Faculty Bibliography

Background: Patients with advanced kidney disease have an elevated symptom burden, increased mortality, and poor quality of life. While palliative care can address these issues, nephrology patients infrequently receive such care. To address this, we implemented an ambulatory kidney palliative care program. We describe our initial outcomes.
Method(s): Utilizing chart abstractions, we characterized the clinic population and symptom burden for patients seen from May 6, 2016-July 6, 2018.
Result(s): Ninety-four patients were referred; 74 (78.7%) patients seen. Forty (54.1%) had follow-up appointments (range 2-13). Mean patient age was 72.7 +/-16 years with 32 (43.2%) on dialysis. The mean symptom burden (n=65) was 12 (+/- 4.9) symptoms (out of 17) with mean severity of 2 (range 0-4), representing moderate severity. The most common physical symptoms were nausea (78%), dyspnea (72%), pain (68%) and itch (66%). Eighty-seven percent reported anxiety and 73% reported depression. There was no difference in symptom burden between patients on dialysis and those on conservative management (n=22). Patients on conservative management were significantly older and had more comorbidities. By visit two, there was a significant reduction in global symptom score (21.9 vs 19.0, p=0.01) in addition to a reduction in anxiety (2.1 vs 1.7, p=0.03), vomiting (0.8 vs 0.2, p=0.04), and restless legs syndrome (1.3 vs 0.8, p = 0.02).
Conclusion(s): Patients with serious kidney disease treated in a kidney palliative care clinic have a high symptom burden regardless of treatment choice. The decision to pursue conservative management is more prevalent in older patients with more comorbidities. Follow up visits to the clinic demonstrated a decrease in symptom burden, suggesting that a dedicated kidney-palliative care clinic may be successful in managing symptoms and addressing unmet need

More than 13 million persons in the United States aged 65 and older have cardiovascular disease (CVD), and this population is expected to increase exponentially over the next several decades. In the absence of clinical studies that would inform how best to manage this population, there is an urgent need for collaborative, thoughtful approaches to their care. Although cardiologists are traditionally regarded as leaders in the care of older adults with CVD, these individuals have multiple comorbidities, physiological differences, and distinct goals of care than younger patients that require a specialized geriatric lens. Thus, collaboration is needed between geriatricians, cardiologists, and other specialists to address the unique needs of this growing population. Accordingly, clinicians at New York University Langone Health and School of Medicine established a monthly Geriatric Cardiology Conference to foster an integrative approach to the care of older adults with CVD by uniting specialists across disciplines to collaborate on treatment strategies. At each conference, an active case is discussed and analyzed in detail, and a consensus is reached among participants regarding optimal treatment strategies. The conference attracts faculty and trainees at multiple levels from geriatrics, cardiology, and cardiothoracic surgery. The model may serve as a paradigm for other institutions moving towards geriatric-informed care of older adults with CVD.

Parkinson's disease (PD) is a complex, multisymptom, neurodegenerative disease affecting primarily older adults. With progression, many individuals become homebound and removed from coordinated, expert care, resulting in excess morbidity, mortality, and healthcare expenditures in acute care settings and institutions. Home visit care models have achieved the triple aim of improving individual and population health while reducing costs in many frail, community-dwelling geriatric cohorts. This study details a novel, interdisciplinary home visit program specifically designed for individuals with PD and related disorders and their family caregivers built upon best practice principles in the care of multimorbid older adults. At each quarterly home visit, a movement disorders-trained neurologist, social worker, and nurse work in parallel with the individual and caregiver to complete a history, physical, detailed medication reconciliation, psychosocial needs assessment, and home safety assessment. A comprehensive, person-centered plan is agreed upon, referrals to community resources are made, standardized documentation is shared, and follow-up communication is instituted. In the first 2 years, 272 visits were conducted with 85 individuals who represent one of the oldest, most disabled PD populations reported. Satisfaction with and retention in the program were high. This study represents the first translation of the success of interdisciplinary and home-based geriatric care models to a population with a specific neurological disease. Preliminary evidence supports the need for such programs in vulnerable populations. Future studies will prospectively assess person-centered outcomes, the effect of using telemedicine on sustainability, and cost effectiveness.

Over the past decade, hearing loss has emerged as a key issue for aging and health. We describe why hearing loss may be especially disabling in nursing home settings and provide an estimate of prevalence using the Minimum Data Set (MDS v.3.0). We outline steps to mitigate hearing loss. Many solutions are inexpensive and low-tech, but require significant awareness and institutional commitment.

Innovative geriatric clinical programs have proliferated in the 21st century, and many have been highlighted in the Journal of the American Geriatrics Society (JAGS). The Affordable Care Act has supported the accelerated innovation of publicized and unpublicized program development, adaptation, and implementation. Many JAGS articles report work conducted in programs with significant improvements in quality; high satisfaction for patients and providers; and for some, reductions in costs. Despite considerable detail, enabling implementers to attempt to adopt reported programs or adapt them to local environments, much less is typically conveyed about the subtleties of the implementation process that led to a successful outcome. Moreover, where we have been given a window into successful initiatives, far less is known about those that failed and even less about why some succeeded but others failed. With a focus on our shared needs as a geriatrics community, to foster the exchange of more-comprehensive models of successful and failed implementation, we propose publications that address implementation itself-a second layer of reporting about the "hidden" elements that may have been decisive factors in taking an efficacious test, treatment, or model and putting it into real-world practice. We propose a new platform for sharing a broader range of healthcare quality improvement initiatives-successes and failures. We include several salient characteristics that could be measured and described in support of dynamic, sustainable, evidence-based implementation of geriatrics programs.