Faculty Bibliography

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.

Background: Research has shown that lesbian, gay, and bisexual (LGB) young adults have substantially higher rates of tobacco, alcohol, and drug use compared to heterosexuals. Many have attributed these higher rates to minority stressors including discrimination and stigma. Substance use behaviors often continue through later life and can interact with chronic medical disease to increase the risk for adverse events. However, little research focuses on the prevalence of unhealthy substance use among older LGB adults. This study estimates the national prevalence of substance use among LGB middle-aged and older adults and odds of use relative to heterosexuals.
Method(s): We examined aggregated data from 25,880 adults age >=50 from the 2015 to 2017 National Survey on Drug Use and Health, an annual cross-sectional survey of a nationally representative sample of non-institutionalized individuals in the United States. We estimated the prevalence for past-month binge drinking and past-year non-medical cannabis use, alcohol use disorder, nicotine dependence, cocaine, methamphetamine, and prescription opioid, sedative, stimulant, and tranquilizer misuse and their odds of use relative to heterosexual adults age >=50 adjusting for age, gender, race, income, and marital status.
Result(s): In adjusted analyses, we found that LGB adults age >=50 were at 2.3 times higher odds (95% confidence interval [CI]=1.6, 3.2) of reporting past-year non-medical cannabis use; they were at 1.7 times higher odds (95% CI 1.1, 2.5) of reporting prescription opioid misuse, and 2.4 times higher odds (95% CI 1.3, 4.3) of reporting prescription tranquilizer misuse compared to heterosexuals. We did not find significant differences in use of other substances.
Conclusion(s): Consistent with other studies of younger LGB, this study shows some substance use is higher in older LGB adults compared to their heterosexual counterparts. LGB middle-aged and older adults are at higher risk for cannabis use, prescription misuse of opioids and tranquilizers. Prevention and interventions for unhealthy substance use should focus on older LGB populations to reduce harms.

Background: Approximately half of patients with HIV in the US are over age 50, but older adults are not commonly screened for HIV despite having known risk factors. Evidence for routine HIV screening in the geriatric population is limited, and the USPSTF only recommends HIV screening in those age 15-65. The aim of this quality improvement project was to measure the rate of HIV screening among older patients as well as assess provider knowledge for HIV testing guidelines in an urban safety net geriatrics clinic.
Method(s): Patient visits between 7/1/2019 - 9/30/2019 in the Bellevue Hospital geriatrics clinic were reviewed for HIV testing and sexual health assessment. In addition, we conducted a brief survey designed to assess how providers (n=14) handle HIV screening in geriatric patients.
Result(s): Of the 1259 patients seen in the geriatrics clinic in a 3 month period, 31 (2.5%) of which were tested for HIV during this time. Of those, 26 (84%) were tested based on a known risk factor. The mean age of the 31 tested was 81.64, and 14 (45%) of the patients were male. Only 7 (22.5%) patients had documentation of their sexual activity. In the provider survey, most providers (10/14) reported knowledge of USPSTF HIV screening guidelines and ordered HIV screening tests if there was a risk factor. Providers responded that they did not order annual HIV screening either because there was "not enough time to discuss" (3/14), or "patient refused to discuss" (3/14). Providers reported discussing patients' sexual practices less than once a year. Of those who did discuss sexual practices, 79% (12/14) assessed condom use.
Conclusion(s): This study showed low rates of HIV screening among geriatric patients, and minimal sexual health documentation. The provider survey demonstrated that clinicians do not assess their patients' sex lives, but order an HIV test if there is a risk factor for HIV. Given this data, we plan to pursue a provider education intervention to increase rates of HIV screening in our older adults

Population health researchers from different fields often address similar substantive questions but rely on different study designs, reflecting their home disciplines. This is especially true in studies involving causal inference, for which semantic and substantive differences inhibit interdisciplinary dialogue and collaboration. In this paper, we group nonrandomized study designs into two categories: those that use confounder-control (such as regression adjustment or propensity score matching) and those that rely on an instrument (such as instrumental variables, regression discontinuity, or differences-in-differences approaches). Using the Shadish, Cook, and Campbell framework for evaluating threats to validity, we contrast the assumptions, strengths, and limitations of these two approaches and illustrate differences with examples from the literature on education and health. Across disciplines, all methods to test a hypothesized causal relationship involve unverifiable assumptions, and rarely is there clear justification for exclusive reliance on one method. Each method entails trade-offs between statistical power, internal validity, measurement quality, and generalizability. The choice between confounder-control and instrument-based methods should be guided by these tradeoffs and consideration of the most important limitations of previous work in the area. Our goals are to foster common understanding of the methods available for causal inference in population health research and the tradeoffs between them; to encourage researchers to objectively evaluate what can be learned from methods outside one's home discipline; and to facilitate the selection of methods that best answer the investigator's scientific questions.

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

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.

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.

Introduction: Functional decline, i.e., a decrement in performing every day activities necessary to live independently, is common after acute myocardial infarction (AMI) and associated with poor long-term outcomes; yet we do not have a tool to identify older AMI survivors at risk for this important patient-centered outcome.
Method(s): We used data from the ComprehenSIVe Evaluation of Risk Factors in Older Patients with AMI (SILVER-AMI) study, a prospective longitudinal study of 3,041 AMI patients adults age >=75 years, recruited from 94 hospitals across the U.S. Participants underwent a structured interview and assessment during hospitalization and at six months to collect data on demographics, geriatric impairments, psychosocial factors, and activities of daily living (ADLs). Clinical variables were abstracted from the medical record. Functional decline was defined as a decrement in ability to independently perform essential activities of daily living (i.e., bathing, dressing, transferring, ambulation) from baseline to six months post-discharge. Backward selection was used to identify significant predictors of functional decline.
Result(s): Mean age of the sample was 82+/-5 years; 57% were male, 90% were white; and 13% reported ADL decline at six months post-discharge. Factors independently associated with increased risk of decline were older age, longer hospital stay, mobility impairment during hospitalization, higher comorbidity score, fall history, and depression. Revascularization during AMI hospitalization (e.g., PCI, CABG) and ability to walk mile prior to AMI were associated with decreased risk. Model discrimination (c=0.79) and calibration were very good.
Conclusion(s): We identified a parsimonious model that predicts risk of ADL decline among older AMI patients. This tool may aid in identifying older AMI patients who may benefit from physical therapy or cardiac rehab to optimize function after AMI.