Faculty Bibliography

Background/UNASSIGNED:care could improve our understanding of disease progression, treatment options, and unmet needs in this vulnerable population, and whether such a model could mitigate decline in QoL. Methods/UNASSIGNED:Patients with PD meeting Medicare homebound criteria were eligible for quarterly interdisciplinary home visits over 12 months. Each visit entailed an evaluation by a movement disorders neurologist, social worker, and nurse, including history, examination, medication reconciliation, psychosocial evaluation, pharmacologic and nonpharmacologic management, and service referrals. Disease severity, as measured by the Unified Parkinson's Disease Rating Scale (UPDRS), and QoL using the Neuro-QoL were measured at visits 1 and 4. Results/UNASSIGNED:= 0.19-0.95). Conclusions/UNASSIGNED:Homebound individuals with advanced PD receiving interdisciplinary home visits experienced no significant decline in QoL over 1 year, despite disease progression. Our findings highlight the disease severity and impaired QoL of the advanced, homebound PD population, and the potential for novel approaches to foster continuity of care.

Sixteen million caregivers currently provide care to more than 5 million persons living with dementia (PLWD) in the United States. Although this population is growing and highly complex, evidence-based management remains poorly integrated within healthcare systems. Therefore, the National Institute on Aging IMPACT Collaboratory was formed to build the nation's ability to conduct embedded pragmatic clinical trials (ePCTs) for PLWD and their caregivers. The pilot core of the IMPACT Collaboratory seeks to provide funds for upward of 40 pilots for ePCTs to accelerate the testing of nonpharmacologic interventions with the goal that these pilots lead to full-scale ePCTs and eventually the embedding of evidence-based care into healthcare systems. The first two challenges for the pilot core in building the pilot study program were (1) to develop a transparent, ethical, and open nationwide process for soliciting, reviewing, and selecting pilot studies; and (2) to begin the process of describing the necessary components of a pilot study for an ePCT. During our initial funding cycle, we received 35 letters of intent, of which 17 were accepted for a full proposal and 14 were submitted. From this process we learned that investigators lack knowledge in ePCTs, many interventions lack readiness for an ePCT pilot study, and many proposed studies lack key pragmatic design elements. We therefore have set three key criteria that future pilot studies must meet at a minimum to be considered viable. We additionally discuss key design decisions investigators should consider in designing a pilot study for an ePCT. J Am Geriatr Soc 68:S14-S20, 2020.

Background: Caregivers (CGs) of older-adults with Alzheimer's disease and related dementias (ADRD) and CGs of older-adults with diabetes (DM) report substantial CG burden. CG burden is known to be linked to patients' behavioral problems, poor cognition, and increased dependency. There is no literature addressing CG burden in CGs of individuals with co-occurring diabetes and dementia (DM-ADRD). The aim of this study was to identify CG and care-recipient (CR) factors associated with high levels of CG burden in CGs of DM-ADRD patients.
Method(s): This study used bivariate and descriptive statistics to analyze surveys collected as part of a quality improvement intervention being conducted at NYU Langone Health primary care and endocrine Faculty Group Practices and Family Health Centers. Inclusion criteria for patients were age >= 65, cognitive impairment, and DM with recent HbA1c > 6.4 or ever prescribed hyperglyemic medication. Telephonic surveys were conducted with CGs of eligible patients. The Treatment Burden Questionnaire (TBQ) was used to measure CG burden. TBQ results were analyzed for association with CG factors including age, sex, race, relationship to patient, education level, residence status, and level of social support, as well as CR factors including age, sex, race, dementia severity, Charlson comorbidity score, and recent HbA1c values.
Result(s): CGs that completed surveys (n=58) had a mean age of 54.3 years, 74% (n=43) female, 46% (n=27) white, 84% (n=49) were children of CRs, 70% (n=41) had education beyond 12th grade, and 55% (n=32) lived separately from CR. CRs of CGs that completed surveys (n=58) had a mean age of 80.5 years, 67% (n=39) female, 67% (n=37) white. We found CGs who were male, Asian, co-resident, with low level of social support, of CRs with more-advanced dementia, and of CRs with recent out-of-range HbA1c had significantly higher levels of CG burden (p<0.1).
Conclusion(s): Our study demonstrates there are several CG and CR factors that are associated with increased levels of CG burden in this population. Findings may assist in identification of CGs at risk for increased burden. If these results are found to be replicable, future studies should focus on the development of prevention and treatment plans consistent with these findings

Racial minorities experience a high burden of food insecurity relative to non-Hispanic whites. Government-subsidized nutrition programs can positively impact food insecurity and nutritional risk among older adults. Yet, in New York City, where nearly 60% of people over 65 years are non-white, older minorities participate in government nutrition programs at very low rates. In this commentary, we focus on 2 programs: the Child and Adult Care Food Program and Older Americans Act Nutrition Services Programs. We identify opportunities for strengthening these programs to improve their reach and engagement with diverse older adults in New York City and similarly diverse urban communities.

Background: Sleep disturbance is common among nursing home (NH) residents, yet impacts on mood and other health outcomes remain unclear. Evidence from community-dwelling older adults has demonstrated relationships between sleep quality, mood, and adverse health outcomes. The aim of this study was to describe and identify relationships between self-reported sleep quality, mood and cognition among NH residents participating in a large randomized trial.
Method(s): We analyzed baseline assessment data from residents of two New York City NHs participating in an ongoing trial of a novel non-pharmacological intervention to improve sleep disturbance (Sleep Using Mentored Behavioral and Environmental Restructuring, SLUMBER). Participants were English or Spanish speakers who had capacity to consent for research. Baseline assessments included sleep quality (Pittsburgh Sleep Quality Index, PSQI), depressive symptoms (Patient Health Questionnaire-9, PHQ-9 and Brief Anxiety and Depression Scale, BADS), and cognition (Brief Cognitive Assessment Tool, BCAT).
Result(s): Participants' (n=70) mean age was 76.6 +/- 15.1 years; 45 (64.2%) were female. The sample was ethnically diverse: 31.4% Black/African American, 11.4% Hispanic/Latino, and 2.9% Asian. Mean BCAT score was 28.3 +/- 1.2 (23-33 suggests mild dementia). Poor sleep was common; mean PSQI total score: 7.8 +/- 4.3 (> 5 = poor sleep). 31% (n=22) had PHQ-9 scores (>= 5) indicative of depression. Higher (worse) PSQI total score was strongly associated with higher (worse) PHQ-8 (less sleep item) and BADS depression (r2=0.42, p<0.01). Interestingly, PSQI-categorized "good sleepers" were more likely to have BCAT scores indicative of dementia (p=0.042).
Conclusion(s): A significant association between worse self-reported sleep and more depressive symptoms suggests an opportunity for sleep interventions to improve not only sleep quality but also mood in NH residents. The relationship between worse cognition and better self-reported sleep may indicate that objective sleep measurement (e.g., actigraphy) is an important component of sleep assessment in NH residents with cognitive impairment

Background: Deconditioning from prolonged bedrest during hospitalization predisposes older patients to loss of mobility and the need for additional rehabilitation post-discharge. Despite recognition of the harms of prolonged bedrest and evidence that resistance training (RT) reverses deconditioning, few interventions have provided such exercise for hospitalized older adults. We evaluated the safety and feasibility of a novel exercise device used in a high-intensity RT routine in older age inpatients.
Method(s): In collaboration with the NYU Grossman School of Medicine Center for Healthcare Innovation and Delivery Science we developed a lightweight, portable RT device, which attaches to a hospital bed footboard and allows for over 20 exercises in 4 categories: upper-body, lower-body, back and core. We recruited and trained willing patients to use this device with a goal of completing 7 exercises per workout. We included inpatients (age > 70) on a general medical unit with a PT/OT order. Those having exercise limiting orthopedic or neurologic disability, and acute cardiopulmonary limitations were excluded. Each workout included exercises from each category, 10-20 isometric 3-second holds per exercise, and minimal rest. Patients were: (1) evaluated on their ability to complete each workout; (2) surveyed on their experience with the device; and (3) monitored for adverse events.
Result(s): 11 patients were trained using the device for an average of 2.0 total sessions per hospitalization (mean age: 80.9 years, range: 71-101; 54.5% female). Reasons for fewer sessions included early discharge, delirium, and contact precautions. Patients completed 89.3% of the exercises they performed. We noted no adverse events. 72.7% stated they would use the device on their own and 90.9% believed there is not enough exercise performed in hospitals.
Conclusion(s): This pilot study provides evidence of the safety and feasibility of a novel RT device to prevent inpatient deconditioning. Patients were eager and able to participate in RT. We did not observe fear of safety or views of high intensity RT as inappropriate for older hospitalized patients. Whether use of RT will change discharge-related outcomes requires further study

Background: Warfarin is efficacious in reducing thromboembolic risks but its use presents challenges to both patients and physicians including the need for monitoring, diet modification, and attention to drug-related interactions. Novel anticoagulants have circumvented many of these issues. Although prior research includes physician consideration of patients' perspective as important in the choice of anticoagulants, patient perceptions about anticoagulant use is unknown.
Method(s): We sought to identify patient perceptions about anticoagulant use in the Geriatrics Warfarin Clinic in Bellevue Hospital, a well-known, large safety net institution in New York City. We formulated a semi-structured telephone interview guide based on prior literature. Two geriatrics fellows (JK, NT) conducted interviews with role switches between interviewer and scribe every 3 interviews. We reviewed interview notes and identified codes. Both fellows independently analyzed all interviews and codes and categorized codes into themes. Any discrepancies were resolved by consensus discussion.
Result(s): Interviews were 10-15 minutes each. Respondents' mean age was 80.4 years (Standard deviation: 8.1); 7 were women (39%). Eight interviews were in English, five (28%) required a language interpreter and five were by proxy at patient request. Thematic saturation was reached at 18 patient interviews revealing six themes. These were: resignation about current warfarin use (n=12); lack of knowledge of alternative anticoagulation (n=16); perceived need for monitoring and efficacy checks (n=6); concerns about side effect profile (n=7); primary physician's recommendation (n=7) and dietary restrictions (n=4). Preference for warfarin use was driven by ability to know its therapeutic level and many patients expressed hesitance in switching with no monitoring procedure.
Conclusion(s): Patients' use of warfarin was generally well accepted. The primary concern was need for dietary modification. Of those patients that appeared neutral or accepting of alternative anticoagulation, the main discussion points were the drug's efficacy, side effect profile, and their physician's recommendation. This study provides useful information on guiding shared decision-making conversations about anticoagulation choice, especially in a patient demographic of predominantly low socioeconomic status individuals

Background: Up to one third of older adults with diabetes (DM) have co-occurring cognitive impairment and/or Alzheimer's disease and Related Dementias (ADRD). These patients are more likely to experience episodes of hypo and hyperglycemia. The American Geriatric Society (AGS) and American Diabetic Association (ADA) recommend liberalizing hemoglobin (Hb) A1c targets for patients with multiple comorbidities, but the impact of ADRD on glycemic management of patients with DM-ADRD is unknown.
Method(s): Within the primary care and endocrine clinics in the NYU Langone Health System, we collected characteristics of DM-ADRD patients participating in a DM-ADRD clinical quality improvement program. We administratively collected patients' most recent (within18 months) HbA1c from the Electronic Medical Record. We also surveyed the English and Spanish-speaking caregivers (CG) of these DM-ADRD patients. The CG survey included a measure of CG-reported patient dementia severity using the Dementia Severity Rating Scale (DSRS). We examined the relationship between the DSRS score and HbA1c.
Result(s): Patients (n=173) had a mean age of 79.7 (+/-7.18) and a mean HbA1c of 7.08%. 63% (n=106) were female, 63% (n=106) white; 37% (n=64) identified as being Latino/Hispanic. The mean DSRS score was 25 (+/-12.7) (range: 0-54), within the range of moderate cognitive impairment (18-36). Those older than 75 and those who were Spanish speaking had higher DSRS scores (26.1, p=.02; and 26.7, p=.04, respectively). Mean HbA1c of patients in the severe DSRS range (scores 37-54) was 6.81 (N=35) and was lower than in patients with moderate and mild dementia severity (mean 7.15 and 7.24, respectively); however, this difference was not statistically significant.
Conclusion(s): While the data does not confirm a statistically significant relationship between dementia severity and lower A1c, this finding is worrisome for DM-ADRD patients. Our data suggests possible overtreatment and if confirmed, there is a clear need for increased family and provider education and quality improvement programs for this vulnerable population