Faculty Bibliography

Background: We recently implemented the Age-Friendly Health System's 4Ms (What Matters, Medication, Mentation, and Mobility) framework in New York City Health + Hospitals/Bellevue Hospital Center's Geriatrics clinic to improve care of older adults.
Method(s): We examined the impact of 4Ms assessment on patient care and changes in care processes through specific interventions triggered after assessment. We conducted chart reviews of patient visits during March 2021, the first month of 4Ms implementation and identified interventions made during these visits. To assess "What Matters" providers asked "What Matters the most to you;" potentially inappropriate Medications (PIM) were identified using the Beers list; Mentation was evaluated using the Mini-Cog; and Mobility was determined using timed up and go (TUG) test. We used descriptive statistics to characterize findings.
Result(s): Among the 121 patients who had 4Ms assessment in March 2021, 85% (n=103) were asked "What Matters;" providers reviewed Medications for almost all (n=118; 98%) and conducted a Mini-Cog for 64% (n=78). Most not cognitively assessed were either previously screened (n=11; 9%) or had dementia (n=12; 10%). Providers used the TUG test for 87% (n=105). What Mattered to patients most commonly was "getting better" (n=24; 23%). There were 39 (33%) patients with potentially inappropriate Medications (including proton pump inhibitors, gabapentinoids, and NSAIDS) of which 10 (26%) Medications were either discontinued or reduced. Other interventions included further cognitive evaluation (n=2) and home care referrals (n=2) among 14 (18%) with an abnormal Mini- Cog. Among the 51 (42%) patients with an abnormal TUG, providers intervened for 19 (37%) with devices, referrals or home services.
Conclusion(s): The adoption of 4Ms assessment during routine visits identified issues with Medications, Mentation and Mobility, triggering several interventions for common geriatric conditions. 4Ms assessment is a helpful strategy to organize geriatric care, routinely assess patients for common geriatric syndromes, and improve care. Future directions include prioritizing interventions integrated with "What Matters" to maintain patient-centered care

Background: Mobile health cardiac rehabilitation (mHealth-CR) may improve outcomes among older adults with ischemic heart disease, but variable engagement is not yet understood. We therefore analyzed preliminary data from the RESILIENT trial, an ongoing randomized trial of mHealth-CR vs. usual care in patients age >= 65.
Method(s): Data from the first 50 intervention participants were analyzed. Weekly engagement was scored from 0-11 based on exercise completion, therapist communication, video viewing, and BP self-measurement. Participants were classified as high or low engagement based on median engagement scores. Groups were compared by age, sex, social support (living alone), depression (PHQ-8), and Charlson Comorbidity Index (CCI).
Result(s): There was widely varying engagement with mHealth-CR that ranged from nearly zero to nearly perfect engagement (Figure). There were no significant differences between high and low engagement groups based on mean age (72.6 vs. 72.8, P=0.8), sex (76% male vs. 80%, P=0.7), living alone (28% vs. 44%, P=0.2), depression (mean 3.9 vs. 4.6, P=0.5), or comorbidity burden (mean 4.4 vs. 4.8, P=0.3), although the sample size was small.
Conclusion(s): Our early findings show wide variation in mHealth-CR engagement among older adults

INTRODUCTION/UNASSIGNED:In order to obtain FDA Marketing Authorization for aid in the diagnosis of concussion, an eye tracking study in an intended use population was conducted. METHODS/UNASSIGNED:Potentially concussed subjects recruited in emergency department and concussion clinic settings prospectively underwent eye tracking and a subset of the Sport Concussion Assessment Tool 3 at 6 sites. The results of an eye tracking-based classifier model were then validated against a pre-specified algorithm with a cutoff for concussed vs. non-concussed. The sensitivity and specificity of eye tracking were calculated after plotting of the receiver operating characteristic curve and calculation of the AUC (area under curve). RESULTS/UNASSIGNED:= 282) was 31.6%. CONCLUSION/UNASSIGNED:A pre-specified algorithm and cutoff for diagnosis of concussion vs. non-concussion has a sensitivity and specificity that is useful as a baseline-free aid in diagnosis of concussion. Eye tracking has potential to serve as an objective "gold-standard" for detection of neurophysiologic disruption due to brain injury.

Introduction:Patient and family-centered rounds (PFCRs) are an important element of family-centered care often used in the inpatient pediatric setting. However, techniques and best practices vary, and faculty, trainees, nurses, and advanced care providers may not receive formal education in strategies that specifically enhance communication on PFCRs. Methods:Harnessing the use of structured communication, we developed the Patient and Family-Centered I-PASS Safer Communication on Rounds Every Time (SCORE) Program. The program uses a standardized framework for rounds communication via the I-PASS mnemonic, principles of health literacy, and techniques for patient/family engagement and bidirectional communication. The resident and advanced care provider training materials, a component of the larger SCORE Program, incorporate a flipped classroom approach as well as interactive exercises, simulations, and virtual learning options to optimize learning and retention via a 90-minute workshop. Results:Two hundred forty-six residents completed the training and were evaluated on their knowledge and confidence regarding key elements of the curriculum. Eighty-eight percent of residents agreed/strongly agreed that after training they could activate and engage families and all members of the interprofessional team to create a shared mental model; 90% agreed/strongly agreed that they could discuss the roles/responsibilities of various team members during PFCRs. Discussion:The Patient and Family-Centered I-PASS SCORE Program provides a structured framework for teaching advanced communication techniques that can improve provider knowledge of and confidence with engaging and communicating with patients/families and other members of the interprofessional team during PFCRs.

BACKGROUND:City-wide lockdowns and school closures have demonstrably impacted COVID-19 transmission. However, simulation studies have suggested an increased risk of COVID-19 related morbidity for older individuals inoculated by house-bound children. This study examines whether the March 2020 lockdown in New York City (NYC) was associated with higher COVID-19 hospitalization rates in neighborhoods with larger proportions of multigenerational households. METHODS:We obtained daily age-segmented COVID-19 hospitalization counts in each of 166 ZIP code tabulation areas (ZCTAs) in NYC. Using Bayesian Poisson regression models that account for spatiotemporal dependencies between ZCTAs, as well as socioeconomic risk factors, we conducted a difference-in-differences study amongst ZCTA-level hospitalization rates from February 23 to May 2, 2020. We compared ZCTAs in the lowest quartile of multigenerational housing to other quartiles before and after the lockdown. FINDINGS/RESULTS:Among individuals over 55 years, the lockdown was associated with higher COVID-19 hospitalization rates in ZCTAs with more multigenerational households. The greatest difference occurred three weeks after lockdown: Q2 vs. Q1: 54% increase (95% Bayesian credible intervals: 22-96%); Q3 vs. Q1: 48% (17-89%); Q4 vs. Q1: 66% (30-211%). After accounting for pandemic-related population shifts, a significant difference was observed only in Q4 ZCTAs: 37% (7-76%). INTERPRETATION/CONCLUSIONS:By increasing house-bound mixing across older and younger age groups, city-wide lockdown mandates imposed during the growth of COVID-19 cases may have inadvertently, but transiently, contributed to increased transmission in multigenerational households.

INTRODUCTION:This study aimed to characterize the association of cognitive decline starting in midlife with brain pathology in late life in the absence of dementia. METHODS:Nondemented Atherosclerosis Risk in Communities participants with brain imaging, all cognitive factor scores (CFSs), and nonmissing covariates were included. CFSs were collected at three visits across 21 years (1990-2013) (short-term cognitive change [1990-1996], long-term cognitive change [1990-2013]), and brain magnetic resonance imaging and florbetapir positron emission tomography (PET) imaging were collected in 2011-13 (PET subset n = 327). Outcomes of interest were total and regional brain volumes (cm3), log2 (white matter hyperintensity volume), white matter integrity (fractional anisotropy, mean diffusivity), ≥1 lacunar infarct (3-20 mm), and elevated brain β-amyloid (SUVR >1.2). Multivariable linear/logistic regression related outcomes to CFS slopes after adjusting for demographics and total intracranial volume. RESULTS:At baseline, the 1,734 participants had a mean (SD) age of 55 (5.2) years, and were 60% female and 26% Black. After adjustment, a 1-SD larger long-term decline in CFS was associated with a smaller relative total brain volume by 1.2% (95% CI: 1.0, 1.5), a smaller relative temporal lobe meta region volume by 1.9% (1.5, 2.3), a 13% (9, 17) larger volume of white matter hyperintensities, a 1.3-fold (1.2, 1.4) higher odds of having ≥1 lacune, and 1.7-fold (1.3, 2.2) higher odds of elevated brain β-amyloid deposition and worse white matter integrity. Some long-term associations were also found for midlife short-term declines in CFS. CONCLUSIONS:This study provides evidence that starting in midlife, short-term and long-term declines in cognition are associated with multiple deleterious late-life differences in nondemented brains.