Faculty Bibliography

Background: Delirium affects 14-56% of hospitalized older adults, and leads to higher morbidity and increased healthcare costs. At NYULH we implemented the EmpoweRing elder Novel Interventions (ERNI) program in 2017, modeled after Hospital Elder Life Program (HELP), but we utilize trained pre-med and pre-nursing volunteers to prevent delirium. We have shown reduced length of stay and a decreased incidence of delirium with ERNI. Here we report on ERNI as a novel method to grow the geriatrics workforce.
Method(s): Patients 65 years or older admitted to ICU, ED observation, neurology, cardiology, and general medicine units determined to be at high risk for delirium were visited by trained pre-med/ nursing volunteers who engaged them in conversations, listened to music, reoriented them, worked on puzzles, and advocated for patients' needs. We assessed nursing and volunteer satisfaction, and patient/family satisfaction using Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) data from April 2017- July 2019.
Result(s): 26/31 (84%) nurses rated volunteers 7 or higher on a scale of 1-10, and 84% of nurses felt volunteers helped prevent delirium. The volunteers expressed satisfaction with the program, 17/18 (94%), and felt appreciated by patients and families[BC1]. 16/18 (89%) volunteers plan to pursue a career in healthcare, and 17/18 volunteers (94%) plan to work with older adults. 12/18 (67%) volunteers were the first in their families to work in healthcare. Although not directly related to ERNI, patient HCAHPS scores in the Observation Unit (measured by the hospital), improved after ERNI implementation, with nursing communication increasing from 70.5% to 77% and pain communication from 34.1% to 45.6%.
Conclusion(s): Our ERNI program demonstrated high rates of nursing and volunteer satisfaction, and patients in ED Observation had increased satisfaction. Exposing pre-med/nursing volunteers to older patients in a modified HELP program may be an important step toward increasing recruitment to the geriatrics workforce. For those already considering this career, the ERNI experience might solidify those intentions. Future plans are to expand this program by recruiting more college students as volunteers

Background: Social isolation is common among community dwelling older adults and is associated with adverse health outcomes. Its inverse, social engagement, depends on verbal communication, which can be disrupted by age-related hearing loss (AHRL). AHRL is mitigated with hearing aids, but hearing aid costs can be prohibitive for low income, under-resourced communities. As such, personal amplifiers or hearing assistance devices (HADs), are a feasible alternative that can be delivered at point-of-care to older adults with AHRL. Despite the link between social engagement and hearing, there is little research on mitigating hearing loss to improve patient-reported outcomes such as depressed mood and loneliness, particularly in low-income communities.
Method(s): This ongoing pilot study has enrolled older adults living in federally subsidized Los Angeles housing to assess the feasibility of community-based hearing assessment and provision of hearing assistance devices (HAD). We seek to understand the potential impact of HAD use on patient-reported symptoms. We measure self-reported hearing loss using the Hearing Handicap Inventory (HHI), and at baseline, one, and two months: social isolation using a 4-item instrument, depressed mood using the Patient Health Questionnaire (PHQ)-9, a 6-item loneliness score, and HAD utility using the International Outcome Inventory for Alternative Interventions (IOI-AI).
Result(s): Among 36 recruited participants in three buildings thus far, 30 (83%) reported having hearing difficulties (HHI >=10) and were given Pocket-Talkers. For those with self-reported hearing-related psychosocial difficulties, 8 (27%) endorsed social isolation (>1 of 4); 18 (60%) endorsed at least mild depression (PHQ-9 > 4); and 19 (63%) endorsed loneliness (>1 of 6). Among 16 who have completed 1-month follow-up, no changes have been noted, but 1-month scores on the IOI-AI (mean: 4; range 0-5) suggest very favorable utility.
Conclusion(s): Early results from this pilot study support this as a feasible intervention with positive impact associated with Pocket- Talker use. Further follow-up and subject enrollment is needed to determine whether this intervention improves patient-reported outcomes

Background: Warfarin is efficacious in reducing thromboembolic risks but its use presents challenges to both patients and physicians including the need for monitoring, diet modification, and attention to drug-related interactions. Novel anticoagulants have circumvented many of these issues. Although prior research includes physician consideration of patients' perspective as important in the choice of anticoagulants, patient perceptions about anticoagulant use is unknown.
Method(s): We sought to identify patient perceptions about anticoagulant use in the Geriatrics Warfarin Clinic in Bellevue Hospital, a well-known, large safety net institution in New York City. We formulated a semi-structured telephone interview guide based on prior literature. Two geriatrics fellows (JK, NT) conducted interviews with role switches between interviewer and scribe every 3 interviews. We reviewed interview notes and identified codes. Both fellows independently analyzed all interviews and codes and categorized codes into themes. Any discrepancies were resolved by consensus discussion.
Result(s): Interviews were 10-15 minutes each. Respondents' mean age was 80.4 years (Standard deviation: 8.1); 7 were women (39%). Eight interviews were in English, five (28%) required a language interpreter and five were by proxy at patient request. Thematic saturation was reached at 18 patient interviews revealing six themes. These were: resignation about current warfarin use (n=12); lack of knowledge of alternative anticoagulation (n=16); perceived need for monitoring and efficacy checks (n=6); concerns about side effect profile (n=7); primary physician's recommendation (n=7) and dietary restrictions (n=4). Preference for warfarin use was driven by ability to know its therapeutic level and many patients expressed hesitance in switching with no monitoring procedure.
Conclusion(s): Patients' use of warfarin was generally well accepted. The primary concern was need for dietary modification. Of those patients that appeared neutral or accepting of alternative anticoagulation, the main discussion points were the drug's efficacy, side effect profile, and their physician's recommendation. This study provides useful information on guiding shared decision-making conversations about anticoagulation choice, especially in a patient demographic of predominantly low socioeconomic status individuals

Background: Deconditioning from prolonged bedrest during hospitalization predisposes older patients to loss of mobility and the need for additional rehabilitation post-discharge. Despite recognition of the harms of prolonged bedrest and evidence that resistance training (RT) reverses deconditioning, few interventions have provided such exercise for hospitalized older adults. We evaluated the safety and feasibility of a novel exercise device used in a high-intensity RT routine in older age inpatients.
Method(s): In collaboration with the NYU Grossman School of Medicine Center for Healthcare Innovation and Delivery Science we developed a lightweight, portable RT device, which attaches to a hospital bed footboard and allows for over 20 exercises in 4 categories: upper-body, lower-body, back and core. We recruited and trained willing patients to use this device with a goal of completing 7 exercises per workout. We included inpatients (age > 70) on a general medical unit with a PT/OT order. Those having exercise limiting orthopedic or neurologic disability, and acute cardiopulmonary limitations were excluded. Each workout included exercises from each category, 10-20 isometric 3-second holds per exercise, and minimal rest. Patients were: (1) evaluated on their ability to complete each workout; (2) surveyed on their experience with the device; and (3) monitored for adverse events.
Result(s): 11 patients were trained using the device for an average of 2.0 total sessions per hospitalization (mean age: 80.9 years, range: 71-101; 54.5% female). Reasons for fewer sessions included early discharge, delirium, and contact precautions. Patients completed 89.3% of the exercises they performed. We noted no adverse events. 72.7% stated they would use the device on their own and 90.9% believed there is not enough exercise performed in hospitals.
Conclusion(s): This pilot study provides evidence of the safety and feasibility of a novel RT device to prevent inpatient deconditioning. Patients were eager and able to participate in RT. We did not observe fear of safety or views of high intensity RT as inappropriate for older hospitalized patients. Whether use of RT will change discharge-related outcomes requires further study

Colorectal cancer (CRC) screening has increased substantially in New York City in recent years. However, screening uptake measured by telephone surveys may not fully capture rates among underserved populations. We measured screening completion within one year of a primary care visit among previously unscreened patients in a large urban safety-net hospital and identified sociodemographic and health-related predictors of screening. We identified 21,256 patients aged 50-75 who were seen by primary care providers (PCPs) in 2014, of whom 14,425 (67.9%) were not up-to-date with screening. Since PCPs facilitate the majority of screening, we compared patients who received screening within one year of an initial PCP visit to those who remained unscreened using multivariable logistic regression. Among patients not up-to-date with screening at study outset, 11.5% (1,658 patients) completed screening within one year of a PCP visit. Asian race, more PCP visits, and higher area-level income were associated with higher screening completion. Factors associated with remaining unscreened included morbid obesity, ever smoking, Elixhauser comorbidity index of 0, and having Medicaid/Medicare insurance. Age, sex, language, and travel time to the hospital were not associated with screening status. Overall, 39.9% of patients were up-to-date with screening by 2015. In an underserved urban population, CRC screening disparities remain, and overall screening uptake was low. Since more PCP visits were associated with modestly higher screening completion at one year, additional community-level education and outreach may be crucial to increase CRC screening in underserved populations.

BACKGROUND:The 6-min walk test (6MWT) is a commonly used clinical assessment of exercise capacity in patients with cardiopulmonary or neuromuscular disease, but normal values are lacking for young adults, who are frequent subjects of testing. METHODS:In a two-center study, 272 young adults, ages 18-50, underwent American Thoracic Society protocolized 6-min walk testing, and 56 underwent repeat testing. A linear regression model was developed based on anthropomorphic data. This model was compared to existing prediction equations. RESULTS:Median 6MWD for the cohort was 637 m (IQR 584-686 m) and was not significantly impacted by age. This is in contrast to existing equations extrapolated from older subjects that predict increasing 6MWD in younger subjects. We found weak correlation of 6MWD with height, weight, BMI, and resting heart rate. Heart rate at completion correlated most strongly with 6MWD (rho 0.53 p < 0.0001). Repeat 6MWD was surprisingly variable, with a median difference between tests of 32.5 ± 31.9 m. Established reference equations performed poorly in this population, largely because age has much less effect on 6MWD in this group than in older adults. CONCLUSIONS:Established reference equations should be reconfigured to include data from young adults, as age has minimal effect on 6MWD in this population. Heart rate response may be a valuable measure of effort in normal subjects. Six-minute walk distance, as with pulmonary function and exercise testing, should have predictive equations across the spectrum of age to allow for accurate assessment of exercise limitation.

Adult day centers (ADSCs) provide community-based long-term care, including meals, to racially diverse older adults, 47% of whom have dementia and consequently experience elevated nutritional risk. We examine nutritional practices for Chinese and Vietnamese persons living with dementia (PLWD) in ADSCs, and evaluate the extent to which ADSC's provide person-centered nutritional care. Multi-stakeholder interviews were conducted. Data was coded using Dedoose and analyzed using Braun and Clarke's six-step method. The Model for the Provision of Good Nutritional Care in Dementia guided analysis. Barriers to food intake included distracting meal environment, rigid meal-times, and excessively restrictive diets. Conversely, peer relationships, culturally-tailored meals and celebrations, and consistent staff assisting with feeding benefitted PLWD. ADSCs can support healthy weight and quality of life among PLWD through personcentered nutritional care. To optimize nutritional services, further exploration is needed with respect to the ADSC environment, users' culture and ethnicity, and liberalized diets for PLWD

Non-consensual sexual contact in bars is common, but few studies have focused on the extent of this problem at electronic dance music (EDM) parties, which are growing in popularity. We aimed to estimate prevalence and correlates of non-consensual sexual contact among individuals who attend EDM parties in New York City (NYC). Adults (ages 18-40 years) entering EDM parties in NYC were surveyed in 2018 using time-space sampling. Participants (n = 1005) were asked whether they had experienced unwanted or uninvited sexual contact including unwanted groping, kissing, or touching at an EDM party. We estimate that 15.2% of EDM party attendees in NYC have experienced non-consensual sexual contact at such parties. The majority (62.5%) of those reported that it occurred 1-2 times and 49.1% were usually or always drunk or high during the encounter(s). Almost all women experiencing non-consensual contact (99.5%) were all or mostly touched by men; 38.6% of men were all or mostly touched by other men. Women were at more than twice the odds of reporting non-consensual sexual contact than men (aOR = 2.38, p < .05) with 21.8% of women reporting experiencing non-consensual sexual contact compared to 11.0% of men. Among women, those ages 18-24 were at over twice the odds (aOR = 2.75, p < .05) of experiencing non-consensual sexual contact than those ages 25-40. EDM party environments can increase susceptibility to non-consensual sexual contact. Prevention needs to be geared toward those at risk, and education is needed for those likely to commit non-consensual sexual contact.

BACKGROUND:Elderly patients with Traumatic Brain Injury (TBI) are frequently transferred to designated Trauma Centers (TC). We hypothesized that TC transfer is associated with improved outcomes. METHODS:Retrospective study utilizing the National Trauma Databank. Demographics, injury and outcomes data were abstracted. Patients were dichotomized by transfer to a designated level I/II TC vs. not. Multivariate regression was used to derive the adjusted primary outcome, mortality, and secondary outcomes, complications and discharge disposition. RESULTS:19,664 patients were included, with a mean age of 78.1 years. 70% were transferred to a level I/II TC. Transferred patients had a higher ISS (12 vs. 10, p < 0.001). Mortality was significantly lower in patients transferred to level I/II TCs (5.6% vs. 6.2%, Adjusted Odds Ratio (AOR) 0.84, p = 0.011), as was the likelihood of discharge to skilled nursing facilities (26.4% vs. 30.2%, AOR 0.80, p < 0.001). CONCLUSIONS:Elderly patients with mild TBI transferred to level I/II TCs have improved outcomes. Which patients with mild TBI require level I/II TC care should be examined prospectively.