Faculty Bibliography

Background: Conservative kidney management (CKM) of kidney failure is an important treatment option for many patients. However, its availability in the United States (US) is not well described. We describe CKM resources and provider practice patterns in US Chronic Kidney Disease (CKD) clinics.
Method(s): Cross sectional analysis of provider surveys (n=22) from unique clinics in the US from the CKD Outcomes and Practice Patterns Study (CKDopps) collected between 2014-2017.
Result(s): Only eight (36%) providers reported involving palliative care in planning for and educating patients about kidney failure. A majority (59%) were extremely comfortable discussing CKM and nearly 100% typically discussed CKM as a treatment option. Nearly all (95%) reported their clinics had the ability to routinely deliver CKM, but only one had a CKM protocol or guideline, and none offered a specific CKM clinic. Most providers said their clinics used the word conservative to describe CKM, with 24% choosing palliative or supportive terminology. Regardless of involvement of PC, most providers estimated that 5% of their patients with or approaching kidney failure were managed with CKM. Patient preference, functional status, frailty, and comorbidities were the most important factors influencing provider decisions in contemplating the suitability of CKM for patients. (Figure 1)
Conclusion(s): Most providers report feeling comfortable discussing CKM, yet almost no clinics report resources or dedicated infrastructure for CKM delivery. Despite reported high frequency of discussing CKM, few patients were described as choosing this treatment pathway. Factors that influence consideration of CKM are consistent with elements that generally influence well-informed geriatric and end-of-life care. Efforts to improve assessment of those elements may allow for more informed recommendations of CKM

Objective: To describe sociodemographic differences between individuals with advanced Parkinson's Disease (PD) still receiving care in an outpatient clinic vs. those enrolled in an interdisciplinary home visit study.
Background(s): Individuals with PD from underrepresented minority backgrounds face disparities in access to expert neurologic care. Such disparities also persist in PD research participation, sometimes attributed to mistrust and stigma. As minority patients become homebound, they are further estranged from care and research representation. We launched an interdisciplinary home visit study to extend continuity of care to homebound individuals with advanced PD. Here, we seek to identify sociodemographic differences between home visit (HV) participants and the outpatient (OP) clinic population from which they were recruited to determine whether disparities in care and research enrollment among minority patients persist with this patient-centered, care-focused intervention. Design/Methods: Cross-sectional study comparing individuals with advanced PD-Hoehn & Yahr stage >3-drawn from a single movement disorders center between 2017- 2019. We conducted a chart review for demographic information and used t-tests or Wilcoxon signed-rank tests as appropriate to assess population differences.
Result(s): The HV population is significantly older (n = 58 HV, 1015 OP; mean age 78.4 (SD 7.5) vs. 75.0 (SD 9.2), respectively, p = 0.002) and includes nearly twice the percentage of minority patients (26.3% non-Caucasian vs. 14.7% non-Caucasian in OP, p = 0.02). As expected, HV had worse PD severity, with 62.1% stage 4 and 17.2% stage 5, vs. 28.6% and 11.0% of OP, respectively (p <0.0001).
Conclusion(s): The proportion of minority patients with advanced PD enrolled in a home-based study is significantly greater than that receiving care in the OP setting from which they originated. This suggests that social determinants of health may contribute to advanced PD patients from underrepresented minorities becoming lost to follow-up earlier than white patients. We are actively comparing our homebound population with matched controls from a longitudinal national registry to determine the generalizability of this finding. Our results suggest that despite their advanced age, disease, and homebound status, this population is amenable to research participation. Ultimately, continued access to care poses a large but surmountable hurdle to research participation for minority patients

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 one 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 liters 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. 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.

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: 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

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: 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