Faculty Bibliography

Case Presentation: An 86 yo male with history of chronic sinusitis, HTN and DM came to the hospital with cough, exertional dyspnea, and unintentional weight loss for 3 months. Initial chest CT showed right middle lobe consolidation and pulmonary nodules. He was treated for pneumonia and discharged home. He returned 8 days later and repeat chest CT showed increased size of bilateral nodu-lar consolidations, and new small subsegmental pulmonary emboli. Despite treatment, he developed acute respiratory failure requiring intubation, acute kidney injury and hypotension requiring vasopres-sors. Geriatrics was involved to assist with family meetings, to under-stand the patient's goals of care, and to set realistic treatment plans. Due to the patient's lack of capacity, his friend as healthcare proxy (HCP) along with patient's niece and nephew made the decision to not resuscitate. Given patient's history of chronic sinusitis with rapidly progressive lung involvement, Granulomatosis with polyangiitis (GPA) was suspected and lung biopsy result confirmed the diagnosis. A multidis-ciplinary meeting was held with patient's HCP, niece, nephew, geriat-rics and rheumatology to discuss treatment options. After much debate, the family decided to pursue a trial of aggressive treatment with rituxin. However, rituxin infusion was stopped when patient further decom-pensated. After patient's condition stabilized, he firmly expressed his wish to go home. Another family meeting was held and treatment was shifted to comfort care to align with the patient's goals of care.
Discussion(s): GPA is a systemic necrotizing vasculitis affect-ing small-and medium-sized vessels. The reported peak incidence of GPA is between ages 65 to 70 years. Upper airway disease is the most common presenting feature of GPA. Our patient presented with typical features of GPA at an atypical age. Although early initiation of treatment has shown to improve patient survival in the average population, there is lack of evidence in frail older adults. Questions regarding treatment side effect, outcome and disease prognosis should be explored with patients at the earliest point of care possible in order to set a realistic treatment plan. Establishing rapport with patient and family, and involving them in management is crucial for making treat-ment decisions that align with their goals of care

Background: Older adults visit Emergency Departments (ED) more often and have repeated visits, compared with younger individu-als. Cognitive impairment may drive ED use and may be more preva-lent in ED settings; yet it is often unrecognized, potentially resulting in suboptimal discharge planning. Cognitive screening is not routine ED care and staff are not typically trained in proper procedures.
Method(s): Using a volunteer workforce of college students and recent graduates provides an opportunity for clinical training as cogni-tive screeners and increases opportunities for system change. Volunteers screened for cognitive impairment among English and Spanish speaking patients who were admitted to a large academic ED and were likely to be discharged to home. We targeted patients >= 75 years and requested screening with the MiniCog$sup$

Background: The United States is experiencing a demographic shift, where the older adult population is expected to more than double from 32 million in 2012 to more than 88 million in 2050. Coupled with the current and anticipated shortage of providers, there is a need to identify alternative ways for clinicians to serve the healthcare needs of older adults. This is especially relevant in post-acute care (PAC) where one of the greatest challenges in providing comprehensive healthcare services is a lack of access. Alternative delivery models such as telehealth can allow providers to evaluate a resident with a change of condition, provide specialist consultations or manage care continuum transitions in place. Despite its benefits, telehealth adop-tion in PAC has been limited. Challenges in information dissemination on how telehealth can be used in PAC and lack of specific guidance on implementation for staff contributes to the lack of proliferation of telehealth models. Thus, there is a need for informative and guiding resources to assist PAC facilities in the implementation and utilization of telehealth tools and processes.
Method(s): The West Health Institute convened leading tele-health organizations to understand best practices for telehealth in PAC settings. The leading organizations that participated in this endeavor are Curavi Health, TripleCare, Avera eCARE, AGS, AMDA, Cobble Hill, CCHP, Foley & Lardner, LLC, SHARP HealthCare and UC San Diego Health.
Result(s): This collaboration developed and shared recommenda-tions on critical components of telehealth implementation to empower PAC settings to improve access and quality of care with telehealth. The completed implementation manual includes guidelines and recommendations on topics such as: Needs Assessments, Readiness Assessments, Financial and Reimbursement models, Implementation, Legal and Policy considerations and Performance Monitoring and Sustainability.
Conclusion(s): Through this extensive network of telehealth advocates, the goal of the collaboration is to disseminate learnings to advance telehealth implementation and enable older adults to success-fully age in place. With informative and guiding resources to assist staff, we can provide them with necessary tools to implement and utilize telehealth and help shape the next generation of post-acute care clinicians

BACKGROUND/OBJECTIVES/OBJECTIVE:Patient activation encompasses the knowledge, skills, and confidence that equip adults to participate actively in their healthcare. Patients with hearing loss may be less able to participate due to poor aural communication. We examined whether difficulty hearing is associated with lower patient activation. DESIGN/METHODS:Cross-sectional study. SETTING/PARTICIPANTS/METHODS:A nationally representative sample of Americans aged 65 years and older (n = 13 940) who participated in the Medicare Current Beneficiary Survey (MCBS) during the years 2011 to 2013. MEASUREMENT/METHODS:Self-reported degree of difficulty hearing ("no trouble," "a little trouble," and "a lot of trouble") and overall activation based on aggregated scored responses to 16 questions from the MCBS Patient Activation Supplement: low activation (below the mean minus 0.5 SDs), high activation (above the mean plus 0.5 SDs), and medium activation (the remainder). Sociodemographic and self-reported clinical measures were also included. RESULTS:"A little trouble" hearing was reported by 5655 (40.6%) of respondents, and "a lot of trouble" hearing was reported by 893 (6.4%) of respondents. Difficulty hearing was significantly associated with low patient activation: in analyses using multivariable multinomial logistic regression, respondents with "a little trouble" hearing had 1.42 times the risk of low vs high activation (95% confidence interval [CI] = 1.27-1.58), and those with "a lot of trouble" hearing had 1.70 times the risk of low vs high activation (95% CI = 1.29-2.11), compared with those with "no trouble" hearing. CONCLUSIONS:Nearly half of people aged 65 years and older reported difficulty hearing, and those reporting difficulty were at risk of low patient activation. That risk rose with increased difficulty hearing. Given the established link between activation and outcomes of care, and in view of the association between hearing loss and poor healthcare quality and outcomes, clinicians may be able to improve care for people with hearing loss by attending to aural communication barriers.

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.

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)