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Christopher Carpenter, MD, |
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| Non-Traumatic, Acute Abdominal Pain in ED Elderly, A Series of Systematic Reviews and A Clinical Consensus Conference | |
| Older adults continue to utilize emergency medical services at unprecedented rates. The demographic tsunami approaching the landscape of 21st Century medicine mandates an enhanced understanding of the diagnostic and prognostic impact various aspects of the history, physical exam, laboratory, and radiological evaluation possesses in making decisions during busy clinical shifts. The complex task of decision making includes the interweaving of out own clinical and personal experience, external rules and constraints, scientific evidence, and patient preferences. The frantic-paced, information-poor environment which is Emergency Medicine (EM) benefits from simple, highly sensitive tools called Clinical Decision Rules (CDR's) to utilize key components of the clinical evaluation to risk stratify patients and speed Emergency Department (ED) thoroughfare with out compromising patient safety or optimal outcomes. Designing useful CDR's necessitates the input of a multidisciplinary team to systematically and unequivocally define variables and clinically important outcomes. Although aging patients represent a disproportionate volume of admissions and overall ED resource consumption, CDR's have not yet been designed solely for older adults. A CDR for elderly abdominal pain could prevent unnecessary hospitalizations or surgery and save lives. Emergency Medicine |
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| Pablo Celnik, MD, | |
| Use Dependent Placticity in Frail Older Adults | |
| Aging results in a systemic decline of motor memory and physical performance. Training involving performance of simple repetitive thumb movements encodes a memory trace in the primary motor cortex that reflects the kinematic details of the practiced movements. This form of motor memory may represent a crucial step in the acquisition of complex motor skills, such as those used to perform activities of daily living (ADL), and likely a fundamental step in the process of recovery of motor function after brain lesions like stroke. The process of forming this type of motor memory has been extensively studied as a reliable and valid marker of use dependent brain plasticity (UDP). In healthy older adults, motor memory formation is decreased, but can be enhanced by different interventions. However, it remains unknown whether frail individuals have decreased ability to form motor memories when compare to non-frail older adults. It is possible that the systemic biological decline affecting frail individuals affects the ability to sustain UDP. In this proposal we plan to test the hypothesis that motor memory formation as a result of motor training is decreased in frail relative to non-frail older adults. To accomplish this we will conduct a case control study measuring the magnitude of motor memory formation as a result of simple motor training in frail and non-frail older adults using transcranial magnetic stimulation. We then plan to apply this new knowledge to more detailed biologic and physiologic studies of brain plasticity in this vulnerable subset of the older adult population and to develop specific rehabilitation interventions gear to reduce functional decline in older adults in general and frail in particular. Physical Medicine & Rehabilitation |
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| Gregory S. Cherr, MD, | |
| Determinants of Health-Related Quality of Life in Patients with Peripheral Arterial Disease | |
| Peripheral arterial disease (PAD) affects 8-12 million Americans with an increased prevalence among the elderly. Patients with PAD have functional disability, chronic pain, and reduced health-related quality-of-life (HRQOL). However, the correlation between functional disability, chronic pain, and HRQOL is poor. For patients with PAD, other determinants of HRQOL must exist. Patients with PAD have an increased prevalence of depressive symptoms and 36% of patients with severe PAD have depression. Chronic pain and functional disability may lead to depression, and depressed patients experience more chronic pain and functional disability. However, previous research on PAD and HRQOL has not included depression, and no systematic evaluation of HRQOL has been performed. We hypothesize the relationship between PAD and HRQOL as conveyed by the following path diagram.  The specific aim of this proposal is to examine the associations between functional disability, chronic pain, depression, and HRQOL in elderly patients with PAD. Subjects for this cross-sectional study will be elderly persons (age>65) recruited from outpatient clinics at two hospitals. Using validated questionnaires, the subjects will complete a single assessment of HRQOL, walking ability, depression, and chronic pain. Medications and other medical conditions will be recorded. Peripheral arterial disease will be diagnosed by ankle-brachial index and functional status will be evaluated with a 6-minute walk test. Statistical analyses will include descriptive statistics, path analysis methodologies, and multiple linear regression. To demonstrate a meaningful dependence between PAD and HRQOL, 200 patients will be enrolled with 80% power to find a correlation as small as 0.197. Peripheral arterial disease, a condition with considerable impact on HRQOL, affects 10% of adults over age 65. We have little understanding of the determinants of HRQOL for these patients. The proposed project will begin to address this problem and lay the ground work for potential interventions to improve HRQOL in patients with PAD. General Surgery |
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| Ellen Flanagan, MD, | |
| Postsurgical Outcomes of Elderly and Old Elderly Patients with DNR Orders | |
| Do Not Resuscitate (DNR) orders may be used as a marker for the sickest of elderly patients. These patients may choose to undergo palliative surgery when benefits outweigh the burdens of anesthesia, surgery and recovery. DNR orders in elderly surgical patients predict thirty-day postoperative morbidity and mortality, however, the course and therefore the burden of the thirty days prior to death is unknown. It is essential that elderly patients be provided with outcome data specific to their surgical procedure, prior to surgery that will assist them in determining how their final days, weeks or months will be spent. These patients should be offered surgical relief with the understanding that, if severe complications occur, they may choose to reduce the level of aggressive postoperative intervention and focus on palliation of symptoms. We propose to build multivariable risk models to identify key preoperative characteristics and complications at forty-eight hours predictive of thirty-day postoperative morbidity and mortality in the elderly and old elderly. The National Surgical Quality Improvement Program (NSQIP) database should provide data necessary for development of these models. We will examine patient and family acceptance of these models in a small feasibility study. Improved prognostication may better inform patients, families and physicians of likely postoperative complications. Preoperative discussion may allow elderly patients to voice preferences for acceptable types and duration of treatments prior to serious complications. Prior discussions of preferences may facilitate transition of care from aggressive postoperative to palliative care earlier in the intensive care unit stay thus providing care most consistent with the elderly patient's end of life goals. These studies will be used to write an NIH proposal for a prospective, randomized controlled clinical trial evaluating an educational intervention that uses prognostic models to assist elderly patients and their families in making critical decisions prior to palliative surgery. This proposal describes a series of studies that will generate data with immediate impact for geriatric patients confronting surgery at the end of life. These studies will also generate hypotheses that will be tested in future randomized controlled clinical trials. Anesthesiology |
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| Fredric Hustey, MD, | |
| The Use of a Computerized System to Improve Information Transfer During Patient Transition from Skilled Nursing Facilities to the Emergency Department | |
| Background: At least one-fourth of patients residing in skilled nursing facilities (SNF) are transferred to emergency departments (ED) each year for evaluation. Accurate transfer of essential information, which is critical to optimal management of these patients in the ED, is often lacking. Hospitals and skilled nursing facilities (SNFs) are increasingly using electronic systems for health care information maintenance and transfer. Incorporating a standardized electronic method for information transfer into these pre-existing systems may be an effective way to improve communication during the ED transition. Hypothesis: Communication between SNFs and the ED at the time of ED patient transition is improved after implementation of a standardized electronic transfer form. Methods: Before and after study incorporating a standardized electronic transfer form into a pre-existing electronic discharge system (ECIN) used by many hospitals and skilled nursing facilities for discharge planning. Participants: A consecutive sample of patients transferred from the largest subacute SNF affiliated with the Cleveland Clinic Foundation (CCF) to the CCF ED for evaluation. Interventions: Implementation of a standardized electronic transfer form to communicate essential patient information to the ED at the time of the patient transition. This form will be incorporated into a pre-existing electronic discharge system that is used by many hospitals and SNFs and can be transmitted via secure internet connection to the ED. Main outcome measurements: A scoring system is devised to measure communication of elements of critical information. One point is assigned for each element of critical information included during patient transfer (total of 9 elements with a maximum score of 9). Scores are assessed pre and post intervention via chart review. Additional outcomes include measurements of information transfer efficiency, impact of the intervention on markers of quality of care, and satisfaction of the ED and SNF staff with the information transfer process pre and post intervention. Emergency Medicine |
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| Jason Johanning, MD, | |
| Evaluation of Gait Abnormalities in Geriatric Patients Induced by Peripheral Arterial Disease Utilizing Advanced Biomedical Measures | |
| PAD is a manifestation of atherosclerosis affecting nearly 12 million people living in the United States, most who are elderly. Every year 150,000 surgical procedures are performed for patients with advanced PAD. With the anticipated increase of our elderly population, PAD will continue to result in significant morbidity and mortality. Caludication (Latin root word: "to limp") is the most common clinical manifestation of PAD where reduced blood flows results in limb heaviness, pain and ambulatory dysfunction. Despite obvious Dysfunction, very few reports have examined claudication as a primary gait or disability or impaired balance state. Even fewer reports have investigated the impact of improving blood flow on the parameters. These initial rudimentary gait and balance studies combined with our preliminary advanced biomechanical analyses suggest PAD produces significant gain and balance abnormalities. Unfortunately, the effects of surgical intervention on gait and balance of elderly patients with PAD are essentially unknown. The current study is based on two hypotheses; 1) Advanced biomechanical analyses can delineate the full spectrum of elderly PAD gait and balance abnormalities and 2) these abnormalities are reversed or attenuated by improving blood flow. The specific aims are: 1) Delineate the full spectrum of gait and balance impairments incurred by elderly PAD patients. Patients will be evaluated using non-invasive vascular testing, lower extremity joint kinetics analysis, electromyographic assisted balance evaluation, and validated questionnaires to assess function. 2) Establish the efficacy of currently performed endovascular and open operation in improving gait and balance. Analyses will be repeated after therapeutic intervention. Response to treatment will then be ascertained. A critical need exists to establish baseline impairment in elderly claudicants and determine optimal approaches for reversal of gait and balance abnormalities. It is our desire to capitalize on our unique multi-disciplinary approach to gait and balance abnormalities in the elderly PAD patient to answer these key questions. General Surgery |
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| John Schweinfurth, MD, | |
| Assessment of swallowing Outcomes Following Neuromuscular Electrical Stimulation Therapy in Stroke Victims | |
| Mississippi has the highest incidence of cardiovascular disease and stroke in the U.S., and dysphasia is a common sequelae. Until recently, no good interventions were available for stroke victims to improve swallowing, and these patients largely became dependent on enteral feeding for sustenance and suffered from pneumonia due to aspiration. The proposed study has two parts: 1) to evaluate the efficacy of a new swallowing therapy in the treatment of stroke victims, and 2) to establish an interprofessional training program for health professionals in the area of geriatric swallowing disorders. Swallowing therapy will be based on relatively new technology which employs electrical stimulation of neuromuscular structures of the tongue, neck, and larynx to improve swallowing function and has been shown to greatly decrease the time required to rehabilitate stroke victims to safe oral feeding. Because of the intensive therapy required, a projected 3 - 4 participants will be enrolled monthly at the time of initiation of rehabilitation. Participants will be randomized to immediate neuromuscular electrical stimulation therapy (NMEST) in addition to traditional dysphasia therapy (TDT), TDT followed by delayed NMEST, or TDT alone. Swallowing performance will be assessed by videoflouroscopic and/or endoscopic swallowing examinations before therapy and at intervals during treatment depending on progress. The primary outcome measure will be length of therapy required to achieve significantly improved performance on a dysphasia assessment scale or a steady-state. The education program is intended to address the lack of formal training in swallowing disorders in otolaryngology residents as well as benefit speech language pathology graduate students. The interprofessional approach to education has been widely used in gerontology and provides a unique, effective, and comprehensive training experience that is adaptable to other fields. Training will consist of participation in a multidisciplinary team which treats swallowing disorders in a tertiary care center. Otolaryngology |
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| Neil A. Segal, MD, | |
| Enabling Elders with Knee Osteoarthritis Through Reducing Functional Limitations | |
| Older adults are at a high risk for disability and knee osteoarthritis is one of the most prominent causes. Prior studies have focused on increasing quadriceps strength in elders with knee inform rehabilitation strategies to optimize function and reduced disabilities in elders with knee osteoarthritis, but have not assess whether there are additional impairments contributing to these patient's functional limitations. The proposed research aims to assess for functional limitations in elders with knee osteoarthritis through comparing three-dimensional motion analysis, capable of detecting compensatory forces and energy expenditures at unaffected joints. The will inform rehabilitation strategies to optimize function and reduced disability in elders with knee osteoarthritis. Physical Medicine & Rehabilitation |
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| Julie Ann Sosa, MD, | |
| A Multi-Institutional Randomized Controlled Trial Measuring the Effects of Surgery on Depression, Memory and Concentration Among Elderly Patients with Asymptomatic Primary Hypothyroidism | |
| Primary hyperparathyroidism (pHPT) is a common disease among the elderly associated with elevated serum calcium and parathyroid hormone (iPTH) levels. Its signs and symptoms range from serum biochemical abnormalities, to loss of energy, body aches, kidney stones, pancreatitis, and osteoporosis. Parathyroidectomy can cure pHPT in 98% of patients and significantly improve some symptoms. Depression and memory difficulties are believed to be part of the symptom complex, but there is a paucity of evidence addressing prevalence and optimal treatment. Our pilot data from 19 elderly subjects with pHPT referred for surgery revealed higher depression scores and greater spatial memory deficits when compared to age-matched patients with benign euthyroid thyroid disease referred for thyroidectomy. One month after surgery (using minimally invasive [MIP] or traditional parathyroidectomy), depression scores and spatial memory deficits were significantly improved when compared with thyroidectomy patients. Our multidisciplinary randomized controlled trial will focus on psychological and cognitive problems in asymptomatic elderly patients with pHPT. We will randomize 60 patients with pHPT to medical follow-up or early surgery using MIP. We will evaluate all patients from a psychiatric standpoint using standard instruments, and from a cognitive perspective using verbal and novel, validated spatial memory tests, as well as evoked response potentials. Patients randomized to medical follow-up will be evaluated at baseline and at 6 month intervals for two years or until they become symptomatic. Patients randomized to surgery will be evaluated pre- and post-operatively at 3 and 6 months, and then at 6 month intervals for two years. Serum calcium, iPTH, creatinine, and urinary calcium will be obtained and correlated. Bone density will be evaluated annually. This study will lead to a better understanding of the natural history of the neuropsychological findings associated with pHPT, and clarify the role of early surgery, especially MIP, in elderly patients with asymptomatic pHPT. General Surgery |
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| Benjamin Sun, MD, | |
| Identification of "Low Risk" Older Patients with Syncope | |
| Geriatric syncope is a high-risk, emergency department presentation that may herald life-threatening conditions, and asymptomatic patients are frequently hospitalized for diagnostic evaluation. However, current admission patterns are characterized by low diagnostic and therapeutic benefit, potential for iatrogenic injury, and high costs. A prediction instrument to identify older patients at low risk of developing 30-day dangerous clinical outcomes, including death, arrhythmias, myocardial infarction, pulmonary embolism, aortic dissection, stroke, internal hemorrhage, and major traumatic injuries, may safely reduce hospitalizations and improve clinical outcomes. Using a nested case-control research design, we propose to study a large, managed care cohort of older patients who presented with syncope to an emergency department with the following Aims: Describe the frequency, timing, and event type of predefined, dangerous clinical outcomes occurring 30 days after an emergency department visit for syncope in patients over age 60 Derive a prediction instrument to identify patients over age 60 at low risk of developing a predefined, dangerous clinical outcome within 30 days of an emergency department visit for syncope Our research team includes nationally recognized clinical scientists with specific skills in prediction instrument research in the elderly and in large emergency department cohorts. Our partnership with a large, integrated health system with an electronic medical records system will allow us to study a large population of older patients and obtain complete outcomes data at low marginal costs. The proposed research will lay the foundations for a definitive, prospective validation study and a randomized trial to assess the effects of prediction instrument use on health resource use and clinical outcomes. Emergency Medicine |
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| Zhongcong Xie, MD, PhD, | |
| Anesthesia and Alzheimer's Disease | |
| Alzheimer's disease (AD) is one of the greatest public health problems in the U.S., and its impact will only increase with demographic changes anticipated in the coming decades. Genetic evidence, confirmed by neuropathological and biochemical studies, indicates that excessive -amyloid peptide (A ) generated from amyloidogenic processing of the -amyloid precursor protein (APP) and cellular apoptosis play fundamental roles in the AD neuropathogenesis. Recent studies indicated that anesthetics isoflurane and proposal can enhance the oligomerization and cytotoxicity of A . However, the effects of anesthetics on apoptosis, APP processing and A generation, the key aspects of AD neuropathogenesis, are entirely unknown. This gap of knowledge impedes the progress toward a better anesthesia care for aging and AD patients, as well as further understandings of AD neuropathogenesis. The goal of this proposal is to primarily assess the effects of anesthetics on APP processing, A generation and apoptosis. The anesthetics that can influence APP processing and A generation will be further studied to determine the molecular mechanisms underlying these effects, especially, the extent to which the anesthetics affect -secretase activity leading to changes in APP processing, and ultimately, A production. Finally, we will also assess the effects of anesthetics on APP processing, A generation and apoptosis in AD transgenic mice. Specifically, the anesthetics to be individually assessed are nitrous oxide, isoflurane, sevoflurane and desflurane. These studies should eventually facilitate the development of strategies for a better anesthesia care for aging and AD patients, as well as for prevention and treatment of AD. Anesthesiology |
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