Faculty Bibliography

BACKGROUND:Homebound individuals with advanced Parkinson's Disease (PD) require intensive caregiving, the majority of which is provided by informal, family caregivers. PD caregiver strain is an independent risk factor for institutionalization. There are currently no effective interventions to support advanced PD caregivers. Studies in other neurologic disorders, however, have demonstrated the potential for peer mentoring interventions to improve caregiver outcomes. In the context of an ongoing trial of interdisciplinary home visits, we designed and piloted a nested trial of caregiver peer mentoring for informal caregivers of individuals with advanced PD. OBJECTIVE:To test the feasibility of peer mentoring for caregivers of homebound individuals with advanced PD and to evaluate its effects on anxiety, depression, and caregiver strain. METHODS:Single-center pilot study of 16 weeks of caregiver peer mentoring nested within a yearlong controlled trial of interdisciplinary home visits. We recruited 34 experienced former or current family caregivers who completed structured mentor training. Caregivers enrolled in the larger interdisciplinary home visit trial consented to receive 16 weeks of weekly, one-to-one peer mentoring calls with a trained peer mentor. Weekly calls were guided by a curriculum on advanced PD management and caregiver support. Fidelity to and satisfaction with the intervention were gathered via biweekly study diaries. Anxiety, depression, and caregiver strain were measured pre- and post-mentoring intervention at Home Visits 2 and 3. RESULTS:Enrollment and peer mentor training began in 2018, and 65 caregivers enrolled in the overarching trial. The majority of mentors and mentees were white, female spouses or partners of individuals with PD, and mentors had a mean of 8.7 years of caregiving experience (SD 6.4). Thirty-three mentors were matched with at least one mentee. CONCLUSIONS:This is the first study of caregiver peer mentoring in PD and may establish an adaptable and sustainable model for disease-specific caregiver interventions in PD and other neurodegenerative diseases. CLINICALTRIAL/BACKGROUND:ClinicalTrials.gov NCT03189459; http://clinicaltrials.gov/ct2/show/ NCT03189459.

BACKGROUND:Substance use disorders (SUD) elevate the risk for COVID-19 hospitalization, but studies are inconsistent on the relationship of SUD to COVID-19 mortality. METHODS:Veterans Health Administration (VHA) patients treated in 2019 and evaluated in 2020 for COVID-19 (n=5,556,315), of whom 62,303 (1.1%) tested positive for COVID-19 (COVID-19+). Outcomes were COVID-19+ by 11/01/20, hospitalization, ICU admission, or death within 60 days of a positive test. Main predictors were any ICD-10-CM SUDs, with substance-specific SUDs (cannabis, cocaine, opioid, stimulant, sedative) explored individually. Logistic regression produced unadjusted and covariate-adjusted odds ratios (OR; aOR). RESULTS:Among COVID-19+ patients, 19.25% were hospitalized, 7.71% admitted to ICU, and 5.84% died. In unadjusted models, any SUD and all substance-specific SUDs except cannabis use disorder were associated with COVID-19+(ORs=1.06-1.85); adjusted models produced similar results. Any SUD and all substance-specific SUDs were associated with hospitalization (aORs: 1.24-1.91). Any SUD, cocaine and opioid disorder were associated with ICU admission in unadjusted but not adjusted models. Any SUD, cannabis, cocaine, and stimulant disorders were inversely associated with mortality in unadjusted models (OR=0.27-0.46). After adjustment, associations with mortality were no longer significant. In ad hoc analyses, adjusted odds of mortality were lower among the 49.9% of COVID-19+ patients with SUD who had SUD treatment in 2019, but not among those without such treatment. CONCLUSIONS:In VHA patients, SUDs are associated with COVID-19 hospitalization but not COVID-19 mortality. SUD treatment may provide closer monitoring of care, ensuring that these patients received needed medical attention, enabling them to ultimately survive serious illness.

BACKGROUND:There is renewed interest in the clinical application of hallucinogenic substances to treat a range of psychiatric conditions. However, there is mixed evidence regarding how use of such substances outside of medical settings relates to psychological distress, depression, and suicidality. METHODS:We examined data from a US representative sample of noninstitutionalized adults from the 2015-2020 National Survey on Drug Use and Health (N = 241,675). We evaluated whether past-year use of specific hallucinogens (i.e., LSD, DMT/AMT/Foxy, salvia divinorum, ecstasy [MDMA/Molly], ketamine) is associated with reporting past-year serious psychological distress (SPD), major depressive episode (MDE), and suicidality. Generalized linear models using Poisson and log link were used to estimate adjusted prevalence ratios (aPRs), controlling for sociodemographic characteristics and past-year use of various other illegal drugs. RESULTS:LSD use was associated with an increased likelihood of MDE (aPR = 1.23, 95% CI: 1.10-1.37) and suicidal thinking (aPR = 1.21, 95% CI: 1.09-1.34). Similar associations were observed between salvia divinorum use and suicidal thinking (aPR = 1.41, 95% CI: 1.00-1.97) and between DMT/AMT/Foxy use and suicidal planning (aPR = 1.81 95% CI: 1.17-2.81). On the other hand, ecstasy use was associated with a decreased likelihood of SPD (aPR = 0.83, 95% CI: 0.77-0.89), MDE (aPR = 0.91, 95% CI: 0.83-1.00), and suicidal thinking (aPR = 0.86, 95% CI: 0.75-0.99). CONCLUSION/CONCLUSIONS:Findings suggest there are differences among specific hallucinogens with respect to depression and suicidality. More research is warranted to understand consequences of and risk factors for hallucinogen use outside of medical settings among adults experiencing depression or suicidality.

BACKGROUND AND OBJECTIVES/OBJECTIVE:The rapidly aging and diversifying U.S. population is challenged by increases in prevalence of Alzheimer's disease (AD) and aging-related disorders. We conducted a scoping review to assess equitable inclusion of diverse older adult populations in aging research focused on National Institutes of Health (NIH)-sponsored research. RESEARCH DESIGN AND METHODS/METHODS:The scoping review was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA-Scr) Protocol. The search was limited to NIH-funded studies focusing on aging, AD and Alzheimer's disease-related dementias (ADRD) and included adults aged 55+. The priority populations and health disparities put forth by the NIA Health Disparities Framework serve as a model for guiding inclusion criteria and for interpreting the representation of these underrepresented groups, including racial ethnic minorities, socioeconomically disadvantaged, rural populations, groups with disabilities, and LGBTQ communities. RESULTS:Our search identified 1,177 records, of which 436 articles were included in the analysis. Inclusion of individuals with ADRD and mild cognitive impairment, racial ethnic minorities, rural populations, socioeconomically disadvantaged, groups with disabilities, and LGBTQ communities were poorly specified in most studies. Studies used multiple recruitment methods, conducting studies in community settings (59%) and hospitals/clinics (38%) most frequently. Incentives, convenience factors, and sustained engagement via community-based and care partners were identified as key strategies for improved retention. DISCUSSION AND IMPLICATIONS/CONCLUSIONS:This scoping review identified gaps in existing literature and aims for future work, including stronger research focus on, better inclusion of, and improved data collection and reporting of older adults from underrepresented groups.

BACKGROUND:Hospice care was initially designed for seriously ill individuals with cancer. Thus, the model and clinicians were geared toward caring for this population. Despite the proportion of persons living with dementia (PLWD) receiving hospice care substantially increased over the past 10 years, and their longer lengths of stay, established hospice interventions for this population are scarce. No systematic review has previously evaluated those interventions that do exist. We synthesized hospice intervention studies for PLWD, their families, and hospice professionals by describing the types of interventions, participants, outcomes, and results; assessing study quality; and identifying promising intervention strategies. METHODS:A systematic review was conducted using a comprehensive search of five databases through March 2021 and follow-up hand searches. Included studies were peer-reviewed, available in English, and focused on hospice interventions for persons with dementia, and/or care partners, and clinicians. Using pre-determined inclusion and exclusion criteria, data was extracted guided by the Cochrane Checklist, and quality was assessed using a 26-item Consolidated Standards of Reporting Trials (CONSORT) Checklist. RESULTS:The search identified 3235 unique studies in total, of which 10 studies met inclusion criteria. The search revealed three types of interventions: clinical education and training, usual care plus care add-on services, and "other" delivered to 707 participants (mostly clinicians). Five studies included underrepresented racial and ethnic groups. Outcomes measured knowledge and skills, psychosocial and health outcomes, feasibility, and acceptability, with significant improvements in six studies. Study quality was reflective of early-stage research with clinical education and training strategies showing deliberate progression towards real-world efficacy testing. IMPLICATIONS/CONCLUSIONS:Hospice interventions for PLWD are sparse and in early-phase research. More research is needed with rigorous designs, diverse samples, and outcomes considering the concordance of care.

OBJECTIVES/OBJECTIVE:Our study documented communication workflows across adult day care centers (ADCs) and primary care providers (PCPs) around complex needs of persons living with dementia (PLWD). We also identified barriers and facilitators to productive communication in clinical decision support and clinical information systems. MATERIALS AND METHODS/METHODS:We conducted 6 focus groups with ADC staff (N = 33) and individual semistructured interviews with PCPs (N = 22) in California. The eHealth Enhanced Chronic Care Model was used to frame the directed qualitative content analysis. RESULTS:Our results captured cumbersome and ineffective workflows currently used to exchange information across PCPs and ADCs. Stakeholders characterized current communication as (1) infrequent, (2) delayed, (3) incomplete, (4) unreliable, (5) irrelevant, and (6) generic. Conversely, communication that was bidirectional, relevant, succinct, and interdisciplinary was needed to elevate the standard of care for PLWD. DISCUSSION AND CONCLUSION/CONCLUSIONS:ADCs possess a wealth of information that can support clinical decision-making across community-based providers involved in the care of PLWD, especially PCPs. However, effective information exchange is mired by complicated workflows that rely on antiquated technologies (eg, facsimile) and standard templates. Current information exchange largely focuses on satisfying regulatory guidelines rather than supporting clinical decision-making. Integrating community-based services into the health care continuum is a necessary step in elevating the standard of care for PLWD. In the absence of interoperable electronic health records, which may not be financially viable for ADCs, other options, such as mobile health, should be explored to facilitate productive information exchange of personalized relevant information.

Given the growth of the older adult population in the United States, there is a greater need for tools to enable students, trainees, and clinicians to master the comprehensive geriatric assessment. Our goal was to develop a mobile phone application (app) to assist in performing this assessment. We performed a market survey of 45 apps that related to geriatrics and health screening. We evaluated for usability, target audience, and instruments used. Deficiencies included: (1) focusing on a single domain; (2) being time-intensive; and (3) having components behind a paywall. We then designed an app that incorporates instruments that are well-validated, available at no cost, and brief in length. GeriKit includes eight domains: cognition, depression, function, strength, medications, falls, and advance care planning. Each instrument requires fewer than 5 minutes, and once it is completed and scored, the user can access relevant educational materials. GeriKit was launched for Apple users in December 2020, and for Android in August 2021. There have been over 3,400 downloads to date. The GeriKit app makes the comprehensive geriatric assessment accessible to a wide audience, improving the ability to for learners to perform geriatric assessments.

In October 2021 the Food and Drug Administration released draft rules creating a new class of hearing aids to be sold over the counter. Since Medicare does not cover hearing aids, the ready availability of low-cost aids is potentially good news for the millions of older Americans with hearing loss, a disorder that is associated with isolation, depression and poor health. However, better financial access to hearing aids will not necessarily translate into better hearing: many older people will need assistance in fitting, using and maintaining their aids. Policymakers, managers, and clinicians need to consider how to structure, fund and deliver these vital adjunctive services.

Americans near the end of life experience high rates of nonbeneficial, burdensome, and preventable hospital-based care. If patients' goals of care are unknown or unclear, they have higher rates of hospitalization at the end of life. The demand for palliative care has grown exponentially because of its impact on quality of life, symptom burden, and resource use, requiring the development of new palliative care models. Nurses' holistic outlook and patient-centered focus make them ideal to deliver telephonic palliative care. This article discusses 4 cases delivered by a nurse-led telephonic palliative care program, a part of the Emergency Medicine Palliative Care Access project, which is a randomized controlled trial comparing outpatient palliative care with nurse-led telephonic case management after an emergency department visit. Telephonic nurses discuss patients' goals, fears, hopes, and concerns regarding their illness and its trajectory that inform decisions for future interventions and treatments. In addition, they share this information with the patients' surrogate decision-makers and clinicians to facilitate care coordination and symptom management. For seriously ill patients, nurses' abilities and expertise, as well as the difficulties of providing care through in-person models of palliative care delivery, make a nurse-led telephonic model an optimal option.