Faculty Bibliography

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.

Background: The AGS Choosing Wisely Workgroup recommends incorporating life expectancy in cancer screening decisions. Previous studies indicate that non-geriatricians consider prognosis important to their clinical decisions, but often do not use prognostic tools. Moreover, they rarely discuss prognosis with patients. Little is known about how geriatricians include life expectancy in cancer screening decisions or whether prognosis is discussed. Methods: We surveyed attending geriatricians and fellows who care for community-dwelling older adults in academic clinics in New York City. We inquired whether these physicians incorporate prognosis in cancer screening decisions and discuss prognosis with patients, and how they estimate prognosis; we measured their confidence in estimating and discussing prognosis (5 point Likert scale: 0="not confident at all" to 4="extremely confident"). We also examined barriers to use of 2 common prognostic tools (ePrognosis and Gait speed) and having these discussions. Results: Twelve attendings and six fellows completed surveys (72% response rate). All respondents incorporated prognosis in cancer screening decisions and discussed prognosis with patients. Respondents estimated prognosis based on clinical impression (n=16), life table (n=5), ePrognosis (n=6) and gait speed (n=2). Confidence in estimating and discussing prognosis with patients was neutral (median for both: 2; range 1-3). Attending physicians were more confident in 1) estimating and 2) discussing prognosis with patients than were fellows (median: 2 versus 1, p=0.001; median: 3 versus 1.5, p=0.01, respectively). "Lack of time" was the most frequently reported barrier to prognostic tool use and prognosis discussions with patients followed by "unfamiliarity", "lack of resources" and "uncertainty about prognosis estimates", respectively (see table). Conclusions: Geriatricians identify considerable barriers to discussing prognosis when making cancer-screening decisions. Addressing these barriers may improve confidence in estimating and discussing prognosis. (Table Presented)

BACKGROUND:Through diet and exercise interventions, community centers offer an opportunity to address health-related issues for some of the oldest, most vulnerable members of our society. OBJECTIVES/OBJECTIVE:The purpose of this investigation is to draw upon nationwide data to better characterize the population served by the congregate meals program and to gather more detailed information on a local level to identify opportunities for service enhancement to improve the health and well-being of older adults. DESIGN/METHODS:We examined community center data from two sources: 2015 National Survey of Older Americans Act and surveys from two New York City community centers. To assess nationwide service delivery, we analyzed participant demographics, functional status defined by activities of daily living, and perceptions of services received. MEASUREMENTS/METHODS:Participants from the two New York City community centers completed a four-day food record. Functional measures included the short physical performance battery, self-reported physical function, grip strength, and the Montreal Cognitive Assessment. RESULTS:Nationwide (n=901), most participants rated the meal quality as good to excellent (91.7%), and would recommend the congregate meals program to a friend (96.0%). Local level data (n=22) were collected for an in-depth understanding of diet, physical activity patterns, body weight, and objective functional status measures. Diets of this small, local convenience sample were higher in fat, cholesterol, and sodium, and lower in calcium, magnesium, and fiber than recommended by current United States Dietary Guidelines. Average time engaged in moderate physical activity was 254 minutes per week (SD=227), exceeding the recommended 150 minutes per week, but just 41% (n=9) and 50% (n=11) of participants engaged in strength or balance exercises, respectively. CONCLUSION/CONCLUSIONS:Research is warranted to test whether improvements in the nutritional quality of food served and access/supports for engaging in strength training within community centers could help older adults achieve diet and physical activity recommendations.

There is now an unprecedented opportunity to improve the care of the over 5 million people who are living with Alzheimer's disease and related dementias and many more with cognitive impairment due to brain injury, systemic diseases, and other causes. The introduction of a new Medicare care planning benefit-long sought openly by advocacy organizations and clinicians and badly needed by patients and families-could greatly improve health care quality, but only if widely and fully implemented. We describe the components of this new benefit and its promise of better clinical care, as well as its potential to create a new platform for clinical and health outcomes research. We highlight external factors-and some that are internal to the benefit structure itself-that challenge the full realization of its value, and we call for broad public and professional engagement to ensure that it will not fail.