2007 Hartford Outcomes Award Winners

Timothy D. Girard, MD, MSCI

Vanderbilt University School of Medicine

“Delirium as a Predictor of Cognitive Impairment in Older ICU Patients”

Tim Girard, MD, MSCI, is an Instructor in Medicine in the Division of Allergy, Pulmonary, and Critical Care Medicine and the Center for Health Services Research at Vanderbilt University. He recently completed a pulmonary and critical care fellowship and the Master of Science in Clinical Investigation Program at Vanderbilt, and he is now continuing a program of aging research as a member of Vanderbilt’s ICU Delirium and Cognitive Impairment Study Group. His research focuses on the clinical epidemiology of critical illness-associated brain dysfunction. As a Hartford Geriatrics Health Outcomes Research Scholar, Dr. Girard will study factors of delirium in older ICU patients associated with the development of long-term cognitive impairment. Specifically, he seeks to identify clinically-defined categories of delirium that confer the highest risk for poor cognitive outcomes in this vulnerable patient population. His long-term research goal is to develop and study interventions to prevent and treat cognitive impairment in older survivors of critical illness.

Supriya Gupta Mohile, MD, MS

University of Rochester

“Patterns of Care and Outcomes of Vulnerable Elders with Cancer”

Supriya Gupta Mohile, MD, MSis currently a Assistant Professor of Medicine and Epidemiology at Columbia Presbyterian Medical Center and is transitioning to a position at the University of Rochester where she will develop a clinical and research program in geriatric oncology. Prior to joining Columbia in August 2005, her training included a fellowship in both Geriatrics and Oncology and a Master’s in Health Services Outcomes research at the University of Chicago. She is a board-certified geriatrician and oncologist with clinical expertise in treating patients with genitourinary and gastrointestinal cancers. Dr. Mohile’s research interests include the evaluation of patterns of care, health outcomes, and quality of life related to treatment for systemic cancer in older patients. She has previously received an American Society of Clinical Oncology Young Investigator Award and Merit Awards that supported the preliminary data for her application. Her current work examines the relationship between disability and decision-making for older adults with prostate cancer and also utilizes the Medicare Current Beneficiary Survey to evaluate the relationship between vulnerability and cancer outcomes in the elderly.

Research Abstract

Name: Supriya Gupta Mohile, MD, MS

Title of Proposed Research: Patterns of Care and Outcomes of Vulnerable Elders with Cancer

Background: As the population ages, the numbers of elders who are vulnerable (i.e., at risk for poor outcomes due to underlying functional, physical or cognitive impairment and/or comorbidities) increases dramatically. Little is known about the patterns of care and outcomes of vulnerable elders with cancer.

Specific Aims: 1) To estimate the prevalence of vulnerability in older cancer patients at progressive stages of cancer and treatment; 2) To assess the differences in the care patterns and clinical outcomes of vulnerable older cancer patients as compared to those who are not vulnerable; 3) To identify clinical and physiologic predictors of poor outcomes for vulnerable elders with cancer.

Proposal Design: In a multi-institutional prospective cohort study, baseline prevalence of vulnerability in 200 ethnically diverse older prostate cancer patients (150 with biochemical recurrence after local therapy and 50 controls) will be estimated using the Vulnerable Elder’s Survey-13 (VES-13) and criteria proposed by Fried and Balducci. A trained research assistant will administer measures of vulnerability and geriatric assessment at baseline, 6 months, and 1 year. Physiologic biomarkers associated with a vulnerable state (hemoglobin, interleukin-6, cholesterol, C-reactive protein, and albumin) will be collected at baseline and 1 year. We will estimate the association between baseline vulnerability and the decision to start androgen ablation at 6 months and identify predictors of poor outcome, i.e., functional decline and/or death, at 1 year. In a second population-based study, we will describe vulnerability and its relationship to patterns of care of older cancer patients within the Medicare Current Beneficiary Survey.

Long-term Objectives: Ideally, this data would contribute to the design of geriatric oncology studies to determine whether geriatric assessment can help with patient selection and improve outcomes and quality of life. In addition, this research will inform the development of geriatric-specific interventions to improve outcomes of vulnerable elders with cancer.

Heather E. Whitson, MD

Duke University

“Adding Insult to Insult: Functional Consequences of Comorbid Cognitive Impairment in Elders with Macular Disease”

Heather E. Whitson, MD is an Instructor of Medicine in the Division of Geriatrics at Duke University Medical Center. She completed clinical training in internal medicine and geriatrics at Duke University Medical Center, and as a VA Special Fellow in Advanced Geriatrics at the Durham VA Medical Center. She is currently pursuing a Masters’ of Health Sciences degree in Duke’s Clinical Research Training Program. Her research focuses on multi-morbidity, or the accumulation of chronic disease. In particular, she is interested in multi-morbidity as a pathway to functional decline, disability, and frailty. Dr. Whitson was recently awarded a Merck/American Geriatric Society New Investigator Award for her work on the combined impact of cognitive impairment and visual impairment in older adults. As a Hartford Geriatrics Health Outcomes awardee, Dr. Whitson plans to explore the functional consequences of cognitive impairment in patients with macular disease and design a novel low-vision rehabilitation strategy tailored to patients with this comorbidity.

Research Abstract

Name: Heather E. Whitson, MD

Background: Low-vision rehabilitation can improve functional outcomes in patients with macular disease, the most common type of incurable vision loss. However, the impact of comorbid cognitive impairment in this population is not known, and no tailored rehabilitation strategies exist for macular disease patients with cognitive impairment.

Aims:

  1. To characterize functional outcomes associated with cognitive impairment among macular disease patients undergoing low-vision rehabilitation.
  2. To design a low-vision rehabilitation program tailored to older adults with both macular disease and cognitive impairment

Study Design: Prospective cohort study

Sample: Patients ≥ 65 years old with macular disease referred to the Duke Low-vision Clinic

Measurements: Independent Variables: 1) demographics 2) health/vision information 3) psychosocial characteristics 4) cognitive measures Dependent Variables: Primary outcome: self-reported instrumental activities of daily living (IADLs), Secondary outcomes: self-reported activities of daily living (ADLs), mobility function, vision function, and measured gait speed Qualitative Data: Standardized interviews with each subject (and/or proxy), the low-vision optometrist, and the low-vision occupational therapist will assess goals, perceived benefits, potential barriers to rehabilitation, and possible solutions.

Analysis: Univariate statistics will describe the cohort with respect to independent and dependent variables. Regression models will assess the association between baseline cognitive status and the dependent variables, while controlling for potentially important covariates. The association will be assessed cross-sectionally using functional measures at baseline and longitudinally by modeling the trajectory of each dependent variable after standard rehabilitation. Qualitative analytic techniques will be applied to data collected from subjects, proxies, and members of the low-vision team to abstract and categorize relevant themes.

A Novel Intervention: Through a series of multi-disciplinary meetings, quantitative and qualitative data from the above analyses will be synthesized to design a tailored rehabilitation strategy. A future trial will evaluate the intervention’s effect on functional outcomes compared to standard rehabilitation.

Brie Williams, MD, MSc

The Regents of the University of California
“The Health, Functional Status and Health Outcomes of Older Adults in Prison and After Release”

Brie Williams, MD, MSc is completing a geriatrics fellowship at the University of California, San Francisco. She received her MD and MS in Community Medicine from the Mount Sinai School of Medicine, was an internal medicine resident at UCSF, and was a Clinician Educator in the Division of General Internal Medicine at UCSF before returning for geriatrics training. Dr. Williams’ research interest is to assess and improve healthcare for hidden geriatric populations. Her current work focuses on understanding the health and healthcare needs of older persons aging in prison and after their release to the community. She plans to describe the health and functional status of geriatric prisoners focusing on those who will soon be released, create a clinical tool that can be used by correctional departments to identify geriatric prisoners at high-risk for adverse health events, and develop a health questionnaire to assess the functional status, health care needs, and health care utilization patterns of older adults recently released from prison.

Research Abstract

Name: Brie Williams, MD, MSc

Title of Proposed Research: The health, functional status and health outcomes of older adults in prison and after release

Background: The rapidly growing population of geriatric prisoners is causing a healthcare crisis. Geriatric prisoners are at high risk for disease, disability and death in an environment designed for younger prisoners. They are also expensive, costing more than $70,000 per year – two to three times that of younger prisoners. Over 90% of geriatric prisoners will be eventually released back into the community, where many confront serious challenges to their health and independent function. Despite the public health and economic implications of this rapidly growing population, older prisoner health has not been studied.

Methods: Our proposal consists of 3 aims. In Aims 1 and 2 we will describe the health and functional status of the 8,534 older prisoners residing in Texas during 2005, and describe the health of those who will be released within the next year. In Aim 2, we will use 2-year follow up data to determine risk factors and develop a clinical prediction tool for adverse health outcomes among geriatric prisoners. In Aim 3, we will design and pilot test a health questionnaire for recently released elders.

Outcomes: This will be the largest study to (1) determine the health and functional status of geriatric prisoners and those who will be released within the year, (2) create a clinical tool that can be used by correctional departments to identify geriatric prisoners at high-risk for adverse health events, and (3) develop and pilot test a health questionnaire to determine the health, functional status, health care needs, and health care utilization patterns of older adults recently released from prison. These projects will lay the groundwork for future independently funded research to develop, implement, and evaluate interventions to improve the health of older persons aging in prison and after their release to the community.

The four recipients, selected by an academic advisory board composed of distinguished academic geriatricians, will receive a $130,000 grant over a two-year period to perform studies in outcomes research addressing clinical strategies, innovative outcomes measures and quality of life. Research findings are presented at the American Geriatrics Society Annual Scientific Meeting at the conclusion of the recipient’s grant. Congratulations!

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