Faculty Bibliography

BACKGROUND AND OBJECTIVES/OBJECTIVE:AKI is a common complication of coronavirus disease 2019 (COVID-19) and is associated with high mortality. Palliative care, a specialty that supports patients with serious illness, is valuable for these patients but is historically underutilized in AKI. The objectives of this paper are to describe the use of palliative care in patients with AKI and COVID-19 and their subsequent health care utilization. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS/METHODS:We conducted a retrospective analysis of New York University Langone Health electronic health data of COVID-19 hospitalizations between March 2, 2020 and August 25, 2020. Regression models were used to examine characteristics associated with receiving a palliative care consult. RESULTS:=0.002). Despite greater use of palliative care, patients with AKI had a significantly longer length of stay, more intensive care unit admissions, and more use of mechanical ventilation. Those with AKI did have a higher frequency of discharges to inpatient hospice (6% versus 3%) and change in code status (34% versus 7%) than those without AKI. CONCLUSIONS:Palliative care was utilized more frequently for patients with AKI and COVID-19 than historically reported in AKI. Despite high mortality, consultation occurred late in the hospital course and was not associated with reduced initiation of life-sustaining interventions. PODCAST/UNASSIGNED:This article contains a podcast at https://www.asn-online.org/media/podcast/CJASN/2022_02_24_CJN11030821.mp3.

Many older adults with diabetes (DM) have co-occurring Alzheimer's Disease (AD) and AD-Related Dementias (ADRD). Complex treatment plans may impose treatment burden for caregivers responsible for day-to-day self-management. The purpose of this qualitative study was to describe caregiver perceptions of treatment burden for people with DM-AD/ADRD. Caregivers (n = 33) of patients with DM-AD/ADRD participated in semi-structured interviews about their caregiver role and perceptions of treatment burden of DM-AD/ADRD management. Qualitative data were analyzed using content analysis (ATLAS.ti). Caregivers reported high levels of burden related to complex treatment/self-management for patients with DM-AD/ADRD that varied day-to-day with the patient's cognitive status. Four themes were: (1) trajectory of treatment burden; (2) navigating multiple healthcare providers/systems of care; (3) caregiver role conflict; and (4) emotional burden. Interventions to reduce caregiver treatment burden should include activating supportive services, education, and care coordination especially, if patient treatment increases in complexity over time.

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

LEARNINGOBJECTIVES 1: Interpersonal /Communication Skill: 1) Identify communication skills needed to recruit older adults LEARNING OBJECTIVES 2: 2) Assess feasibility of GOSCEs to enhance recruitment skills in RAs. SETTING AND PARTICIPANTS: Convenience sample of 18 (5 male, 13 female) Research Assistants (RAs) at an urban hospital who recruit older adults for clinical trials. DESCRIPTION: Increasing older adults' participation in clinical trials is urgently needed. We developed a remote, three station simulation (Group Objective Structured Clinical Exam - GOSCE) to teach RAs communication skills. This 2-hour course included a discussion of challenges in recruiting older adults; skills practice with Standardized Participants (SPs); and a debrief to review experiences, highlight best practices. After discussion, RAs rotated (3 per group) through the stations, each with SP and faculty observer who provided immediate feedback. Thus, learners had opportunities for active and observational learning.Scenarios were: 1) an older white woman with hearing impairment; 2) an older white woman and family member together; and 3) an older Black man mistrustful due to history of racism in medical research. SPs completed behaviorally anchored checklists (11 communication skills across all cases, and 5-7 case-specific questions). Learners completed a 36- item survey of self-assessed change in skill after the workshop; insights on recruitment practice; and educational value. EVALUATION: The communication checklist across all cases included: relationship development (5 items, mean of 58% well done (range: 50-75%), patient education (3 items, 44% (42-58%)), patient satisfaction (2 items, 54% (50-58%)), and information gathering (1 item, 92%). Seventeen RAs completed the survey, 100% felt the workshop provided valuable feedback and taught relevant material, 88% would participate again and 52%reported that the workshop improved their recruitment skills. All RAs reported encountering situations similar to hearing impairment and family member cases, and the majority rated the cases as high in educational value. Just 45% reported experiencing a case similar to the Black male case, and 100% rate it as high in educational value. Key points identified by RAs included the value of building a trusting relationship with potential subjects, recognizing possible barriers to communication early on and addressing these directly in a supportive and respectful style. DISCUSSION / REFLECTION / LESSONS LEARNED: Remote GOSCEs are a feasible mechanism for training RAs in subject recruitment focused on the unique needs of older adults. Responses to the RA survey suggest that GOSCEs are feasible for training RAs in simulated clinical scenarios with which participants are familiar and unfamiliar. SP assessment of RAs identified areas for further reinforcement to improve recruitment skills. This innovation is a feasible, high yield strategy for training research staff. It is highly adaptable to the specific recruitment needs and skills of a clinical trials and will add to the literature on educating RAs

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: 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