Geriatrics

Update from Section Chief Terri Fried, MD

The Section of Geriatrics cares for the most vulnerable patients—older adults who have multiple chronic medical conditions or are living with such problems as cognitive impairment or physical disability. For these patients, the use of standard therapies may cause as much harm as good. Geriatricians have the complicated job of weighing different approaches to care, and considering not just whether a treatment is likely to be life-prolonging but also its effects on other outcomes, like physical and cognitive function. All this must be done in the context of patients’ individual risk factors, social circumstances, and care goals.

Named section chief in June 2021, Terri Fried, MD, will continue the clinical, educational, and research work of the section, organized around the “4Ms” of geriatrics: Mentation, Mobility, Medications, and what Matters most. These “Ms” are key aspects of care that cut across all diseases and specialties. The following highlights show how the section brings the 4Ms to patient care; educates the next generation of clinicians about, and provides new knowledge to continue to improve our understanding of the 4Ms and their role in the care of older persons.

Clinical: 4Ms and the Geriatrics Home Visit Program

One of the best ways to assess the 4Ms is in the patient’s home. Home-based primary care not only decreases the burden of health care for frail and disabled older persons for whom travel to a clinic or the hospital can be difficult, but also allows the clinician to understand how patients function in their own environments. The section is helping to advance the practice of house calls. At the VA Connecticut Healthcare System (VACT) location in North Haven, the Home-Based Primary Care service continues under the leadership of Maura Singh, MD. Through the interdisciplinary team at VACT, pharmacists review medications and provide recommendations, and physical therapists assess mobility and provide modifications to the patient’s home. This newer Yale-based program is expanding through the team-based leadership of Ann Datunashvilli, MD, and James Lai, MD, MHS. Through its participation in the National Home-Based Primary Care Learning Network, the program is contributing to national quality improvement initiatives for homecare.

Education: 4Ms for Interprofessional Learners

Over the past year, the section expanded its educational activities to provide training in the 4Ms to an interdisciplinary group of clinicians at all stages of training. Under the direction of Richard Marottoli, MD, MPH, supported through a grant from the U.S. Health Resources and Services Administration, the Connecticut Older Adult Collaboration for Health (COACH 4M) is working to increase the number of health care professionals with experience in the principles of geriatric care. With the support of COACH 4M, an in-person learning experience for medical, nursing, and physician associate students was successfully converted to a virtual teaching session, as reported by Barry Wu, MD, FACP, and co-authors, in the Journal of the American Geriatrics Society. With a return to in-person learning, 144 medical and physician associate students in the 2021 Interprofessional Longitudinal Clinical Experience course received pocket cards to reinforce their 4Ms education. Chandrika Kumar, MD, is the co-leader of “Across the Lifespan,” one of the master courses for first- and second-year medical students, and she has integrated the 4Ms throughout this curriculum. All primary care and traditional residents participate in a series of eight workshops as part of a three-year rotating 4M curriculum.

Research: Adding to 4M Knowledge across Disciplines

The Yale Claude D. Pepper Older Americans Independence Center is directed by Thomas Gill, MD. Under his leadership, two resource cores, the Operations Core, composed of field and data management staff, and the Biostatistics Core provide support to investigators from a wide range of disciplines whose research lies at the intersection of their own specialty or subspecialty and one or more of the 4Ms. The excellence of the staff was highlighted this year with the receipt of a Department of Internal Medicine Service Excellence Award by the center’s associate director, Mary Geda.

The Pepper Center also provides an important source of support to members of the section. Over this past year, Gregory Ouellet, MD, mentored by Andrew Cohen, MD, published a paper in JAMA Internal Medicine examining the use of anticoagulants among nursing home residents with advanced dementia. This work incorporates three of the 4Ms, highlighting how dementia alters the benefits and harms of this class of medications, and considering whether they provide outcomes that matter most. Mary Tinetti, MD, continues her work developing and disseminating Patient Priorities Care (PPC), an innovative set of tools to align decision making around what matters most, with a publication in the Journal of the American Geriatrics Society reporting on clinicians’ perspectives regarding the benefits and challenges of using PPC.

The Future of the 4Ms: Accomplishments of Junior Faculty

The many accomplishments among Geriatrics’ junior faculty members provide assurance that the section will continue to provide key contributions to the 4Ms. Brienne Miner, MD, MHS, received two prestigious career development awards, the GEMSSTAR (Grants for Early Medical/Surgical Specialists’ Transition to Aging Research) and the Paul B. Beeson Emerging Leaders Career Development Award, both from the National Institute of Aging (NIA). These awards will support Miner’s work evaluating sleep disorders in the older adult, which are associated with both the mentation and mobility of the 4Ms. Gregory Ouellet MD, MHS, also received a GEMSSTAR award for his work on the use of anticoagulants in dementia. Cohen, along with Alexandra Hajduk, PhD, MPH, and Lauren Ferrante, MD, MHS, from the Section of Pulmonary, Critical Care, and Sleep Medicine, received funding through the NIA to conduct a longitudinal cohort study of older patients who survive hospitalization with COVID-19. This study brings the 4Ms to the evaluation of COVID-19 by assessing function, cognition, and symptoms. Cohen was also named the 2020 Junior Investigator of the Year by the American Geriatrics Society.

The clinician-educators within the section continue their work to promote robust dissemination of the innovative educational programs they have developed focused on one or more aspects of the 4Ms. Marcia Mecca, MD, received funding from the VA Patient Safety Center of Inquiry to continue her development of the IMPROVE (Initiative to Minimize Pharmaceutical Risk in Older Veterans) Polypharmacy Clinic. Jennifer Ouellet, MD, was the first author on a publication describing the development of virtual and targeted geriatric medicine and palliative care consults for older persons with COVID-19 to align care with patients’ goals.

In March 2021, Miner and Mecca were named co-vice chiefs for Diversity, Equity, and Inclusion (DEI) for the section. They serve as a vital source of information of DEI initiatives within the department and school.

To learn more about the Section of Geriatrics, visit medicine.yale.edu/intmed/geriatrics/

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