Faculty Bibliography

OBJECTIVES/OBJECTIVE:The number of older adults on methadone maintenance treatment (MMT) for opioid use disorder is increasing, but little is known about the characteristics and healthcare needs of this aging treatment population. This population may experience accelerated aging due to comorbidities and health behaviors. The aim of this study was to compare the prevalence of geriatric conditions among adults age ≥50 on MMT to a nationally representative sample of community-dwelling older adults. METHODS:We performed a geriatric assessment on 47 adults age ≥50 currently on MMT enrolled in 2 opioid treatment programs, in New York City and in East Providence, Rhode Island. We collected data on self-reported geriatric conditions, healthcare utilization, chronic medical conditions, physical function, and substance use. The results were compared to 470 age, sex, and race/ethnicity-matched adults in the national Health and Retirement Study. RESULTS:The mean age of the study sample was 58.8 years and 23.4% were female. The most common chronic diseases were hypertension (59.6%) and arthritis (55.3%) with 66% reporting ≥2 diseases. For geriatric conditions, adults on MMT had a significantly higher prevalence of mobility, hearing, and visual impairments as well as falls, urinary incontinence, chronic pain, and insomnia than the Health and Retirement Study sample. CONCLUSIONS:Older adults on MMT in 2 large opioid treatment programs have a high prevalence of geriatric conditions. An interdisciplinary, geriatric-based approach to care that focuses on function and addresses geriatric conditions is needed to improve the health of this growing population.

BACKGROUND/UNASSIGNED:Fibroblast growth factor 23 (FGF-23) regulates phosphorus and is associated with cardiovascular disease (CVD), particularly in patients with chronic kidney disease. However, data are limited regarding its contribution to different CVD subtypes across wide age ranges in the general population. METHODS/UNASSIGNED:Using data from ARIC, we evaluated the associations of FGF-23 with heart failure (HF), coronary heart disease (CHD), stroke, and composite CVD (any CVD event) in 12,039 participants at mid-life (visit 3 [1993-1995], mean age 60.0 [SD 5.7] years) and 5608 of the same participants at late-life (visit 5 [2011-2013], 75.5 [5.1] years). RESULTS/UNASSIGNED:-for-difference < 0.001). We observed similar patterns in key demographic and clinical subgroups without interactions. Among CVD subtypes, HF was the only subtype robustly associated with higher FGF-23 at both visits. CONCLUSION/UNASSIGNED:Higher FGF-23 concentrations at late-life but not necessarily at mid-life were independently associated with the risk of CVD. Among CVD subtypes tested, only HF showed robust associations with FGF-23 at both mid-life and late-life.

PURPOSE/OBJECTIVE:Population-based surveys are possible sources from which to draw representative control data for case-control studies. However, these surveys involve complex sampling that could lead to biased estimates of measures of association if not properly accounted for in analyses. Approaches to incorporating complex-sampled controls in density-sampled case-control designs have not been examined. METHODS:We used a simulation study to evaluate the performance of different approaches to estimating incidence density ratios (IDR) from case-control studies with controls drawn from complex survey data using risk-set sampling. In simulated population data, we applied four survey sampling approaches, with varying survey sizes, and assessed the performance of four analysis methods for incorporating survey-based controls. RESULTS:Estimates of the IDR were unbiased for methods that conducted risk-set sampling with probability of selection proportional to survey weights. Estimates of the IDR were biased when sampling weights were not incorporated, or only included in regression modeling. The unbiased analysis methods performed comparably and produced estimates with variance comparable to biased methods. Variance increased and confidence interval coverage decreased as survey size decreased. CONCLUSIONS:Unbiased estimates are obtainable in risk-set sampled case-control studies using controls drawn from complex survey data when weights are properly incorporated.

Stigma is a fundamental driver of adverse health outcomes. Although stigma is often studied at the individual level to focus on how stigma influences the mental and physical health of the stigmatized, considerable research has shown that stigma is multilevel and structural. This paper proposes a theoretical approach that synthesizes the literature on stigma with the literature on scapegoating and divide-and-rule as strategies that the wealthy and powerful use to maintain their power and wealth; the literatures on racial, gender, and other subordination; the literature on ideology and organization in sociopolitical systems; and the literature on resistance and rebellion against stigma, oppression and other forms of subordination. we develop a model of the "stigma system" as a dialectic of interacting and conflicting structures and processes. Understanding this system can help public health reorient stigma interventions to address the sources of stigma as well as the individual problems that stigma creates. On a broader level, this model can help those opposing stigma and its effects to develop alliances and strategies with which to oppose stigma and the processes that create it.

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.

Background: Electronic cigarettes (EC) have been proposed as a harm-reducing alternative in smokers with COPD. Racial and ethnic differences can affect the extent to which smokers in the general population switch from combustible cigarettes (CC) to EC. To help design a targeted intervention for smokers with COPD, we conducted a mixed methods study assessing the relationship between race/ethnicity and switching from CC to EC; and evaluated whether it is mediated by social norms, risk perception, and overall opinions of CC and EC.
Method(s): We recruited patients with COPD, aged 21 to 75, listed as current smokers in the NYU Langone Health electronic health record by phone, mail, and My Chart. Smokers who had moderate COPD (based on the COPD Assessment Test score (CAT)), who smoked >=5 CC a day at least 4 days a week and were interested in quitting were eligible. We randomized participants to EC or nicotine replacement therapy (NRT) for switching from CC. Over 12 weeks, participants received 5 counseling sessions and were asked about their COPD symptoms, CC use, NRT/EC use, and nicotine withdrawal symptoms. We used Ecological Momentary Assessment (four text messages/day) to assess current EC/NRT and CC use. We analyzed the influence of race and ethnicity on switching, considering social norms, risk perception, media influence and overall opinions of tobacco and EC as possible mediators. We conducted in-depth interviews to gain descriptive explanations of study experience and reasons for switching or lack thereof. We used chi squared tests to compare categorical variables and analysis of variance for continuous ones.
Result(s): Among the 48 participants, the average age was 60 (STD 8.2) years and 54% were female. Races/ethnicities were 8% Black; 8% Hispanic/Latino; 81% White; and 3% Other/Not Reported. There was a trend towards decreased dyspnea and COPD symptoms, as well as decreased CC use, in the EC arm compared to the NRT arm. We are still collecting the qualitative data on switching perceptions.
Conclusion(s): Understanding the extent to which racial and ethnic differences in switching from CC to EC can be attributed to social norms, risk perception, media influence, and overall opinions of tobacco and EC; may allow us to design a more effective, more engaging smoking cessation intervention

INTRODUCTION:CareMOBI (Mhealth for Organizations to Bolster Interconnectedness) is a mobile application designed to facilitate information exchange between primary care providers (PCPs) and adult day centers (ADCs). A key function of CareMOBI is to synthesize information collected outside of the provider's office (ie,: in the ADC or at home) and distill the most relevant data points into an exportable clinical summary that can help inform clinical decision making by the PCP with information from outside providers who are not formally embedded within health systems. In this study, we used a qualitative approach to understand the acceptability and utility of the clinical summary template within CareMOBI. METHODS:Purposive sampling, followed by snowball sampling, was used to recruit PCPs from a variety of primary care practice settings (i.e. home-based, academic). Semi-structured interviews were conducted virtually to elicit feedback on the user-experience after interaction with a prototype template. Interviews were recorded, transcribed, and analyzed using content analysis. RESULTS:Our sample (n = 10) consisted of physicians and nurse practitioners in a variety of settings. Feedback suggested that the summary template facilitates interdisciplinary, bidirectional, succinct, and relevant information exchange across care teams. The summary template effectively integrates observations and assessments from team members, centralizes them, and allows PCPs to hone in on the most salient components to inform clinical decision making for the geriatric patient. The summary gave PCPs "live texture" about what was happening outside the office and represented a significant improvement over other methodologies of information exchange. Prior to implementation into clinical practice, several refinements are necessary based on feedback including integration into the PCP's workflow. CONCLUSIONS:The template was viewed by PCPs as a concise and actionable record, in contrast to current communication which is characterized as "bloated"-containing too many pages on nonessential information. The summary could potentially save PCP's time in locating and analyzing historical data to enable rapid patient assessment and prompt more ready and informed action.