Faculty Bibliography

BACKGROUND:Current understanding of advanced Parkinson's disease (PD) and its treatment is largely based on data from outpatient visits. The most advanced and disabled individuals become disconnected from both care and research. A previous pilot study among older, multimorbid patients with advanced PD demonstrated the feasibility of interdisciplinary home visits to reach the target population, improve care quality, and potentially avoid institutionalization. OBJECTIVE:The following protocol tests whether interdisciplinary home visits can 1) prevent decline in quality of life and 2) prevent worsening caregiver strain. Finally, the protocol explores whether program costs are offset by savings in healthcare use and institutionalization when compared with usual care. METHODS:In this single-center, controlled trial, 65 patient-caregiver dyads affected by advanced PD (Hoehn & Yahr stages 3-5 and homebound) are recruited to receive quarterly interdisciplinary home visits over one year. The one-year intervention is delivered by a nurse and research coordinator who travel to the home supported by a movement disorders specialist and social worker (both present by video). Each dyad is compared with age-, sex-, and Hoehn and Yahr stage-matched control dyads drawn from US participants in the longitudinal Parkinson's Outcome Project registry. The primary outcome measure is change in patient quality of life between baseline and one year. Secondary outcome measures include change in Hoehn & Yahr stage, caregiver strain, self-reported fall frequency, emergency room visits, hospital admissions, and time-to-institutionalization and/or death. Intervention costs and changes in healthcare utilization will be analyzed in a budget impact analysis exploring the potential for model adaptation and dissemination. RESULTS:The protocol was funded in September 2017 and approved by the Rush Institutional Review Board in October 2017. Recruitment began in May 2018 and closed in November 2019 with 65 patient-caregiver dyads enrolled. All study visits have been completed and analysis is underway. CONCLUSIONS:To our knowledge, this is the first controlled trial to investigate the effects of interdisciplinary home visits among homebound individuals with advanced Parkinson's disease and their caregivers. This study also establishes a unique cohort of patients from whom we can study the natural course of advanced PD, its treatments, and unmet needs. CLINICALTRIAL/UNASSIGNED:Clinicaltrials.gov, NCT03189459.

The needs of persons living with Alzheimer's disease and Alzheimer's disease-related dementia (AD/ADRD) are challenged by tremendous complexity impacting both care delivery and financing. Most persons living with dementia (PLWD) also suffer from other chronic medical or mental health conditions, which further burden quality of life and function. In addition to difficult treatment choices, optimal dementia care models likely involve people and services that are not typical pieces of the health care delivery system but are all critical partners-care partners, social workers, and community services, to name a few. More than 200 models of dementia care have demonstrated some efficacy. However, these successful interventions that might address much of the care needed by PLWD are uninsured in the United States, where insurance coverage has focused on acute care needs. This poses great difficulties for both care provision and care financing. In this article, we review these 3 key challenges: dementia care for those with chronic comorbid disease; care models that require people who are not typical providers in traditional care delivery systems; and the mandate to provide high-quality care that is currently not funded by usual health care insurance. We propose promising next steps that could substantially improve the lives of PLWD and the lives of their care partners, and highlight some of the many research questions that remain.

Background: Home blood pressure measurement (HBPM) has been a time-honored supplement to periodic in-office measurement to facilitate primary care physician (PCP) diagnosis of hypertension (HTN), its ongoing control and medication management. PCPs, in response to COVID-19, adopted telemedicine as the sole means of care, elevating HBPM as the essential HTN surveillance tool. We assessed the feasibility of this approach in a Veteran Affairs (VA) geriatric clinic.
Method(s): Study subjects included all the Veterans seen by New York Harbor VA geriatrics fellows' clinic between January 1, 2019 and March 1, 2020 and who have HTN listed as an electronic health record (EHR) diagnosis. Those with systolic blood pressure (SBP) > 140 mmHg were prioritized. We called these patients to assess adherence to BP self-care and reconcile medications, to identify reasons for poor adherence and to offer solutions. Patients were called again within two months to re-assess adherence, collect BP measures and adjust medications as needed.
Result(s): Among 102 patients diagnosed with HTN, 41 had not achieved the goal of SBP <140 mmHg prior to this intervention. We reached 78% (n=32) of these 41 patients (requiring 1-3 phone calls). All reported medical adherence, but none were found to consistently check BP at home with any frequency or proper technique. For the 14 patients having no BP monitor at home, we sent a monitor to 10 through prescription and enrolled 4 in a home telehealth (HT) program that uses daily remote measurement. We provided detailed instruction of proper HBPM during the initial interview. At follow-up, 47% (n=15) practiced HBPM and reported BP readings within goal, indicating no need for change in care. Of these 15, 11 had their own BP monitors; 2 achieved control through the HT program. However, only 2 of the 10 patients who received the prescribed BP monitor started HBPM and demonstrated good control.
Conclusion(s): Given our reliance on telemedicine, HBPM is feasible for outpatient HTN management. Close PCP follow-up to encourage consistent HBPM practice may improve and sustain the success of this strategy. The quality of self-reported data should be assessed during office visits

BACKGROUND/OBJECTIVES/OBJECTIVE:Poor communication is a barrier to care for people with hearing loss. We assessed the feasibility and potential benefit of providing a simple hearing assistance device during an emergency department (ED) visit, for people who reported difficulty hearing. DESIGN/METHODS:Randomized controlled pilot study. SETTING/METHODS:The ED of New York Harbor Manhattan Veterans Administration Medical Center. PARTICIPANTS/METHODS:One hundred and thirty-three Veterans aged 60 and older, presenting to the ED, likely to be discharged to home, who either (1) said that they had difficulty hearing, or (2) scored 10 or greater (range 0-40) on the Hearing Handicap Inventory-Survey (HHI-S). INTERVENTION/METHODS:Subjects were randomized (1:1), and intervention subjects received a personal amplifier (PA; Williams Sound Pocketalker 2.0) for use during their ED visit. MEASUREMENTS/METHODS:Three survey instruments: (1) six-item Hearing and Understanding Questionnaire (HUQ); (2) three-item Care Transitions Measure; and (3) three-item Patient Understanding of Discharge Information. Post-ED visit phone calls to assess ED returns. RESULTS:Of the 133 subjects, 98.3% were male; mean age was 76.4 years (standard deviation (SD) = 9.2). Mean HHI-S score was 19.2 (SD = 8.3). Across all HUQ items, intervention subjects reported better in-ED experience than controls. Seventy-five percent of intervention subjects agreed or strongly agreed that ability to understand what was said was without effort versus 56% for controls. Seventy-five percent of intervention subjects versus 36% of controls said clinicians provided them with an explanation about presenting problems. Three percent of intervention subjects had an ED revisit within 3 days compared with 9.0% controls. CONCLUSION/CONCLUSIONS:Veterans with hearing difficulties reported improved in-ED experiences with use of PAs, and were less likely to return to the ED within 3 days. PAs may be an important adjunct to older patient ED care but require validation in a larger more definitive randomized controlled trial.

Background: Hearing loss compounds social isolation. We tested acceptability and benefit of simple hearing assistance devices- Personal Amplifiers (PAs)-provided to older people with hearing loss and risk for social isolation, loneliness and depression.
Method(s): We conducted a pre-post pilot trial with 1-and 2-month follow-up of residents of six low-income senior apartment buildings in Los Angeles (n = 74) who had hearing difficulties, based on either (A) >= 10 (range 0-40) on the Hearing Handicap Inventory - Survey; or (B) hearing loss based on a clinically validated audiological iPad assessment (SHOEBOXTM) with surveys at 0, 1 and 2 months using 4 instruments: (1) Social Isolation Score (SIS); (2) Patient Health Questionnaire (PHQ-9); (3) Sense of Social Support scale; and (4) DG Loneliness Scale. We assessed PA use and perceived benefit using the International Outcome Inventory for Alternative Interventions (IOI-AI).
Result(s): Baseline characteristics and degree of hearing problems did not vary significantly among 74 initial enrollees. Fortytwo residents completed 1-and 2-month surveys. Mean age was 78.2 years; 64% were women; 83% scored >=10 on HHI-S and 83% met SHOEBOX criteria for hearing loss. At baseline, 31% met SIS criteria for social isolation (>=2; mean=1.0; SD:0.98); 41% met DG criteria for loneliness; and 19% had low social support. Mean PHQ-9 was 7.0, (SD:5.3); 26% had moderate to severe mood symptoms. At 2-month follow up, 87% reported PA use of >= one hour/day, and 76% indicated that the device changed life enjoyment 'quite a lot.' Psychosocial measures improved over time.
Conclusion(s): In a vulnerable older population with hearing difficulties, simple PAs were enthusiastically received and may have improved social functioning and mood. Further work with stronger study designs is needed to shed more light on the effectiveness of this approach

BACKGROUND:Little is known about long-term recovery from severe COVID-19 disease. Here, we characterize overall health, physical health, and mental health of patients 1 month after discharge for severe COVID-19. METHODS:This was a prospective single health system observational cohort study of patients ≥ 18 years hospitalized with laboratory-confirmed COVID-19 disease who required at least 6 l of oxygen during admission, had intact baseline cognitive and functional status, and were discharged alive. Participants were enrolled between 30 and 40 days after discharge. Outcomes were elicited through validated survey instruments: the PROMIS® Dyspnea Characteristics and PROMIS® Global Health-10. RESULTS:A total of 161 patients (40.6% of eligible) were enrolled; 152 (38.3%) completed the survey. Median age was 62 years (interquartile range [IQR], 50-67); 57 (37%) were female. Overall, 113/152 (74%) participants reported shortness of breath within the prior week (median score 3 out of 10 [IQR 0-5]), vs 47/152 (31%) pre-COVID-19 infection (0, IQR 0-1), p < 0.001. Participants also rated their physical health and mental health as worse in their post-COVID state (43.8, standard deviation 9.3; mental health 47.3, SD 9.3) compared to their pre-COVID state, (54.3, SD 9.3; 54.3, SD 7.8, respectively), both p < 0.001. Physical and mental health means in the general US population are 50 (SD 10). A total of 52/148 (35.1%) patients without pre-COVID oxygen requirements needed home oxygen after hospital discharge; 20/148 (13.5%) reported still using oxygen at time of survey. CONCLUSIONS:Patients with severe COVID-19 disease typically experience sequelae affecting their respiratory status, physical health, and mental health for at least several weeks after hospital discharge.