Faculty Bibliography
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208
Interdisciplinary palliative care for people with advanced Parkinson's disease: a view from the home
BACKGROUND:Advanced Parkinson's disease (PD) is a multidimensional neurodegenerative condition with motor and non-motor symptoms contributing to increasing disability and decreasing quality of life. As the disease progresses, patients may become homebound and estranged from neurological care, with dire consequences. We describe the increasing epidemiologic burden of and individual risks faced by patients with palliative-stage PD and their caregivers. METHODS:With the aim of mitigating these risks, we designed and iterated two models of interdisciplinary home visits to maintain continuity of care and illuminate the unmet needs and barriers to care faced by this population. We describe both models in detail, with data on feasibility and patient-centered outcomes achieved in the initial model, and baseline characteristics of participants in the ongoing expanded model. Finally, we illustrate the scope and common themes of such palliative care-informed home visits with two cases. RESULTS:The pilot model involved over 380 visits with 109 individual patients. Among those patients, PD severity worsened by nearly 12 points annually on the Unified Parkinson's Disease Rating Scale (UPDRS), without a corresponding decline in quality of life. In an ongoing study of the second iteration of the model, 52 patient-caregiver dyads have completed their initial visit, with 44% bearing a diagnosis of dementia and the majority requiring an assistive device or being bedbound. Two cases highlight the critical importance of thorough medication reconciliation and home safety assessment in the comprehensive evaluation and management of such patients. CONCLUSIONS:As our population ages, therapies increase, and the number of individuals living with advanced PD and related disorders grows, so too does the imperative to recognize and address the palliative care needs of such patients and families. For many, home may be a viable, and perhaps optimal, site for this care.
PMID: 31735037
ISSN: 2224-5839
CID: 4208432
A Descriptive Analysis of an Ambulatory Kidney Palliative Care Program
PMID: 31295050
ISSN: 1557-7740
CID: 3976762
Early outcomes from an ambulatory kidney palliative care program [Meeting Abstract]
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
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
EMBASE:633767752
ISSN: 1533-3450
CID: 4755132
BRInging the Diabetes prevention program to GEriatric populations (BRIDGE): a feasibility study
Background/UNASSIGNED:The purpose of this 6-week intervention was to test the feasibility and acceptability of implementing a telehealth-adapted Diabetes Prevention Program (DPP) at a senior center. Methods/UNASSIGNED: = 16) attended weekly interactive webinars. At each measurement time point, participants completed questionnaires covering lifestyle, physical activity, quality of life, and food records and wore physical activity trackers. Qualitative data were gathered from 2 focus groups inviting all 16 participants with 13 and 10 participants attending, respectively. Results/UNASSIGNED:value = 0.001). Conclusion/UNASSIGNED:The feasibility of providing DPP via webinar appears to be high based on the retention and attendance rates. Similar to other behavioral interventions engaging older adults, recruitment rates were low. Acceptability was evidenced by high attendance at the intervention sessions and feedback from participants during focus group sessions. The intervention efficacy should be evaluated based on CDC criteria for program recognition in a larger scale randomized trial. Trial registration/UNASSIGNED:NCT03524404. Registered 14 May 2018-retrospectively registered. Trial protocol will be provided by the corresponding author upon request.
PMCID:6849183
PMID: 31741744
ISSN: 2055-5784
CID: 4208772
Sex-related differences in homebound advanced Parkinson's disease patients
Background/UNASSIGNED:Women with Parkinson's disease (PD) are more likely to be older, have greater disease severity and comorbidities, and yet are less likely to receive care from a neurologist, as compared with men with PD. Within the PD population, homebound individuals are a particularly vulnerable group facing significant barriers to care, yet within this understudied population, sex-related differences have not been reported. Purpose/UNASSIGNED:To identify and describe differences in homebound men and women with advanced PD and related disorders, participating in an interdisciplinary home visit program. Patients and methods/UNASSIGNED:This was an exploratory analysis of homebound patients seen between February 2014 and July 2016 using data collected via in-person interviews and chart review. Results/UNASSIGNED:=0.05). Conclusion/UNASSIGNED:The role of the caregiver in facilitating safe aging-in-place is crucial. Among homebound individuals with advanced PD, women were far more likely to live alone. The absence of a spouse or care partner may be due in part to variable sex-based life expectancies. Our findings suggest that homebound women with advanced PD may face greater barriers to accessing support.
PMCID:6681424
PMID: 31534322
ISSN: 1178-1998
CID: 4089372
Functional Limitations Mediate the Relationship Between Pain and Depressive Symptoms in Former NFL Athletes
The objective of this study was to analyze data from the National Football League Player Care Foundation Study of Retired NFL Players to understand potential risks for depressive symptoms in former athletes by investigating the relationship between pain and depressive symptoms in a multivariate context, while simultaneously exploring the potential connection with functional limitations. Descriptive statistics were used to describe the study sample and to conduct bivariate comparisons by race and age cohort. Linear regression models were conducted in the subsample of respondents reporting on depressive symptoms using the PHQ-9. Models examine the relationship of bodily pain, injury as a reason for retirement or not re-signing with a team, length of NFL career, sociodemographic characteristics, chronic conditions, and functional limitations to depression. Interaction terms tested whether race and age moderated the effect of bodily pain and functional limitations on depressive symptoms. Bivariate associations revealed no significant differences between younger and older former players in indicators of pain and only slightly higher functional limitations among younger former players. In the multivariate models, pain was significantly associated with depressive symptoms (β = 0.36; p < .01), net of a range of relevant controls. Adding an index of functional limitations reduced this association by nearly half (β = 0.20; p < .01) and functional limitations was significantly associated with depressive symptoms (β = 0.40; p < .01). No statistically significant interactions were found. Overall, bodily pain was strongly associated with depressive symptoms. After accounting for the effects of functional limitations, this association was notably reduced. These results may be useful in identifying aging-related physical declines in relatively younger adult men who may be at the greatest risk for depression. They highlight how physical functionality and activity may mitigate the risk of depression, even in the presence of significant bodily pain.
PMID: 31522600
ISSN: 1557-9891
CID: 4088772
Monetizing the MoCA: What Now? [Editorial]
PMID: 31478562
ISSN: 1532-5415
CID: 4067042
Diabetes mellitus and alzheimer's disease and related dementia care in older adults: A systematic literature review [Meeting Abstract]
Background: Forty percent of Americans are expected to develop type 2 diabetes mellitus (DM) within their lifetime, and up to one third of older adults with DM face co-occurring cognitive impair-ment and/or Alzheimer's disease and Related Dementia (ADRD). These co-morbidities create significant challenges in management for both patient and care partner, which is further compounded by a lack of consensus regarding optimal care. We conducted a systematic liter-ature review to better characterize the evidence guiding care for older patients with DM-ADRD.
Method(s): We used the PRISMA method to guide this system-atic review. A specialized librarian searched PubMed (Medline) using relevant search terms related to the management of DM and ADRD. This process yielded 2,158 DM studies and 1,401 ADRD studies. We included studies that were applicable to adults over 60 years old, published within the past 5 years, conducted within a primary care setting and written in English. Our review returned 267 DM and 104 ADRD focused results, of which 50 DM and 40 ADRD studies were included after abstract and full text review requiring two expert votes. Additionally, through expert opinion, we identified an additional 40 DM and 60 ADRD studies for inclusion.
Result(s): Based on this evidence, we identified methods for screening, diagnosis and management of patients with DM and ADRD as well as general principles related to care partner support, geriat-ric care, geriatric syndromes and goals for blood pressure and lipid management.
Conclusion(s): A review of the literature suggested the importance of individualizing care while monitoring and managing care partner stress, geriatric conditions, cognitive changes, complication risks, and glycemic, blood pressure, and cholesterol targets in order to achieve high quality care. The next steps are to use this information to generate decisional guidance for providers of older adults with DM-ADRD
Method(s): We used the PRISMA method to guide this system-atic review. A specialized librarian searched PubMed (Medline) using relevant search terms related to the management of DM and ADRD. This process yielded 2,158 DM studies and 1,401 ADRD studies. We included studies that were applicable to adults over 60 years old, published within the past 5 years, conducted within a primary care setting and written in English. Our review returned 267 DM and 104 ADRD focused results, of which 50 DM and 40 ADRD studies were included after abstract and full text review requiring two expert votes. Additionally, through expert opinion, we identified an additional 40 DM and 60 ADRD studies for inclusion.
Result(s): Based on this evidence, we identified methods for screening, diagnosis and management of patients with DM and ADRD as well as general principles related to care partner support, geriat-ric care, geriatric syndromes and goals for blood pressure and lipid management.
Conclusion(s): A review of the literature suggested the importance of individualizing care while monitoring and managing care partner stress, geriatric conditions, cognitive changes, complication risks, and glycemic, blood pressure, and cholesterol targets in order to achieve high quality care. The next steps are to use this information to generate decisional guidance for providers of older adults with DM-ADRD
EMBASE:627352100
ISSN: 1532-5415
CID: 3831662
Essential components of a quality improvement intervention for patients with DM-ADRD [Meeting Abstract]
Background: As many as 25% of older adults with diabetes (DM) may have co-occurring Alzheimer's Disease and Related Dementias (ADRD), complicated by over-and under-treatment, caregiver burden, and excess healthcare utilization. Despite these co-occurring conditions, there is no specific clinical guidance forsafe and high-quality treatment to achieve health outcomes that matter to patients andcaregivers. describe potential barriers and facilitators to implementing a quality improvement intervention focused on management of patients with DM-ADRD; and explore the support needs of patients and their family caregivers.
Method(s): This qualitative study was conducted in the forma-tive phase of "Enhanced Quality in Primary care for Elders with DM-ADRD (EQUIPED-ADRD) a pragmatic randomized controlled trial in a large, diverse healthcare system. Key stakeholder interviews with clinic staff, providers and caregivers (n=11) guided by a semi-structured interview guide elicited in-depth descriptions of current processes in clinical management including strengths and weaknesses; identified potential barriers and facilitators to the proposed intervention and explored patient and caregiver needs. Qualitative data were analyzed using content analysis and findings were used to refine the intervention.
Result(s): The overarching theme across all stakeholders was that DM-ADRD management should address the unique and individ-ualized needs of patients and caregivers without disrupting patient-provider relationships. Coordinated communication across teams and with patients/caregivers is essential. Caregivers reported increasing burden and need for resources to help manage day to day caregiver responsibilities including tangible (education, transportation, e.g.,) and emotional support.
Conclusion(s): An EQUPED-ADRD toolbox to facilitate interven-tion training and utilization and promote communication among the healthcare team and with patients/caregivers will support implemen-tation success. Activating existing available resources (social/nurs-ing services, respite care) and care coordination may help caregivers especially, as patient care needs increase over time. Health education should focus on DM and ADRD with ongoing re-education as care needs change
Method(s): This qualitative study was conducted in the forma-tive phase of "Enhanced Quality in Primary care for Elders with DM-ADRD (EQUIPED-ADRD) a pragmatic randomized controlled trial in a large, diverse healthcare system. Key stakeholder interviews with clinic staff, providers and caregivers (n=11) guided by a semi-structured interview guide elicited in-depth descriptions of current processes in clinical management including strengths and weaknesses; identified potential barriers and facilitators to the proposed intervention and explored patient and caregiver needs. Qualitative data were analyzed using content analysis and findings were used to refine the intervention.
Result(s): The overarching theme across all stakeholders was that DM-ADRD management should address the unique and individ-ualized needs of patients and caregivers without disrupting patient-provider relationships. Coordinated communication across teams and with patients/caregivers is essential. Caregivers reported increasing burden and need for resources to help manage day to day caregiver responsibilities including tangible (education, transportation, e.g.,) and emotional support.
Conclusion(s): An EQUPED-ADRD toolbox to facilitate interven-tion training and utilization and promote communication among the healthcare team and with patients/caregivers will support implemen-tation success. Activating existing available resources (social/nurs-ing services, respite care) and care coordination may help caregivers especially, as patient care needs increase over time. Health education should focus on DM and ADRD with ongoing re-education as care needs change
EMBASE:627353188
ISSN: 1532-5415
CID: 3831732
Over-treatment of older adults with diabetes and dementia [Meeting Abstract]
BACKGROUND: Harmful effects of intensive glycemic control in adults with diabetes mellitus (DM) highlights the need for de-intensification of therapy in some patients, particularly those with Alzheimer's disease and related dementias (ADRD) with greater self-management challenges. However, the burden and potential adverse effects are unclear. This analysis seeks to quantify the extent of "over-treatment" of adults >= 65 years with DM and ADRD defined by glycemic control in AGS and ADA guidelines, and to determine associations with DM medication and/or healthcare utilization.
METHOD(S): We conducted descriptive and bivariate statistics using 2 years of EHR data from all primary care and endocrine clinics in the NYU Langone Health. Analyses included patients >65 years, with ADRD and DM diagnoses, on DM medication, and recorded HbA1c. Overtreatment was defined as an HbA1c of >7%. Other covariates analyzed included demographics, DM medications, and healthcare utilization.
RESULT(S): Of those meeting inclusion criteria (n=803), 59.7% (n=479) were over-treated for DM. The over-treated group was 56.4% female, 69.1% white, and 19.2% Hispanic. This group had a mean HbA1c value of 6.3% +/-.5, mean age of 79.5 +/- 8.2, and mean number of PCP visits over 2 years of 8.7 +/- 6.5. While those over-treated were less likely to be on insulin than those not over-treated, 70% (n=227) vs. 46% (n=221), respectively, those over-treated and on insulin were found to have statistically significant higher utilization of emergency department (64.3% (n=142) vs. 50.2% (n=114)) and inpatient visits (84.6% (n=187) vs. 67.8% (n=154)) than those not over-treated.
CONCLUSION(S): Many older adults with DM and ADRD are under tight glycemic control, despite the recommendation of recent literature and guidelines. This suggests the need for de-intensification of DM treatment in this population, and further research to opera-tionalize de-intensification, while maintaining individualized patient health status and goals. [Table Presented]
METHOD(S): We conducted descriptive and bivariate statistics using 2 years of EHR data from all primary care and endocrine clinics in the NYU Langone Health. Analyses included patients >65 years, with ADRD and DM diagnoses, on DM medication, and recorded HbA1c. Overtreatment was defined as an HbA1c of >7%. Other covariates analyzed included demographics, DM medications, and healthcare utilization.
RESULT(S): Of those meeting inclusion criteria (n=803), 59.7% (n=479) were over-treated for DM. The over-treated group was 56.4% female, 69.1% white, and 19.2% Hispanic. This group had a mean HbA1c value of 6.3% +/-.5, mean age of 79.5 +/- 8.2, and mean number of PCP visits over 2 years of 8.7 +/- 6.5. While those over-treated were less likely to be on insulin than those not over-treated, 70% (n=227) vs. 46% (n=221), respectively, those over-treated and on insulin were found to have statistically significant higher utilization of emergency department (64.3% (n=142) vs. 50.2% (n=114)) and inpatient visits (84.6% (n=187) vs. 67.8% (n=154)) than those not over-treated.
CONCLUSION(S): Many older adults with DM and ADRD are under tight glycemic control, despite the recommendation of recent literature and guidelines. This suggests the need for de-intensification of DM treatment in this population, and further research to opera-tionalize de-intensification, while maintaining individualized patient health status and goals. [Table Presented]
EMBASE:627352996
ISSN: 1532-5415
CID: 3831772
