Faculty Bibliography

Caring for older adults with multiple chronic conditions (MCCs) is challenging. The American Geriatrics Society (AGS) previously developed The AGS Guiding Principles for the Care of Older Adults with Multimorbidity using a systematic review of the literature and consensus (Table 1). The objective of the current work was to translate these principles into a framework of Actions and accompanying Action Steps for decision-making for clinicians who provide both primary and specialty care to older people with MCCs. A workgroup of geriatricians, cardiologists, and generalists: 1) articulated the core MCC Actions and the Action Steps needed to carry out the Actions; 2) provided decisional tips and communication scripts for implementing the Actions and Action Steps, using commonly encountered situations: 3) performed a scoping review to identify evidence-based, validated tools for carrying out the MCC Actions and Action Steps; and 4) identified potential barriers to, and mitigating factors for, implementing the MCC Actions. The recommended MCC Actions include: 1) Identify and communicate patients' health priorities and health trajectory; 2) Stop, start, or continue care based on health priorities, potential benefit versus harm and burden, and health trajectory; and 3) align decisions and care among patients, caregivers, and other clinicians with patients' health priorities and health trajectory. The tips and scripts for carrying out these Actions are included in the full MCC Action Framework available in the supplement (www.GeriatricsCareOnline.org).

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]

Background: Older adults with multiple chronic conditions (MCCs) must adhere to increasing numbers and complexity of healthcare tasks that may be burdensome and of uncertain benefit. Patient Priorities Care (PPC) is an approach to decision-making focused on achieving patient-specific health outcome goals and avoiding unwanted, potentially burdensome, healthcare. The study aim was to compare perceived treatment burden and categories of ambulatory healthcare utilization between older adults with MCCs who did and did not receive PPC.
Method(s): The design was quasi-experimental with matched PPC and usual care (UC) offices in a primary care practice in Connecticut. Participants included 163 older adults cared for by 10 primary care providers (PCPs) trained in PPC and 203 similar patients who received UC from 7 PCPs at a comparable office. Patient eligibility included: >3 chronic conditions, >=10 medications, or saw >2 specialists in the past year; lack of advanced dementia; and not hospice eligible, resident of a nursing home, or on dialysis. Perceived treatment burden was assessed at baseline and follow-up with the Treatment Burden Questionnaire (TBQ). Healthcare utilization data, abstracted from PCP visit notes over 9-months follow-up, included number (%) of participants with medications added or stopped; diagnostic tests, refer-rals, and procedures ordered or avoided. We estimated a weighted regression model (using inverse probability of PCP office assignment weights) to examine the association between PPC vs UC status and change in TBQ scores. A weighted logistic regression model was esti-mated for the categories of healthcare utilization.
Result(s): TBQ score decreased from baseline to follow-up by 5.2 more points in the PPC vs. UC participants (beta=5.2; p=.05). PPC patients were more likely to have medications stopped (Odds Ratio 2.3; 95% CI, 1.3-3.8) and referrals avoided (5.4; 1.1-25.5) and less likely to have diagnostic tests ordered (0.5; 0.3-0.9) than UC patients. There was a trend of more unwanted procedures avoided (10% vs. 5%) in PPC vs. UC patients.
Conclusion(s): PPC was associated with reduced treatment burden and unwanted utilization, suggesting that aligning care with patients' priorities is feasible and effective for older adults with MCCs

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: Although the population of older adults is rising rapidly, the number of physicians seeking specialty training in geriat-rics is decreasing. This study of fellows in geriatrics training programs across the United States explored motivating factors that led fellows to pursue geriatrics as a career in order to inform the recruiting of more trainees to the field.
Method(s): 10-15 fellows were sought for interviews, until satu-ration was reached. 30-minute semi-structured telephone interviews were conducted by the primary investigator with fifteen geriatrics fellows from academic medical centers across the United States, 14 of whom were at Claude D. Pepper Older Americans Independence Centers. This qualitative study involved interviews that were tran-scribed and descriptively coded by two independent reviewers. A thematic analysis of the codes was summarized.
Result(s): Fifteen geriatrics fellows in seven different states partic-ipated in the study, and they revealed that mentorship and early clin-ical exposure to geriatrics were some of the most influential factors affecting career choice. Having positive attitudes and close relation-ships with older adults prior to medical school are other critical factors in influencing trainees to pursue careers in geriatrics.
Conclusion(s): The results of this study have the potential for a large impact, helping to inform best practices in encouraging trainees to enter the field, and enhancing medical student and resident exposure to geriatrics and mentorship from geriatricians. As the number of older individuals rises, we need innovative ways to draw medical students and residents to geriatrics. This study demonstrates the need for geri-atricians to serve not only as mentors to trainees but also as proactive ambassadors to the field

Background: Forty percent of Americans are expected to develop type 2 diabetes mellitus (DM) within their lifetime, and up to one third of older adults with DM face co-occurring cognitive impair-ment and/or Alzheimer's disease and Related Dementia (ADRD). These co-morbidities create significant challenges in management for both patient and care partner, which is further compounded by a lack of consensus regarding optimal care. We conducted a systematic liter-ature review to better characterize the evidence guiding care for older patients with DM-ADRD.
Method(s): We used the PRISMA method to guide this system-atic review. A specialized librarian searched PubMed (Medline) using relevant search terms related to the management of DM and ADRD. This process yielded 2,158 DM studies and 1,401 ADRD studies. We included studies that were applicable to adults over 60 years old, published within the past 5 years, conducted within a primary care setting and written in English. Our review returned 267 DM and 104 ADRD focused results, of which 50 DM and 40 ADRD studies were included after abstract and full text review requiring two expert votes. Additionally, through expert opinion, we identified an additional 40 DM and 60 ADRD studies for inclusion.
Result(s): Based on this evidence, we identified methods for screening, diagnosis and management of patients with DM and ADRD as well as general principles related to care partner support, geriat-ric care, geriatric syndromes and goals for blood pressure and lipid management.
Conclusion(s): A review of the literature suggested the importance of individualizing care while monitoring and managing care partner stress, geriatric conditions, cognitive changes, complication risks, and glycemic, blood pressure, and cholesterol targets in order to achieve high quality care. The next steps are to use this information to generate decisional guidance for providers of older adults with DM-ADRD

Background/UNASSIGNED:Current guidelines recommend less aggressive target hemoglobin A1c (HbA1c) levels based on older age and lower life expectancy for older adults with diabetes. The effectiveness of electronic health record (EHR) clinical decision support (CDS) in promoting guideline adherence is undermined by alert fatigue and poor workflow integration. Integrating behavioral economics (BE) and CDS tools is a novel approach to improving adherence to guidelines while minimizing clinician burden. Methods/UNASSIGNED: = 8), (2) a 2-h, design-thinking workshop to derive and refine initial module ideas, and (3) semi-structured group interviews at each site with clinic leaders and clinicians to elicit feedback on three proposed nudge module components (navigator section, inbasket refill protocol, medication preference list). Detailed field notes will be summarized by module idea and usability theme for rapid iteration. Frequency of firing and user action taken will be assessed in the first month of implementation via EHR reporting to confirm that module components and related reporting are working as expected as well as assess utilization. To assess the utilization and feasibility of the new tools and generate estimates of clinician compliance with the Choosing Wisely guideline for diabetes management in older adults, a 6-month, single-arm pilot study of the BE-EHR module will be conducted in six outpatient primary care clinics. Discussion/UNASSIGNED:We hypothesize that a low burden, user-centered approach to design will yield a BE-driven, CDS module with relatively high utilization by clinicians. The resulting module will establish a platform for exploring the ability of BE concepts embedded within the EHR to affect guideline adherence for other use cases.

OBJECTIVES/OBJECTIVE:While patients' health priorities should inform healthcare, strategies for doing so are lacking for patients with multiple conditions. We describe challenges to, and strategies that support, patients' priorities-aligned decision-making. DESIGN/METHODS:Participant observation qualitative study. SETTING/METHODS:Primary care and cardiology practices in Connecticut. PARTICIPANTS/METHODS:Ten primary care clinicians, five cardiologists, and the Patient Priorities implementation team (four geriatricians, physician expert in clinician training, behavioral medicine expert). The patients discussed were ≥ 66 years with >3 chronic conditions and ≥10 medications or saw ≥ two specialists. EXPOSURE/METHODS:Following initial training and experience in providing Patient Priorities Care, the clinicians and Patient Priorities implementation team participated in 21 case-based, group discussions (10 face-to-face;11 telephonic). Using emergent learning (i.e. learning which arises from interactions among the participants), participants discussed challenges, posed solutions, and worked together to determine how to align care options with the health priorities of 35 patients participating in the Patient Priorities Care pilot. MAIN OUTCOMES/RESULTS:Challenges to, and strategies for, aligning decision-making with patient's health priorities. RESULTS:Categories of challenges discussed among participants included uncertainty, complexity, and multiplicity of problems and treatments; difficulty switching to patients' priorities as the focus of decision-making; and differing perspectives between patients and clinicians, and among clinicians. Strategies identified to support patient priorities-aligned decision-making included starting with one thing that matters most to each patient; conducting serial trials of starting, stopping, or continuing interventions; focusing on function (i.e. achieving patient's desired activities) rather than eliminating symptoms; basing communications, decision-making, and effectiveness on patients' priorities not solely on diseases; and negotiating shared decisions when there are differences in perspectives. CONCLUSIONS:The discrete set of challenges encountered and the implementable strategies identified suggest that patient priorities-aligned decision-making in the care of patients with multiple chronic conditions is feasible, albeit complicated. Findings require replication in additional settings and determination of their effect on patient outcomes.