Faculty Bibliography

Background: Older adults with multiple chronic conditions (MCCs) must adhere to increasing numbers and complexity of healthcare tasks that may be burdensome and of uncertain benefit. Patient Priorities Care (PPC) is an approach to decision-making focused on achieving patient-specific health outcome goals and avoiding unwanted, potentially burdensome, healthcare. The study aim was to compare perceived treatment burden and categories of ambulatory healthcare utilization between older adults with MCCs who did and did not receive PPC.
Method(s): The design was quasi-experimental with matched PPC and usual care (UC) offices in a primary care practice in Connecticut. Participants included 163 older adults cared for by 10 primary care providers (PCPs) trained in PPC and 203 similar patients who received UC from 7 PCPs at a comparable office. Patient eligibility included: >3 chronic conditions, >=10 medications, or saw >2 specialists in the past year; lack of advanced dementia; and not hospice eligible, resident of a nursing home, or on dialysis. Perceived treatment burden was assessed at baseline and follow-up with the Treatment Burden Questionnaire (TBQ). Healthcare utilization data, abstracted from PCP visit notes over 9-months follow-up, included number (%) of participants with medications added or stopped; diagnostic tests, refer-rals, and procedures ordered or avoided. We estimated a weighted regression model (using inverse probability of PCP office assignment weights) to examine the association between PPC vs UC status and change in TBQ scores. A weighted logistic regression model was esti-mated for the categories of healthcare utilization.
Result(s): TBQ score decreased from baseline to follow-up by 5.2 more points in the PPC vs. UC participants (beta=5.2; p=.05). PPC patients were more likely to have medications stopped (Odds Ratio 2.3; 95% CI, 1.3-3.8) and referrals avoided (5.4; 1.1-25.5) and less likely to have diagnostic tests ordered (0.5; 0.3-0.9) than UC patients. There was a trend of more unwanted procedures avoided (10% vs. 5%) in PPC vs. UC patients.
Conclusion(s): PPC was associated with reduced treatment burden and unwanted utilization, suggesting that aligning care with patients' priorities is feasible and effective for older adults with MCCs

Background: As many as 25% of older adults with diabetes (DM) may have co-occurring Alzheimer's Disease and Related Dementias (ADRD), complicated by over-and under-treatment, caregiver burden, and excess healthcare utilization. Despite these co-occurring conditions, there is no specific clinical guidance forsafe and high-quality treatment to achieve health outcomes that matter to patients andcaregivers. describe potential barriers and facilitators to implementing a quality improvement intervention focused on management of patients with DM-ADRD; and explore the support needs of patients and their family caregivers.
Method(s): This qualitative study was conducted in the forma-tive phase of "Enhanced Quality in Primary care for Elders with DM-ADRD (EQUIPED-ADRD) a pragmatic randomized controlled trial in a large, diverse healthcare system. Key stakeholder interviews with clinic staff, providers and caregivers (n=11) guided by a semi-structured interview guide elicited in-depth descriptions of current processes in clinical management including strengths and weaknesses; identified potential barriers and facilitators to the proposed intervention and explored patient and caregiver needs. Qualitative data were analyzed using content analysis and findings were used to refine the intervention.
Result(s): The overarching theme across all stakeholders was that DM-ADRD management should address the unique and individ-ualized needs of patients and caregivers without disrupting patient-provider relationships. Coordinated communication across teams and with patients/caregivers is essential. Caregivers reported increasing burden and need for resources to help manage day to day caregiver responsibilities including tangible (education, transportation, e.g.,) and emotional support.
Conclusion(s): An EQUPED-ADRD toolbox to facilitate interven-tion training and utilization and promote communication among the healthcare team and with patients/caregivers will support implemen-tation success. Activating existing available resources (social/nurs-ing services, respite care) and care coordination may help caregivers especially, as patient care needs increase over time. Health education should focus on DM and ADRD with ongoing re-education as care needs change

BACKGROUND: Harmful effects of intensive glycemic control in adults with diabetes mellitus (DM) highlights the need for de-intensification of therapy in some patients, particularly those with Alzheimer's disease and related dementias (ADRD) with greater self-management challenges. However, the burden and potential adverse effects are unclear. This analysis seeks to quantify the extent of "over-treatment" of adults >= 65 years with DM and ADRD defined by glycemic control in AGS and ADA guidelines, and to determine associations with DM medication and/or healthcare utilization.
METHOD(S): We conducted descriptive and bivariate statistics using 2 years of EHR data from all primary care and endocrine clinics in the NYU Langone Health. Analyses included patients >65 years, with ADRD and DM diagnoses, on DM medication, and recorded HbA1c. Overtreatment was defined as an HbA1c of >7%. Other covariates analyzed included demographics, DM medications, and healthcare utilization.
RESULT(S): Of those meeting inclusion criteria (n=803), 59.7% (n=479) were over-treated for DM. The over-treated group was 56.4% female, 69.1% white, and 19.2% Hispanic. This group had a mean HbA1c value of 6.3% +/-.5, mean age of 79.5 +/- 8.2, and mean number of PCP visits over 2 years of 8.7 +/- 6.5. While those over-treated were less likely to be on insulin than those not over-treated, 70% (n=227) vs. 46% (n=221), respectively, those over-treated and on insulin were found to have statistically significant higher utilization of emergency department (64.3% (n=142) vs. 50.2% (n=114)) and inpatient visits (84.6% (n=187) vs. 67.8% (n=154)) than those not over-treated.
CONCLUSION(S): Many older adults with DM and ADRD are under tight glycemic control, despite the recommendation of recent literature and guidelines. This suggests the need for de-intensification of DM treatment in this population, and further research to opera-tionalize de-intensification, while maintaining individualized patient health status and goals. [Table Presented]

Case Presentation: An 86 yo male with history of chronic sinusitis, HTN and DM came to the hospital with cough, exertional dyspnea, and unintentional weight loss for 3 months. Initial chest CT showed right middle lobe consolidation and pulmonary nodules. He was treated for pneumonia and discharged home. He returned 8 days later and repeat chest CT showed increased size of bilateral nodu-lar consolidations, and new small subsegmental pulmonary emboli. Despite treatment, he developed acute respiratory failure requiring intubation, acute kidney injury and hypotension requiring vasopres-sors. Geriatrics was involved to assist with family meetings, to under-stand the patient's goals of care, and to set realistic treatment plans. Due to the patient's lack of capacity, his friend as healthcare proxy (HCP) along with patient's niece and nephew made the decision to not resuscitate. Given patient's history of chronic sinusitis with rapidly progressive lung involvement, Granulomatosis with polyangiitis (GPA) was suspected and lung biopsy result confirmed the diagnosis. A multidis-ciplinary meeting was held with patient's HCP, niece, nephew, geriat-rics and rheumatology to discuss treatment options. After much debate, the family decided to pursue a trial of aggressive treatment with rituxin. However, rituxin infusion was stopped when patient further decom-pensated. After patient's condition stabilized, he firmly expressed his wish to go home. Another family meeting was held and treatment was shifted to comfort care to align with the patient's goals of care.
Discussion(s): GPA is a systemic necrotizing vasculitis affect-ing small-and medium-sized vessels. The reported peak incidence of GPA is between ages 65 to 70 years. Upper airway disease is the most common presenting feature of GPA. Our patient presented with typical features of GPA at an atypical age. Although early initiation of treatment has shown to improve patient survival in the average population, there is lack of evidence in frail older adults. Questions regarding treatment side effect, outcome and disease prognosis should be explored with patients at the earliest point of care possible in order to set a realistic treatment plan. Establishing rapport with patient and family, and involving them in management is crucial for making treat-ment decisions that align with their goals of care

Background: Among older adults with cardiovascular disease (CVD), cardiac rehabilitation (CR) has multiple benefits including improved quality of life and reduced mortality. Despite the known benefits of CR, early termination (ET) by patients (attending <12/36 recommended sessions) may attenuate these benefits. Our aim was to determine the incidence of ET in our older adult patient population, as well as risk factors associated with this outcome.
Method(s): We reviewed records from 792 consecutive older adult patients (>= 65 years old) enrolled in the NYU Langone Rusk CR program (2013-2017). Sessions attended, demographics, comor-bidities, and primary referral diagnosis were abstracted. We analyzed the overall rate of ET (defined as attending <12 sessions). Categorical variables were described with percentages and continuous variables with mean values. Multivariable logistic regression was subsequently used to analyze predictors of ET, considering age, race, ethnicity, sex, body mass index, diabetes, chronic lung disease, coronary artery disease, heart failure, and stroke.
Result(s): In our total study population, mean age was 74 +/- 7 years, mean BMI was 26 +/- 5, 38% were female, and 18% were nonwhite. Most patients (65%) were referred to CR due to ischemic heart disease (chronic stable angina, post-myocardial infarction, CABG, or elective PCI), with an additional 23% referred for valvular heart disease, 9% for systolic heart failure, and 3% for congenital heart disease. Early termination occurred in 129 patients (16.3%). Patients who terminated early were significantly older (75.6 vs. 73.9, p=0.005) and less likely to have coronary artery disease (13.6% vs. 19.5%, p=0.03). After multivariable logistic regression, the independent risk factors for ET were age (adjusted OR 1.04, 95% CI 1.01-1.07) and Hispanic ethnicity (adjusted OR 2.32, 95% CI 1.01-5.33).
Conclusion(s): Nearly 1 in 6 older adults terminated CR within 1 month (<12/36 sessions), potentially limiting the benefits of CR within this subgroup. Among factors we analyzed, age and Hispanic ethnicity were risk factors for ET, but the overall strength of associ-ation was weak. Further research is necessary to identify novel risk factors for ET in order to better target prevention efforts

Background: Older adults visit Emergency Departments (ED) more often and have repeated visits, compared with younger individu-als. Cognitive impairment may drive ED use and may be more preva-lent in ED settings; yet it is often unrecognized, potentially resulting in suboptimal discharge planning. Cognitive screening is not routine ED care and staff are not typically trained in proper procedures.
Method(s): Using a volunteer workforce of college students and recent graduates provides an opportunity for clinical training as cogni-tive screeners and increases opportunities for system change. Volunteers screened for cognitive impairment among English and Spanish speaking patients who were admitted to a large academic ED and were likely to be discharged to home. We targeted patients >= 75 years and requested screening with the MiniCog$sup$

Airway hyperreactivity (AHR) related to environmental exposure is a significant public health risk worldwide. Similarly, metabolic syndrome (MetSyn), a risk factor for obstructive airway disease (OAD) and systemic inflammation, is a significant contributor to global adverse health. This prospective cohort study followed N = 7486 World Trade Center (WTC)-exposed male firefighters from 11 September 2001 (9/11) until 1 August 2017 and investigated N = 539 with newly developed AHR for clinical biomarkers of MetSyn and compared them to the non-AHR group. Male firefighters with normal lung function and no AHR pre-9/11 who had blood drawn from 9 September 2001-24 July 2002 were assessed. World Trade Center-Airway Hyperreactivity (WTC-AHR) was defined as either a positive bronchodilator response (BDR) or methacholine challenge test (MCT). The electronic medical record (EMR) was queried for their MetSyn characteristics (lipid profile, body mass index (BMI), glucose), and routine clinical biomarkers (such as complete blood counts). We modeled the association of MetSyn characteristics at the first post-9/11 exam with AHR. Those with AHR were significantly more likely to be older, have higher BMIs, have high intensity exposure, and have MetSyn. Smoking history was not associated with WTC-AHR. Those present on the morning of 9/11 had 224% increased risk of developing AHR, and those who arrived in the afternoon of 9/11 had a 75.9% increased risk. Having ≥3 MetSyn parameters increased the risk of WTC-AHR by 65.4%. Co-existing MetSyn and high WTC exposure are predictive of future AHR and suggest that systemic inflammation may be a contributor.

OBJECTIVE:/UNASSIGNED:Self-regulation includes the volitional and nonvolitional regulation of emotional, cognitive, and physiological responses to stimulation. It develops from infancy through individual characteristics and the environment, with the stress hormone system as a central player. Accordingly, the authors hypothesized that genes involved in regulating the stress system, such as FK506 binding protein 5 (FKBP5), interact with early-life stress exposure, such as exposure to intimate partner violence (IPV), to predict self-regulation indicators and associated outcomes, including behavioral and learning problems in school. METHODS:/UNASSIGNED:Study participants were a longitudinal birth cohort of 910 children for whom FKBP5 genotypes were available and who were assessed for exposure to IPV during the first 2 years of life as well as multiple measures of self-regulation: stress-induced cortisol reactivity and fear-elicited emotional reactivity at 7, 15, and 24 months, executive function at 36, 48, and 60 months, and emotional and behavioral difficulties and reading and math achievement in school grades 1, 2, and 5. Data were analyzed using longitudinal clustering and ordinal logistic regression procedures followed by mixed linear modeling. RESULTS:/UNASSIGNED:Children with two copies of a risk FKBP5 haplotype and IPV exposure were significantly more likely to have a developmental trajectory characterized by high, prolonged stress-induced cortisol reactivity and emotional reactivity in toddlerhood, followed by low executive function at school entry and high emotional and behavior problems and low reading ability in the primary school grades. CONCLUSIONS:/UNASSIGNED:The interaction of FKBP5 and IPV affects the physiological response to stress early in life, with consequences for emotional and cognitive self-regulation. Targeting self-regulation may present an early intervention strategy for children facing genetic and environmental risk.

BACKGROUND:The diagnosis of posttraumatic stress disorder (PTSD) is usually based on clinical interviews or self-report measures. Both approaches are subject to under- and over-reporting of symptoms. An objective test is lacking. We have developed a classifier of PTSD based on objective speech-marker features that discriminate PTSD cases from controls. METHODS:Speech samples were obtained from warzone-exposed veterans, 52 cases with PTSD and 77 controls, assessed with the Clinician-Administered PTSD Scale. Individuals with major depressive disorder (MDD) were excluded. Audio recordings of clinical interviews were used to obtain 40,526 speech features which were input to a random forest (RF) algorithm. RESULTS:The selected RF used 18 speech features and the receiver operating characteristic curve had an area under the curve (AUC) of 0.954. At a probability of PTSD cut point of 0.423, Youden's index was 0.787, and overall correct classification rate was 89.1%. The probability of PTSD was higher for markers that indicated slower, more monotonous speech, less change in tonality, and less activation. Depression symptoms, alcohol use disorder, and TBI did not meet statistical tests to be considered confounders. CONCLUSIONS:This study demonstrates that a speech-based algorithm can objectively differentiate PTSD cases from controls. The RF classifier had a high AUC. Further validation in an independent sample and appraisal of the classifier to identify those with MDD only compared with those with PTSD comorbid with MDD is required.