Faculty Bibliography

Background/UNASSIGNED:A large proportion of our older adults live with Alzheimer's Disease and Related Dementias and the number of those diagnosed in the future is expected to increase dramatically as the population ages. Persons with dementia bring unique healthcare challenges due to the manifestation of behavioral and psychological symptoms associated with the disease. The lack of geriatric clinicians as well as a properly trained non-geriatric specialist workforce capable of addressing the symptoms persons with dementia exacerbate the challenge of providing effective care. Pharmacological interventions are contraindicated for treatment of most behavioral psychological symptoms of dementia (BPSD). The Centers for Medicare and Medicaid Services now requires that nonpharmacological interventions be used as a first-line treatment. It has not been determined what nonpharmacological intervention for BPSD are most effective and what the infrastructure would entail for such interventions for PWD living at home. Purpose of Review/UNASSIGNED:The purpose of this study is to examine the literature focusing on interventions aimed towards managing persons' symptoms of dementia living in home-based settings. A scoping review examining the literature published on this topic over the last three years was conducted. Recent Findings/UNASSIGNED:One thousand twenty four articles were found, of which nine met inclusion criteria. Five articles used occupational based therapy, two used exercise therapy and one article was found utilizing aromatherapy and music therapy.

Information regarding nutritional risk among users of American adult day health centers (ADHCs), 60% of whom are racial minorities, is scant. This study examined nutritional risk and associated factors in a diverse sample ADHC users aged 50+ using secondary cross-sectional analysis of data collected between 2013 and 2017. Risk was assessed using the DETERMINE checklist, and results were stratified by race. The majority of the sample (N = 188) was at moderate (45.2%) or high (38.5%) nutritional risk, with statistically significant racial differences. Blacks were at greater risk than any other group: 65% had high nutritional risk; 76.5% ate <5 servings of fruits, vegetables, or milk daily; 21% ate <2 meals daily, 48.5% reported involuntary weight loss/gain, and 41.2% had tooth loss/mouth pain. Older adults in ADHCs are at elevated risk of malnutrition, disproportionately so amongst blacks. Both routine nutrition screening and population-specific approaches are needed to attenuate risk.

INTRODUCTION/BACKGROUND:Emergency departments (ED) care for society's most vulnerable older adults who present with exacerbations of chronic disease at the end of life, yet the clinical paradigm focuses on treatment of acute pathologies. Palliative care interventions in the ED capture high-risk patients at a time of crisis and can dramatically improve patient-centred outcomes. This study aims to implement and evaluate Primary Palliative Care for Emergency Medicine (PRIM-ER) on ED disposition, healthcare utilisation and survival in older adults with serious illness. METHODS AND ANALYSIS/UNASSIGNED:This is the protocol for a pragmatic, cluster-randomised stepped wedge trial to test the effectiveness of PRIM-ER in 35 EDs across the USA. The intervention includes four core components: (1) evidence-based, multidisciplinary primary palliative care education; (2) simulation-based workshops; (3) clinical decision support; and (4) audit and feedback. The study is divided into two phases: a pilot phase, to ensure feasibility in two sites, and an implementation and evaluation phase, where we implement the intervention and test the effectiveness in 33 EDs over 2 years. Using Centers for Medicare and Medicaid Services (CMS) data, we will assess the primary outcomes in approximately 300 000 patients: ED disposition to an acute care setting, healthcare utilisation in the 6 months following the ED visit and survival following the index ED visit. Analysis will also determine the site, provider and patient-level characteristics that are associated with variation in impact of PRIM-ER. ETHICS AND DISSEMINATION/UNASSIGNED:Institutional Review Board approval was obtained at New York University School of Medicine to evaluate the CMS data. Oversight will also be provided by the National Institutes of Health, an Independent Monitoring Committee and a Clinical Informatics Advisory Board. Trial results will be submitted for publication in a peer-reviewed journal. TRIAL REGISTRATION NUMBER/BACKGROUND:NCT03424109; Pre-results.

Objectives/UNASSIGNED:Adult day health centers (ADHCs) serve >260,000 chronically ill individuals annually and are a preferred long-term care source for racial minorities, who also experience diet related disparities. Evidence regarding prevalence of nutritional risk is needed to inform dietary intervention planning in ADHCs. This study (1) identified prevalence of nutritional risk and associated factors, in a diverse sample of older ADHC users, (2) stratified differences in nutritional risk by race, and (3) explored associations between nutritional risk, chronic illness, and healthcare utilization. Methods/UNASSIGNED: < .05) differences among White Non-Hispanics, Blacks, Hispanics, and Asians aged >50. Bivariate chi-square tests were used to explore associations between nutritional risk and chronic disease, as well as healthcare utilization. Results/UNASSIGNED: = .01) were significant. Among blacks, 76.5% ate < 5 servings of fruits, vegetables, or milk daily, compared to 39.5% of whites; 21% of blacks ate <2 meals a day, compared to 2% of whites and Hispanics. Blacks (48.5%) more often reported involuntary weight loss/gain compared to whites (23.3%), and had the highest prevalence of tooth loss/mouth pain (41.2%) of any racial group. Conclusions/UNASSIGNED:Older adults in ADHCs are at elevated risk of malnutrition, and blacks disproportionately so. Routine nutritional screening in ADHCs should be considered, but customized population specific approaches are needed to address unique drivers of malnutrition risk. Funding Sources/UNASSIGNED:New York University Center for the Study of Asian American Health Pilot Project Program for Alzheimer's Disease & Thomas J. Long Foundation. Supporting Tables Images and/or Graphs/UNASSIGNED/:

Few investigations examine patterns of opioid and nonopioid analgesic prescribing and concurrent pain intensity ratings before and after institution of safer prescribing programs such as the October 2013 Veterans Health Administration system-wide Opioid Safety Initiative (OSI) implementation. We conducted a quasi-experimental pre-post observational study of all older U.S. veterans (≥50 years old) with osteoarthritis of the knee or hip. All associated outpatient analgesic prescriptions and outpatient pain intensity ratings from January 1, 2012 to December 31, 2016, were analyzed with segmented regression of interrupted time series. Standardized monthly rates for each analgesic class (total, opioid, nonsteroidal anti-inflammatory drug, acetaminophen, and other study analgesics) were analyzed with segmented negative binomial regression models with overall slope, step, and slope change. Similarly, segmented linear regression was used to analyze pain intensity ratings and percentage of those reporting pain. All models were additionally adjusted for age, sex, and race. Before OSI implementation, total analgesic prescriptions showed a steady rise, abruptly decreasing to a flat trajectory after OSI implementation. This trend was primarily due to a decrease in opioid prescribing after OSI. Total prescribing after OSI implementation was partially compensated by continuing increased prescribing of other study analgesics as well as a significant rise in acetaminophen prescriptions (post-OSI). No changes in nonsteroidal anti-inflammatory drug prescribing were seen. A small rise in the percentage of those reporting pain but not mean pain intensity ratings continued over the study period with no changes associated with OSI. Changes in analgesic prescribing trends were not paralleled by changes in reported pain intensity for older veterans with osteoarthritis.

BACKGROUND:Hospital at home (HaH) is a model of care that provides acute-level services in the home. HaH has been shown to improve quality and patient satisfaction, and reduce iatrogenesis and costs. Uptake of HaH in the United States has been limited, and little research exists on how to implement it successfully. OBJECTIVES/OBJECTIVE:This study examined facilitators and barriers to implementation of an HaH program. DESIGN/METHODS:A HaH program that included a 30-day transitional care bundle following the acute stay was implemented through a Centers for Medicare & Medicaid Services Innovations Award. Informants completed a priming table describing initial implementation components, their barriers, and facilitators. These were followed up with semistructured focus groups and individual interviews that were transcribed and independently coded using thematic analysis by two independent investigators. SETTING/METHODS:Large urban academic health system. PARTICIPANTS/METHODS:Clinical and administrative personnel from Mount Sinai, the Visiting Nurse Service of New York, and executive leaders at partner organizations (laboratory, pharmacy, radiology, and transportation). RESULTS:To facilitate successful development and implementation of a high-quality HaH program, a number of barriers needed to be overcome through significant teamwork and communication internally with policymakers and external partners. Areas of paramount importance include facilitating work-arounds to regulatory barriers and health system policies; altering an electronic health record that was not designed for HaH; developing the necessary payment and billing mechanisms; and building effective and collaborative partnerships and communication with outside vendors. CONCLUSION/CONCLUSIONS:Development of HaH programs in the United States are feasible but require strategic planning and development of strong, tightly coordinated partnerships.