Faculty Bibliography

Background: Cognitive and physical impairments are common, coexisting chronic conditions that have complex, and often bidirectional relationships in which presence of one has the potential to initiate, synergize, or result from the other. Understanding how the processes that lead to dementia and physical disability interrelate at early stages of dysfunction affords the opportunity for preventative or restorative interventions. We evaluated both crosssectional and longitudinal associations between cognitive and physical function to better understand the directionality of the relationships. Methods: Data from 2 studies of cognitive and functional aging were used: a longitudinal study conducted at the Knight ADRC at Washington University in St. Louis (766 individuals followed up for up to 8 years) and a cross-sectional study conducted at NYU (272 individuals). Both studies enrolled community-dwelling individuals over the age of 50 who underwent cognitive and physical assessments tapping into global (e.g., CDR-SB, MoCA, AD8) and individual cognitive domains (e.g., Naming, Trailmaking) and physical performance (PP) measures (e.g., grip-strength (GS), muscle mass (MM)). Formal diagnoses were available in the longitudinal study, while the cross-sectional studies established impaired vs. non-impaired. Associations were investigated with regression analysis techniques. Results: GS impairment was associated with lower MoCA (B=-2.0, p=0.011); when combined with low MM the likelihood of dual cognitive-physical impairment increased. The effect of low GS on global cognition doubled when poor PP was also present (indicator of later stage physical impairment; B=-3.77, p<0.001). However, while the rate of decline in cognitive (various measures; p<0.001) and physical (slope=-1.22, p<0.001) performance was sharper in those with baseline cognitive impairment, baseline physical impairment had no significant impact on either cognitive or physical decline. Cross-sectionally, GS impacted MoCA through poor PP (indirect effect=0.018, p<0.01). When type of dementia was considered, vascular dementia declined faster than controls (slope=-2.70, p<0.001) or AD (slope=-2.18, p<0.001). Conclusions: Earlier indicators of physical dysfunction (i.e. low GS) are associated with cognitive impairment with evidence for a dose-response operating in the direction of cognitive-to-physical impairment (although the reverse cannot be ruled out). Targeted interventions to maintain physical functionality and strength in individuals with dementia, particularly vascular dementia may mitigate future decline and disability

Background: Approximately 5.2 million Americans are affected by Alzheimer's disease (AD), with another 1.3 million individuals affected by Lewy Body Dementia (LBD), the second most common cause. Nearly 60% of dementia caregivers rate emotional stress of caregiving as high or very high, and this will only increase as more resources are required with dementia progression. As such, the grieving process for caregivers likely begins early, as adult children and spouses often take on a multitude of new responsibilities previously managed by the patient, often prior to the formal diagnosis. Adverse outcomes for the caregiver (e.g., stress, depression and poor health) directly lead to declines in quality of life for both the patient and the caregiver. Improved understanding of caregiver grief will provide important information to develop interventions for the early identification of caregiver grief. We examine the sensitivity of the underlying constructs measured by the Marwit-Meuser Caregiver Grief Inventory Short Form (MMCGI-SF), a common self-reported measure of caregiver grief. Methods: An online survey of dementia caregivers [AD (n=64), LBD (n=350)] was completed including the MMCGI-SF. The MMCGI-SF contains three constructs: Personal Sacrifice Burden, Heartfelt Sadness, and Worry and Felt Isolation. We conducted confirmatory factor analyses to determine goodness of fit testing whether this model of grief holds for spouse and child primary caregivers for patients with AD and LBD. Results: Caregiver ages were equivalent (M=62.0(610.5) as were patient dementia stage (CDR Box Scores; M=10.4(64.4). Confirmatory factor analysis rejected the current MMCGI-SF model for both groups. The model was improved by separating the construct of "Worry and Felt Isolation" into separate categories in both AD: CFI = .88, NFI = .89, RMSEA = .091 (.062-.117) and LBD: CFI = .93, NFI = .92, RMSEA = .072 (.063-.080). Conclusions: Isolation was shown to be an important component of grief state for spouse and adult child caregivers, particularly caregivers of LBD. This may be due to constellation of cognitive, motor, behavioral, and autonomic features that distinguish LBD from AD. We believe that changes in healthcare and the extended lifespan of patients have led to the need for caregiver interventions that specifically targeting isolation

Background: There are significant cultural differences regarding knowledge and perceptions of Alzheimer disease (AD) potentially leading to delays in diagnosis and treatment. There is a need to better understand differences between Caucasian and African American older adults regarding their knowledge of AD, perceived access to care, health beliefs, and willingness to discuss memory problems with providers. Methods: A population-based survey of 1,039 non-demented older adults across three counties (urban, suburban, rural) had a mean age of 62.7+10.2 (range, 50-97); 94% high school education; 67% women, 86% white, mean Short Blessed Test = 1.7+2.2. Constructs from behavioral models including Health Belief Model, Self-efficacy, and Social Support were compared between White (n=863) and Black (n=121) respondents attitudes and perceptions regarding dementia screening. Results: African American older adults were less likely to use the internet for health information (p=.005) and more dependent on public transportation (p<.001) for doctor visits. Black older adults were more likely to believe memory loss a part of normal aging (p=.01), had less knowledge about dementia (p=.003) and its consequences (p=.002), were less likely to know their healthcare provider could test for dementia (p=.004), had lower perceived accessibility of dementia-related services (p=.001), and reported lower self-efficacy to discuss memory problems with their providers (p=.006). Health Belief model constructs differed with African Americans reporting higher perceived barriers (p=.003) and lower perceived severity (p=.03). Logistic regression models showed that intention for screening is predicted by white race (OR 4.28); male gender (OR 2.10), self-reported anxiety (OR 1.44), self-efficacy to discuss memory problems (OR 2.72), knowledge their MD can test memory (OR 1.70), and social support (OR 1.23). Conclusions: We found significant differences in socioeconomic factors, utilization and accessibility to medical services, and knowledge of dementia between Caucasians and African- Americans. Although older African-Americans reported intention to have their memory evaluated, actual screening behaviors were more likely to occur in individuals with high self-efficacy for discussing memory problems, perceived accessibility to dementia services, already present preventive health behaviors, and a social support system. These constructs can be used to develop interventions to evaluate and improve cognitive health in African Americans

BACKGROUND: Substance use screening is widely encouraged in healthcare settings, but the lack of a screening approach that fits easily into clinical workflows has restricted its broad implementation. The Substance Use Brief Screen (SUBS) was developed as a brief, self-administered instrument to identify unhealthy use of tobacco, alcohol, illicit drugs, and prescription drugs. We evaluated the validity and test-retest reliability of the SUBS in adult primary care patients. METHODS: Adults age 18-65 were enrolled from urban safety net primary care clinics to self-administer the SUBS using touch-screen tablet computers for a test-retest reliability study (n=54) and a two-site validation study (n=586). In the test-retest reliability study, the SUBS was administered twice within a 2-week period. In the validation study, the SUBS was compared to reference standard measures, including self-reported measures and saliva drug tests. We measured test-retest reliability and diagnostic accuracy of the SUBS for detection of unhealthy use and substance use disorder for tobacco, alcohol, and drugs (illicit and prescription drug misuse). RESULTS: Test-retest reliability was good or excellent for each substance class. For detection of unhealthy use, the SUBS had sensitivity and specificity of 97.8% (95% CI 93.7 to 99.5) and 95.7% (95% CI 92.4 to 97.8), respectively, for tobacco; and 85.2% (95% CI 79.3 to 89.9) and 77.0% (95% CI 72.6 to 81.1) for alcohol. For unhealthy use of illicit or prescription drugs, sensitivity was 82.5% (95% CI 75.7 to 88.0) and specificity 91.1% (95% CI 87.9 to 93.6). With respect to identifying a substance use disorder, the SUBS had sensitivity and specificity of 100.0% (95% CI 92.7 to 100.0) and 72.1% (95% CI 67.1 to 76.8) for tobacco; 93.5% (95% CI 85.5 to 97.9) and 64.6% (95% CI 60.2 to 68.7) for alcohol; and 85.7% (95% CI 77.2 to 92.0) and 82.0% (95% CI 78.2 to 85.3) for drugs. Analyses of area under the receiver operating curve (AUC) indicated good discrimination (AUC 0.74-0.97) for all substance classes. Assistance in completing the SUBS was requested by 11% of participants. CONCLUSIONS: The SUBS was feasible for self-administration and generated valid results in a diverse primary care patient population. The 4-item SUBS can be recommended for primary care settings that are seeking to implement substance use screening.

Shared decision-making (SDM), a collaborative process in which patients and providers make health care decisions together, taking into account the best scientific evidence available, as well as the patient's values and preferences, is being increasingly advocated as the optimal approach to decision-making for many health care decisions. The rapidly paced and often chaotic environment of the emergency department (ED), however, is a unique clinical setting that offers many practical and contextual challenges. Despite these challenges, in a recent survey emergency physicians reported there to be more than one reasonable management option for over 50% of their patients and that they take an SDM approach in 58% of such patients. SDM has also been selected as the topic on which to develop a future research agenda at the 2016 Academic Emergency Medicine consensus conference, "Shared Decision-making in the Emergency Department: Development of a Policy-relevant Patient-centered Research Agenda" (http://www.saem.org/annual-meeting/education/2016-aem-consensus-conference). In this paper the authors describe the conceptual model of SDM as originally conceived by Charles and Gafni and highlight aspects of the model relevant to the practice of emergency medicine. In addition, through the use of vignettes from the authors' clinical practices, the applicability of SDM to contemporary EM practice is illustrated and the ethical and pragmatic implications of taking an SDM approach are explored. It is hoped that this document will be read in advance of the 2016 Academic Emergency Medicine consensus conference, to facilitate group discussions at the conference.

BACKGROUND: Fundoplication is often performed in conjunction with gastrostomy tube (GT) placement in children, but there is a great deal of variation in rates of and indications for this procedure. Little is known about the impact of fundoplication on peri-operative outcomes. This study examines a national cohort of pediatric patients to compare risk-adjusted surgical outcomes in patients undergoing GT placement with or without concomitant fundoplication. METHODS: We identified all patients undergoing GT placement in the 2012 National Surgical Quality Improvement Program - Pediatric. We evaluated demographics, comorbidities, complications, and length of stay for GT with fundoplication versus GT alone. We defined composite morbidity as a dichotomous variable for the presence of any complication. Logistic regression was performed to identify predictors of morbidity after adjusting for covariates. RESULTS: 1289 GT patients were identified, and 148 (11.5%) underwent concurrent fundoplication. The fundoplication patients were more likely to be younger, have cardiac risk factors, and be on respiratory support. They also had higher rates of surgical site infection (7.4% vs 3.7%, p=0.03) and composite morbidity (16.9% vs 8.7%, p=0.001), and longer LOS (median 5 vs 3 days, p=<0.0001) compared to GT only. After adjusting for covariates, fundoplication was a predictor of composite morbidity and increased LOS. CONCLUSION: Concomitant fundoplication is an independent risk factor for 30-day post-operative morbidity in patients undergoing GT placement. These findings do not negate the value of fundoplication but underscore the importance of careful patient selection, and should be taken into consideration when discussing risks and benefits with families.

We sought to determine the association of major cardiovascular risk factors and other comorbidities with the presence or absence of coronary collateral (CC) circulation. All electronic medical records from 2010 to 2011 were retrospectively reviewed. A total of 563 patients were divided into 2 groups: CC present (180) and CC absent (383). Smoking (P = .012, odds ratio [OR] 1.58), hypercholesterolemia (P = .001, OR 2.21), and hypertension (P = .034, OR 1.75) were associated with the presence of CC. Increasing body mass index (BMI, P = .001) and decreasing estimated glomerular filtration rate (eGFR, P = .042) were associated with the absence of CC. On multivariable linear regression analysis, hypercholesterolemia (P = .001, OR 2.28), BMI (P = .012, OR 0.77), and eGFR (P = .001, OR 0.70) were found to be independently associated with CC. Our findings will help predict patient populations more likely to have presence or absence of CC circulation.

BACKGROUND/PURPOSE: Group-based services can improve quality-of-life outcomes for oncology patients. We assessed preferences for supportive and educational programming to better meet patient needs and allocate resources. METHODS: Patients from three cancer centers in New York City completed a 15-item survey provided in English, Spanish, and Chinese about their interest in educational topics (wellness, nutrition, legal issues, etc.) and services (support groups, lectures, and exercise programs). Participants were recruited in the treatment and waiting areas by a patient navigator. Logistic regressions were used to assess associations between age, education, and gender on likelihood of attending each type of service. RESULTS: Three hundred eleven patients participated. Mean age was 59, and most were female (74%). The most common cancer was breast (40%), followed by genitourinary (15%). In terms of groups, women preferred wellness workshops followed by informative sessions; men preferred informative sessions, followed equally by post-treatment support and wellness workshops. Older age was related to reduced likelihood of group attendance, p =0.04. Overall, 68% of participants reported that they would be likely to attend groups. For lectures, nutrition was of greatest interest for both men (43%) and women (34%) followed by anxiety management (17% and 18%, respectively). Overall, 64% of participants reported that they would be likely to attend a lecture. More women (59%) than men (42%) reported interest in exercise programs, p = 0.02. A majority of respondents (54%) expressed desire for exercise programs at the cancer centers. CONCLUSIONS: This psychosocial needs assessment identified services most preferred by patients and can be used by cancer centers in developing programming to meet patient needs. These results may be useful to suggest ways that the healthcare team can respond most effectively to the psychosocial needs of cancer patients. Research Implications: The findings reflect gender, age, and educational level differences in terms of patient preferences for support programming; however, the generalizability is limited. Practice Implications: The psychosocial needs assessment provides a starting point for developing interventions. Therefore, this information should be helpful to clinicians planning new initiatives and refining existing psychoeducational and wellness programs and support groups

OBJECTIVE: To examine public and media response to the United States Preventive Services Task Force's (USPSTF) draft (October 2011) and finalized (May 2012) recommendations against prostate-specific antigen (PSA) testing using Twitter, a popular social network with over 200 million active users. MATERIALS AND METHODS: We used a mixed methods design to analyze posts on Twitter, called "tweets." Using the search term "prostate cancer," we archived tweets in the 24 hour periods following the release of the USPSTF draft and finalized recommendations. We recorded tweet rate per hour and developed a coding system to assess type of user and sentiment expressed in tweets and linked articles. RESULTS: After the draft and finalized recommendations, 2042 and 5357 tweets focused on the USPSTF report, respectively. Tweet rate nearly doubled within two hours of both announcements. Fewer than 10% of tweets expressed an opinion about screening, and the majority of these were pro-screening during both periods. In contrast, anti-screening articles were tweeted more frequently in both draft and finalized study periods. From the draft to the finalized recommendations, the proportion of anti-screening tweets and anti-screening article links increased (p= 0.03 and p<0.01, respectively). CONCLUSIONS: There was increased Twitter activity surrounding the USPSTF draft and finalized recommendations. The percentage of anti-screening tweets and articles appeared to increase, perhaps due to the interval public comment period. Despite this, most tweets did not express an opinion, suggesting a missed opportunity in this important arena for advocacy.