurate in patients under 90 years of age compared to older patients. Future investigation into both patient and provider characteristics that contribute to the limited accuracy of this simple assessment tool may further illustrate potential biases that impact successful prognostication

Background: Postoperative delirium occurs in 11-53% of older hospitalized patients, and is associated with cognitive and functional decline, increase in hospital associated complications, prolonged hospital stay, and a greater mortality. Delirium is often unrecognized which delays interventions that can reduce the burden on patients and caregivers. We report on a partnership between geriatrics and pre-admission testing (PAT) now expanded to improve recognition of preoperative cognitive impairment in patients undergoing spine surgery to proactively address modifiable delirium risks.
Method(s): This project was initiated in March 2018 and is ongo-ing. A trained RN in PAT conducted a Mini-COG screen on patients aged >=65. The inpatient geriatric consult service (GCS) and spine surgical team were notified if the patient had a positive screening result (<=3/5). GCS identified any high-risk deliriogenic medications in the EMR and searched the controlled substance registry in NY and surrounding areas. GCS collaborated with the surgical team day 1 post-operatively to consider a proactive geriatric consultation for delirium prevention.
Result(s): 150 patients over the age of 65 with planned elective spine surgery completed a Mini-COG screening test in PAT from March-November 2018. Eleven patients had a positive Mini-COG screen. Of the 11 patients, 1 did not have surgery and 2 developed delirium postoperatively. GCS was consulted for both patients who developed delirium and saw 1 patient proactively who did not go on to have delirium. One of the patients who developed delirium was on a high risk medication preoperatively and 2 patients were on high risk medications and did not go on to develop delirium.
Conclusion(s): This unique collaboration between PAT and geriat-rics suggests a framework can be established to increase surveillance for delirium in the perioperative period. This population of patients over 65 years old with planned elective spine surgery are a particularly high risk group due to deliriogenic medications used in the preopera-tive period to manage pain and muscle spasms, along with the poten-tial need for benzodiazepenes for muscle spasms in the postoperative period. We plan to continue to evaluate trends in delirium occurrence in patients with abnormal preoperative cognitive screening and work towards interventions that can be tailored to this population

Background: Delirium is one of the foremost geriatric emer-gencies. Its incidence increases after age 65 years and leads to higher healthcare expenses, morbidity, and mortality. NYU utilizes BERT (Behavioral Emergency Response Team) to de-escalate behav-ioral emergencies in patients with delirium but it is expensive and traumatizing to patients. We report on a modified version of the Hospital Elder Life Program, entitled the EmpoweRing elder Novel Interventions (ERNI) program, which is a novel partnership among geriatrics, psychiatry, nursing and rehabilitation to proactively iden-tify patients at high risk for delirium and utilize trained volunteers to provide non-pharmacologic interventions to prevent delirium and decrease the number of BERT calls in the hospital.
Method(s): Patients age 65 years or older admitted to the medical ICU, ED observation, or one general medicine floor who were deter-mined by the charge nurse to be at high risk for delirium, but not actively delirious, were chosen to participate in this project. Trained volunteers are utilized by nursing staff to spend time talking to these patients, offering cognitively stimulating activities such as puzzle searches, listening to music, re-orienting patients on a regular basis, and advocating for patients. Outcomes used for this study are length of stay, number of BERT calls, percent of episodes of delirium and nursing satisfaction. Data was collected 3 months before and after intervention was initiated.
Result(s): Preliminary data demonstrated a decrease in the percent of episodes of delirium and average length of stay but a slight increase in the number of BERT calls in the post-intervention period (Table 1). Nursing survey showed a 90% satisfaction rate with interventions performed by volunteers for delirium prevention.
Conclusion(s): Our data suggests that proactive non-pharmacologic interventions lead to higher nursing satisfaction and may decrease the incidence of delirium in geriatric patients in the hospital setting. Further analysis with longer intervention period and more measured outcomes would be helpful in determining the effect of non-pharmacologic interventions in delirium prevention. [Table Presented]