Faculty Bibliography

OBJECTIVE:Self-management education and support are essential for improved diabetes control. A 1-year randomized telephonic diabetes self-management intervention (Bronx A1C) among a predominantly Latino and African American population in New York City was found effective in improving blood glucose control. To further those findings, this current study assessed the intervention's impact in reducing health care utilization and costs over 4 years. RESEARCH DESIGN AND METHODS:= 816) health care utilization for Bronx A1C participants using an administrative data set containing all hospital discharges for New York State from 2006 to 2014. Multilevel mixed modeling was used to assess changes in health care utilization and costs between the telephonic diabetes intervention (Tele/Pr) arm and print-only (PrO) control arm. RESULTS:during individuals' participation in the 1-year intervention. CONCLUSIONS:These results indicate that the impact of the Bronx A1C intervention was not just on short-term improvements in glycemic control but also on long-term health care utilization. This finding is important because it suggests the benefits of the intervention were long-lasting with the potential to not only reduce hospitalizations but also to lower hospital-associated costs.

Background: Up to one third of older adults with diabetes (DM) have co-occurring cognitive impairment and/or Alzheimer's disease and Related Dementias (ADRD). These patients are more likely to experience episodes of hypo and hyperglycemia. The American Geriatric Society (AGS) and American Diabetic Association (ADA) recommend liberalizing hemoglobin (Hb) A1c targets for patients with multiple comorbidities, but the impact of ADRD on glycemic management of patients with DM-ADRD is unknown.
Method(s): Within the primary care and endocrine clinics in the NYU Langone Health System, we collected characteristics of DM-ADRD patients participating in a DM-ADRD clinical quality improvement program. We administratively collected patients' most recent (within18 months) HbA1c from the Electronic Medical Record. We also surveyed the English and Spanish-speaking caregivers (CG) of these DM-ADRD patients. The CG survey included a measure of CG-reported patient dementia severity using the Dementia Severity Rating Scale (DSRS). We examined the relationship between the DSRS score and HbA1c.
Result(s): Patients (n=173) had a mean age of 79.7 (+/-7.18) and a mean HbA1c of 7.08%. 63% (n=106) were female, 63% (n=106) white; 37% (n=64) identified as being Latino/Hispanic. The mean DSRS score was 25 (+/-12.7) (range: 0-54), within the range of moderate cognitive impairment (18-36). Those older than 75 and those who were Spanish speaking had higher DSRS scores (26.1, p=.02; and 26.7, p=.04, respectively). Mean HbA1c of patients in the severe DSRS range (scores 37-54) was 6.81 (N=35) and was lower than in patients with moderate and mild dementia severity (mean 7.15 and 7.24, respectively); however, this difference was not statistically significant.
Conclusion(s): While the data does not confirm a statistically significant relationship between dementia severity and lower A1c, this finding is worrisome for DM-ADRD patients. Our data suggests possible overtreatment and if confirmed, there is a clear need for increased family and provider education and quality improvement programs for this vulnerable population

Background: Caregivers (CGs) of older-adults with Alzheimer's disease and related dementias (ADRD) and CGs of older-adults with diabetes (DM) report substantial CG burden. CG burden is known to be linked to patients' behavioral problems, poor cognition, and increased dependency. There is no literature addressing CG burden in CGs of individuals with co-occurring diabetes and dementia (DM-ADRD). The aim of this study was to identify CG and care-recipient (CR) factors associated with high levels of CG burden in CGs of DM-ADRD patients.
Method(s): This study used bivariate and descriptive statistics to analyze surveys collected as part of a quality improvement intervention being conducted at NYU Langone Health primary care and endocrine Faculty Group Practices and Family Health Centers. Inclusion criteria for patients were age >= 65, cognitive impairment, and DM with recent HbA1c > 6.4 or ever prescribed hyperglyemic medication. Telephonic surveys were conducted with CGs of eligible patients. The Treatment Burden Questionnaire (TBQ) was used to measure CG burden. TBQ results were analyzed for association with CG factors including age, sex, race, relationship to patient, education level, residence status, and level of social support, as well as CR factors including age, sex, race, dementia severity, Charlson comorbidity score, and recent HbA1c values.
Result(s): CGs that completed surveys (n=58) had a mean age of 54.3 years, 74% (n=43) female, 46% (n=27) white, 84% (n=49) were children of CRs, 70% (n=41) had education beyond 12th grade, and 55% (n=32) lived separately from CR. CRs of CGs that completed surveys (n=58) had a mean age of 80.5 years, 67% (n=39) female, 67% (n=37) white. We found CGs who were male, Asian, co-resident, with low level of social support, of CRs with more-advanced dementia, and of CRs with recent out-of-range HbA1c had significantly higher levels of CG burden (p<0.1).
Conclusion(s): Our study demonstrates there are several CG and CR factors that are associated with increased levels of CG burden in this population. Findings may assist in identification of CGs at risk for increased burden. If these results are found to be replicable, future studies should focus on the development of prevention and treatment plans consistent with these findings

BACKGROUND:Fetal epigenetic programming plays a critical role in development. DNA methyltransferase 3 alpha (DNMT3A), which is involved in de novo DNA methylation (DNAm), is a prime candidate gene as a mediator between prenatal exposures and birth outcomes. We evaluated the relationships between in utero arsenic (As) exposure, birth outcomes, and DNMT3A DNAm. METHODS:(toenail As), birth weight, and gestational age. RESULTS:In an adjusted SEM including birth weight and gestational age, maternal toenail As levels were associated with DNMT3A DNAm (B = 0.40; 95% CI: 0.15, 0.66) and gestational age (B = -0.19 weeks; 95% CI: 0.36, -0.03). DNMT3A DNAm was associated with gestational age (B = -0.10 weeks; 95% CI: 0.16, -0.04) and birth weight (B = -11.0 g; 95% CI: 21.5, 0.4). There was an indirect effect of As on gestational age mediated through DNMT3A DNAm (B = -0.04; 95% CI: 0.08, -0.01), and there were indirect effects of maternal toenail As levels on birth weight through pathways including gestational age (B = -14.4 g; 95% CI: 29.2, -1.9), DNMT3A DNAm and gestational age (B = -3.1 g; 95% CI: 6.6, -0.8), and maternal weight gain and gestational age (B = -5.1 g; 95% CI: 9.6, -1.5). The total effect of a doubling in maternal toenail As concentration is a decrease in gestational age of 2.1 days (95% CI: 0.9, 3.3) and a decrease in birth weight of 29 g (95% CI: 14, 46). CONCLUSIONS:DNMT3A plays a critical role in fetal epigenetic programming. In utero arsenic exposure was associated with greater methylation of CpGs in DNMT3A which partially mediated associations between prenatal As exposure and birth outcomes. Additional studies are needed to verify this finding.

Although it is well accepted that air pollution exposure exacerbates preexisting airway disease, it has not been firmly established that long-term pollution exposure increases the risk of new-onset asthma or chronic obstruction pulmonary disease (COPD). This Workshop brought together experts on mechanistic, epidemiological, and clinical aspects of airway disease to review current knowledge regarding whether air pollution is a causal factor in the development of asthma and/or COPD. Speakers presented recent evidence in their respective areas of expertise related to air pollution and new airway disease incidence, followed by interactive discussions. A writing committee summarized their collective findings. The Epidemiology Group found that long-term exposure to air pollution, especially metrics of traffic-related air pollution such as nitrogen dioxide and black carbon, is associated with onset of childhood asthma. However, the evidence for a causal role in adult-onset asthma or COPD remains insufficient. The Mechanistic Group concluded that air pollution exposure can cause airway remodeling, which can lead to asthma or COPD, as well as asthma-like phenotypes that worsen with long-term exposure to air pollution, especially fine particulate matter and ozone. The Clinical Group concluded that air pollution is a plausible contributor to the onset of both asthma and COPD. Available evidence indicates that long-term exposure to air pollution is a cause of childhood asthma, but the evidence for a similar determination for adult asthma or COPD remains insufficient. Further research is needed to elucidate the exact biological mechanism underlying incident childhood asthma, and the specific air pollutant that causes it.

Racial minorities experience a high burden of food insecurity relative to non-Hispanic whites. Government-subsidized nutrition programs can positively impact food insecurity and nutritional risk among older adults. Yet, in New York City, where nearly 60% of people over 65 years are non-white, older minorities participate in government nutrition programs at very low rates. In this commentary, we focus on 2 programs: the Child and Adult Care Food Program and Older Americans Act Nutrition Services Programs. We identify opportunities for strengthening these programs to improve their reach and engagement with diverse older adults in New York City and similarly diverse urban communities.

Background: Sleep disturbance is common among nursing home (NH) residents, yet impacts on mood and other health outcomes remain unclear. Evidence from community-dwelling older adults has demonstrated relationships between sleep quality, mood, and adverse health outcomes. The aim of this study was to describe and identify relationships between self-reported sleep quality, mood and cognition among NH residents participating in a large randomized trial.
Method(s): We analyzed baseline assessment data from residents of two New York City NHs participating in an ongoing trial of a novel non-pharmacological intervention to improve sleep disturbance (Sleep Using Mentored Behavioral and Environmental Restructuring, SLUMBER). Participants were English or Spanish speakers who had capacity to consent for research. Baseline assessments included sleep quality (Pittsburgh Sleep Quality Index, PSQI), depressive symptoms (Patient Health Questionnaire-9, PHQ-9 and Brief Anxiety and Depression Scale, BADS), and cognition (Brief Cognitive Assessment Tool, BCAT).
Result(s): Participants' (n=70) mean age was 76.6 +/- 15.1 years; 45 (64.2%) were female. The sample was ethnically diverse: 31.4% Black/African American, 11.4% Hispanic/Latino, and 2.9% Asian. Mean BCAT score was 28.3 +/- 1.2 (23-33 suggests mild dementia). Poor sleep was common; mean PSQI total score: 7.8 +/- 4.3 (> 5 = poor sleep). 31% (n=22) had PHQ-9 scores (>= 5) indicative of depression. Higher (worse) PSQI total score was strongly associated with higher (worse) PHQ-8 (less sleep item) and BADS depression (r2=0.42, p<0.01). Interestingly, PSQI-categorized "good sleepers" were more likely to have BCAT scores indicative of dementia (p=0.042).
Conclusion(s): A significant association between worse self-reported sleep and more depressive symptoms suggests an opportunity for sleep interventions to improve not only sleep quality but also mood in NH residents. The relationship between worse cognition and better self-reported sleep may indicate that objective sleep measurement (e.g., actigraphy) is an important component of sleep assessment in NH residents with cognitive impairment

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: 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