Faculty Bibliography

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: 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