Faculty Bibliography

Background: As many as 25% of older adults with diabetes (DM) may have co-occurring Alzheimer's Disease and Related Dementias (ADRD), complicated by over-and under-treatment, caregiver burden, and excess healthcare utilization. Despite these co-occurring conditions, there is no specific clinical guidance forsafe and high-quality treatment to achieve health outcomes that matter to patients andcaregivers. describe potential barriers and facilitators to implementing a quality improvement intervention focused on management of patients with DM-ADRD; and explore the support needs of patients and their family caregivers.
Method(s): This qualitative study was conducted in the forma-tive phase of "Enhanced Quality in Primary care for Elders with DM-ADRD (EQUIPED-ADRD) a pragmatic randomized controlled trial in a large, diverse healthcare system. Key stakeholder interviews with clinic staff, providers and caregivers (n=11) guided by a semi-structured interview guide elicited in-depth descriptions of current processes in clinical management including strengths and weaknesses; identified potential barriers and facilitators to the proposed intervention and explored patient and caregiver needs. Qualitative data were analyzed using content analysis and findings were used to refine the intervention.
Result(s): The overarching theme across all stakeholders was that DM-ADRD management should address the unique and individ-ualized needs of patients and caregivers without disrupting patient-provider relationships. Coordinated communication across teams and with patients/caregivers is essential. Caregivers reported increasing burden and need for resources to help manage day to day caregiver responsibilities including tangible (education, transportation, e.g.,) and emotional support.
Conclusion(s): An EQUPED-ADRD toolbox to facilitate interven-tion training and utilization and promote communication among the healthcare team and with patients/caregivers will support implemen-tation success. Activating existing available resources (social/nurs-ing services, respite care) and care coordination may help caregivers especially, as patient care needs increase over time. Health education should focus on DM and ADRD with ongoing re-education as care needs change

BACKGROUND: Harmful effects of intensive glycemic control in adults with diabetes mellitus (DM) highlights the need for de-intensification of therapy in some patients, particularly those with Alzheimer's disease and related dementias (ADRD) with greater self-management challenges. However, the burden and potential adverse effects are unclear. This analysis seeks to quantify the extent of "over-treatment" of adults >= 65 years with DM and ADRD defined by glycemic control in AGS and ADA guidelines, and to determine associations with DM medication and/or healthcare utilization.
METHOD(S): We conducted descriptive and bivariate statistics using 2 years of EHR data from all primary care and endocrine clinics in the NYU Langone Health. Analyses included patients >65 years, with ADRD and DM diagnoses, on DM medication, and recorded HbA1c. Overtreatment was defined as an HbA1c of >7%. Other covariates analyzed included demographics, DM medications, and healthcare utilization.
RESULT(S): Of those meeting inclusion criteria (n=803), 59.7% (n=479) were over-treated for DM. The over-treated group was 56.4% female, 69.1% white, and 19.2% Hispanic. This group had a mean HbA1c value of 6.3% +/-.5, mean age of 79.5 +/- 8.2, and mean number of PCP visits over 2 years of 8.7 +/- 6.5. While those over-treated were less likely to be on insulin than those not over-treated, 70% (n=227) vs. 46% (n=221), respectively, those over-treated and on insulin were found to have statistically significant higher utilization of emergency department (64.3% (n=142) vs. 50.2% (n=114)) and inpatient visits (84.6% (n=187) vs. 67.8% (n=154)) than those not over-treated.
CONCLUSION(S): Many older adults with DM and ADRD are under tight glycemic control, despite the recommendation of recent literature and guidelines. This suggests the need for de-intensification of DM treatment in this population, and further research to opera-tionalize de-intensification, while maintaining individualized patient health status and goals. [Table Presented]

Case Presentation: An 86 yo male with history of chronic sinusitis, HTN and DM came to the hospital with cough, exertional dyspnea, and unintentional weight loss for 3 months. Initial chest CT showed right middle lobe consolidation and pulmonary nodules. He was treated for pneumonia and discharged home. He returned 8 days later and repeat chest CT showed increased size of bilateral nodu-lar consolidations, and new small subsegmental pulmonary emboli. Despite treatment, he developed acute respiratory failure requiring intubation, acute kidney injury and hypotension requiring vasopres-sors. Geriatrics was involved to assist with family meetings, to under-stand the patient's goals of care, and to set realistic treatment plans. Due to the patient's lack of capacity, his friend as healthcare proxy (HCP) along with patient's niece and nephew made the decision to not resuscitate. Given patient's history of chronic sinusitis with rapidly progressive lung involvement, Granulomatosis with polyangiitis (GPA) was suspected and lung biopsy result confirmed the diagnosis. A multidis-ciplinary meeting was held with patient's HCP, niece, nephew, geriat-rics and rheumatology to discuss treatment options. After much debate, the family decided to pursue a trial of aggressive treatment with rituxin. However, rituxin infusion was stopped when patient further decom-pensated. After patient's condition stabilized, he firmly expressed his wish to go home. Another family meeting was held and treatment was shifted to comfort care to align with the patient's goals of care.
Discussion(s): GPA is a systemic necrotizing vasculitis affect-ing small-and medium-sized vessels. The reported peak incidence of GPA is between ages 65 to 70 years. Upper airway disease is the most common presenting feature of GPA. Our patient presented with typical features of GPA at an atypical age. Although early initiation of treatment has shown to improve patient survival in the average population, there is lack of evidence in frail older adults. Questions regarding treatment side effect, outcome and disease prognosis should be explored with patients at the earliest point of care possible in order to set a realistic treatment plan. Establishing rapport with patient and family, and involving them in management is crucial for making treat-ment decisions that align with their goals of care

Background: Older adults visit Emergency Departments (ED) more often and have repeated visits, compared with younger individu-als. Cognitive impairment may drive ED use and may be more preva-lent in ED settings; yet it is often unrecognized, potentially resulting in suboptimal discharge planning. Cognitive screening is not routine ED care and staff are not typically trained in proper procedures.
Method(s): Using a volunteer workforce of college students and recent graduates provides an opportunity for clinical training as cogni-tive screeners and increases opportunities for system change. Volunteers screened for cognitive impairment among English and Spanish speaking patients who were admitted to a large academic ED and were likely to be discharged to home. We targeted patients >= 75 years and requested screening with the MiniCog$sup$

Background: The United States is experiencing a demographic shift, where the older adult population is expected to more than double from 32 million in 2012 to more than 88 million in 2050. Coupled with the current and anticipated shortage of providers, there is a need to identify alternative ways for clinicians to serve the healthcare needs of older adults. This is especially relevant in post-acute care (PAC) where one of the greatest challenges in providing comprehensive healthcare services is a lack of access. Alternative delivery models such as telehealth can allow providers to evaluate a resident with a change of condition, provide specialist consultations or manage care continuum transitions in place. Despite its benefits, telehealth adop-tion in PAC has been limited. Challenges in information dissemination on how telehealth can be used in PAC and lack of specific guidance on implementation for staff contributes to the lack of proliferation of telehealth models. Thus, there is a need for informative and guiding resources to assist PAC facilities in the implementation and utilization of telehealth tools and processes.
Method(s): The West Health Institute convened leading tele-health organizations to understand best practices for telehealth in PAC settings. The leading organizations that participated in this endeavor are Curavi Health, TripleCare, Avera eCARE, AGS, AMDA, Cobble Hill, CCHP, Foley & Lardner, LLC, SHARP HealthCare and UC San Diego Health.
Result(s): This collaboration developed and shared recommenda-tions on critical components of telehealth implementation to empower PAC settings to improve access and quality of care with telehealth. The completed implementation manual includes guidelines and recommendations on topics such as: Needs Assessments, Readiness Assessments, Financial and Reimbursement models, Implementation, Legal and Policy considerations and Performance Monitoring and Sustainability.
Conclusion(s): Through this extensive network of telehealth advocates, the goal of the collaboration is to disseminate learnings to advance telehealth implementation and enable older adults to success-fully age in place. With informative and guiding resources to assist staff, we can provide them with necessary tools to implement and utilize telehealth and help shape the next generation of post-acute care clinicians

Background/UNASSIGNED:Women with Parkinson's disease (PD) are more likely to be older, have greater disease severity and comorbidities, and yet are less likely to receive care from a neurologist, as compared with men with PD. Within the PD population, homebound individuals are a particularly vulnerable group facing significant barriers to care, yet within this understudied population, sex-related differences have not been reported. Purpose/UNASSIGNED:To identify and describe differences in homebound men and women with advanced PD and related disorders, participating in an interdisciplinary home visit program. Patients and methods/UNASSIGNED:This was an exploratory analysis of homebound patients seen between February 2014 and July 2016 using data collected via in-person interviews and chart review. Results/UNASSIGNED:=0.05). Conclusion/UNASSIGNED:The role of the caregiver in facilitating safe aging-in-place is crucial. Among homebound individuals with advanced PD, women were far more likely to live alone. The absence of a spouse or care partner may be due in part to variable sex-based life expectancies. Our findings suggest that homebound women with advanced PD may face greater barriers to accessing support.

Background/UNASSIGNED:The purpose of this 6-week intervention was to test the feasibility and acceptability of implementing a telehealth-adapted Diabetes Prevention Program (DPP) at a senior center. Methods/UNASSIGNED: = 16) attended weekly interactive webinars. At each measurement time point, participants completed questionnaires covering lifestyle, physical activity, quality of life, and food records and wore physical activity trackers. Qualitative data were gathered from 2 focus groups inviting all 16 participants with 13 and 10 participants attending, respectively. Results/UNASSIGNED:value = 0.001). Conclusion/UNASSIGNED:The feasibility of providing DPP via webinar appears to be high based on the retention and attendance rates. Similar to other behavioral interventions engaging older adults, recruitment rates were low. Acceptability was evidenced by high attendance at the intervention sessions and feedback from participants during focus group sessions. The intervention efficacy should be evaluated based on CDC criteria for program recognition in a larger scale randomized trial. Trial registration/UNASSIGNED:NCT03524404. Registered 14 May 2018-retrospectively registered. Trial protocol will be provided by the corresponding author upon request.

Background: Patients with advanced kidney disease have an elevated symptom burden, increased mortality, and poor quality of life. While palliative care can address these issues, nephrology patients infrequently receive such care. To address this, we implemented an ambulatory kidney palliative care program. We describe our initial outcomes.
Method(s): Utilizing chart abstractions, we characterized the clinic population and symptom burden for patients seen from May 6, 2016-July 6, 2018.
Result(s): Ninety-four patients were referred; 74 (78.7%) patients seen. Forty (54.1%) had follow-up appointments (range 2-13). Mean patient age was 72.7 +/-16 years with 32 (43.2%) on dialysis. The mean symptom burden (n=65) was 12 (+/- 4.9) symptoms (out of 17) with mean severity of 2 (range 0-4), representing moderate severity. The most common physical symptoms were nausea (78%), dyspnea (72%), pain (68%) and itch (66%). Eighty-seven percent reported anxiety and 73% reported depression. There was no difference in symptom burden between patients on dialysis and those on conservative management (n=22). Patients on conservative management were significantly older and had more comorbidities. By visit two, there was a significant reduction in global symptom score (21.9 vs 19.0, p=0.01) in addition to a reduction in anxiety (2.1 vs 1.7, p=0.03), vomiting (0.8 vs 0.2, p=0.04), and restless legs syndrome (1.3 vs 0.8, p = 0.02).
Conclusion(s): Patients with serious kidney disease treated in a kidney palliative care clinic have a high symptom burden regardless of treatment choice. The decision to pursue conservative management is more prevalent in older patients with more comorbidities. Follow up visits to the clinic demonstrated a decrease in symptom burden, suggesting that a dedicated kidney-palliative care clinic may be successful in managing symptoms and addressing unmet need