Claude D. Pepper Older Americans Independence Center

  Principal Investigator    Kenneth Covinsky M.D., M.P.H.  415-221-4810 x 24363
  Program Administrator    Sarah Ngo

Established in 2013, the UCSF Claude D. Pepper Older Americans Independence Center focuses on addressing predictors, outcomes, and amelioration of late-life disability in vulnerable populations. Late-life disability, defined as needing help with daily activities, is common, burdensome, and costly to patients, families, and society. Late-life disability is influenced by medical vulnerabilities (including comorbid illnesses, aspects of medical care, medicines, procedures, neuropsychiatric conditions, and behaviors), social vulnerabilities (social supports, financial resources, communication and literacy, and ethnicity), and their interaction. The overriding goal of the UCSF OAIC is to improve the health care and quality of life of vulnerable older adults with or at risk for disability through the following aims:

  1. Catalyze research on disability in vulnerable older persons at UCSF by serving as a hub that brings together scholars and leverages resources
  2. Provide tangible, high-value support to funded projects at UCSF that stimulates new research on disability, and leads to new research opportunities for senior and junior investigators
  3. Support pilot studies that accelerate gerontologic science and lead to research funding in late life disability
  4. Identify the future leaders of geriatrics research and support them with career development funding and exceptional mentoring
  5. Develop a leadership and administrative structure that spurs interdisciplinary collaboration, making the OAIC greater than the sum of its parts

Our Center supports researchers who share our passion for improving the well-being of older persons. We view our resources as venture capital that will catalyze the careers and research paths of investigators who will do cutting edge research that advances the care, health, and wellbeing of older persons, both within the UCSF community and nationally.

  Data and Analysis Core (DAC)
Leader 1:    Mike Steinman, MD
Leader 2:    John Boscardin, PhD
The Data and Analysis Core (DAC) provides OAIC investigators access to statistical services at all stages of the research lifecycle. Through the establishment of a central hub of statistical expertise, the DAC ensures smooth delivery of statistical knowledge and rigor across the spectrum of scientific research at the OAIC. This improves the quality of OAIC research studies, helps nurture trainees, facilitates interdisciplinary research groups, and ultimately enhances research on prediction, outcomes, and amelioration of late-life disability, especially in vulnerable populations. The DAC promotes wider use of state of the art statistical practice, lowers barriers of access to basic statistical services to all research groups including trainees, provides access to specialized statistical resources (such as state of the art prognostic model development, complex longitudinal and latent class analysis, and causal inference methods), and develops statistical procedures targeted to solving problems in aging research, and more specifically to challenges that commonly arise in research on disability and function.

Leadership and Administrative Core (LAC)
Leader 1:    Ken Covinsky, MD, MPH
The Leadership Administrative Core (LAC) plays the central role in coordinating the five UCSF OAIC cores, in maintaining communication across programs, and identifying new opportunities, both within and outside the OAIC. The LAC monitors the success of each core based on tangible metrics of productivity: Research leading to publications in the highest impact journals and new NIH grant funding. The LAC monitors, stimulates, evaluates, remediates, and reports progress toward the goals of the OAIC. The LAC also maintains the substantial collaborations with other UCSF research centers, including the UCSF CTSI and RCMAR, and seeks to establish new collaborations which will leverage OAIC resources and develop new and established investigators in aging research. The overall goal of the LAC is to provide the leadership and administration to support the activities of the entire UCSF OAIC.

Pilot and Exploratory Studies Core (PESC)
Leader 1:    Christine Ritchie, MD
The Pilot and Exploratory Studies Core (PESC) facilitates the development and progress of innovative research relating to the Pepper Center focus on the predictors, outcomes and outcomes of late-life disability, especially in vulnerable older populations. We are especially interested in the interaction of serious clinical conditions, disability, and social disadvantage. The goals of the PESC include: 1) Solicit and select innovative proposals from highly qualified applicants; 2) Provide investigators of PESC studies with the support and infrastructure of the OAIC Cores; 3) Integrate PESC studies and investigators with resources from the UCSF Clinical and Translational Science Institute (CTSI) and other relevant resources at UCSF; 4) Monitor the progress of PESC studies; and 5) Provide mentorship and resources to transform PESC funded studies into successful independently-funded projects. The PESC focuses on identifying projects from outstanding investigators who are conducting aging research that is likely to lead to external funding and is aligned with the OAIC theme.

Research Education Component (REC)
Leader 1:    Louise Walter, MD
Leader 2:    Kristine Yaffe, MD
The Research Education Component (REC) identifies, supports, and nurtures talented junior investigators who will become national leaders in aging research through the REC Scholars Program and Advanced Scholars Program. The REC Scholars Program targets early career faculty and seeks to accelerate their path towards NIA K awards. The Advanced Scholars Program targets current K award recipients and accelerates the path towards their first R01. Both programs provide extensive mentoring and opportunities to participate in an innovative series of seminars designed to develop skills essential to success in aging research, facilitate interdisciplinary communication, build knowledge and relationships that will stimulate translation between basic and clinical research, and accelerate their productivity. The REC leadership also works with leaders of the Resource Cores to provide scholars access to additional support. These mentorship and curricular programs help junior investigators progress along the pathways that lead to high impact publications and grant funding that develops the scholar’s national reputation as a leader in their area. Mentoring services, seminar series, resource core services, and programmatic support are also available to Associate Scholars whose goals are to develop careers in aging research. A particular focus of the Associate Scholars Program is junior faculty who have trained outside of geriatric medicine, but seek to incorporate Geriatric principles into their developing research program. The Research Education Component also sponsors a diversity supplement program to increase the number of faculty members from underrepresented and diverse backgrounds conducting aging research at UCSF.

Vulnerable Aging Recruitment and Retention Core (VARC)
Leader 1:    Rebecca Sudore, MD
Leader 2:    Brie Williams, MD
The Vulnerable Aging Recruitment and Retention Core (VARC) was established in the UCSF Pepper Center grant renewal application. It was developed in response to increased demand both within and outside UCSF to support research focused on improving the knowledge base regarding the needs of medically vulnerable (e.g., complex chronic disease, serious illness, profound cognitive or functional impairment) and/or socially vulnerable (e.g., isolated, impoverished, homeless, incarcerated, with limited literacy or limited English proficiency) older adults. Because these older adults are often particularly difficult to recruit and retain in clinical research, their representation in research is often limited. This impairs our knowledge about how to optimize their care. Therefore, the VARC core focuses on supporting OAIC-affiliated investigators to (1) recruit, enroll, and retain vulnerable older adults in research; (2) use appropriate measures to study their healthcare needs; and (3) engage communities in research about medically and/or socially vulnerable older adults.

  B. RESEARCH (15 Projects Listed)
  Leader(s): LEE, SEI
    VA I01HX002135 / (2017-2021)
  Ignoring life expectancy can lead to poor clinical decisions. Healthy older adults who could benefit fromscreening have low screening rates. Older adults with dementia or metastatic cancer are screened for slow-growing cancers that are unlikely to cause symptoms but may lead to distress from false-positive results,invasive work-ups and treatments. Life expectancy calculators offer the possibility of moving beyond arbitraryage-based cutoffs to more rational life expectancy based decision-making, incorporating age as well as otherfactors known to predict mortality such as comorbidities, demographics, laboratory results and pharmacy data. The objectives of the study are to (a) develop and validate a 10-year life expectancy calculator using2005 VA electronic data (demographics, comorbidities, laboratory results and pharmacy records); (b) developand validate an Augmented life expectancy calculator that adds 2009 functional assessments (Activities ofDaily Living or ADL and Instrumental Activities of Daily Living or IADL assessments) to the other risk factorsand determine whether the addition of ADL and IADL data lead to improved discrimination; ); (c) develop andvalidate a VA-Medicare life expectancy calculator that adds 2009 Medicare data to the other risk factors anddetermine whether the addition of Medicare data lead to improved discrimination; (d) apply the life expectancycalculator to a national VA cohort to determine the proportion of colorectal cancer (CRC) screening that occursin veterans with limited life expectancy (<25% likelihood of life expectancy of 10+ years) and extended lifeexpectancy (>75% likelihood of life expectancy of 10+ years) in both veterans within the recommended age(50-75) for CRC screening as well as veterans at more advanced age (76-85) when screening is not routinelyrecommended. By developing and validating a VA electronic data driven life expectancy calculator, this project willdetermine the rates of potentially inappropriate CRC overscreening in age-appropriate veterans (age 50-75)with a limited life expectancy (<25% likelihood of life expectancy 10+ years). Conversely, this project will alsoidentify potentially inappropriate CRC underscreening in veterans beyond the recommend age for screening(age 76-85) with an extended life expectancy (>75% likelihood of life expectancy of 10+ years). This work willprovide the critical foundation for an intervention to improve the targeting of CRC screening will estimate anindividual veterans' life expectancy to 1) suppress CRC screening clinical reminders for patients with limited lifeexpectancy (age 50-75) or 2) trigger CRC screening clinical reminders for patients with extended lifeexpectancy (age 76-85). Further, accurate life expectancy estimates could also be utilized to individualizeother prevention decisions that have a long time to benefit, such as breast cancer screening and intensiveglycemic control. Thus, this work would be another way that the VA would become a Learning HealthcareSystem that uses clinical data to individualize veterans' prevention decisions and inform system-wide decisionsregarding prevention clinical alerts.
    NIH K01AG059831 / (2019-2024)
  Project Summary/Abstract This is an application for a K01 award for Krista Lyn Harrison, PhD, whose research focuses on improvinglife for older adults with Alzheimer?s disease and related dementias (ADRD) and their informal caregivers. Dr.Harrison is a health services and policy researcher and Assistant Professor in the Division of Geriatrics at theUniversity of California, San Francisco (UCSF). Dr. Harrison has 12-years of experience in qualitative methodsand led the research enterprise of a large hospice prior to completing a UCSF aging research fellowship andimplementation science certificate. Through the activities proposed in this application, Dr. Harrison willstrengthen and address gaps in her experience through a training plan focused on: a) advanced statisticalmethods in linked datasets, b) ADRD clinical care and research, and c) translating mixed-methods data intoADRD interventions. Resources to foster her career development include UCSF?s nationally-recognizedDivision of Geriatrics, Memory and Aging Center, Institute for Health Policy Studies, and K Scholar?s program,Dr. Harrison has assembled an extraordinary multidisciplinary team with extensive expertise. Alzheimer?s disease and related dementias are progressive incurable illnesses causing significant publichealth burden. Palliative care focuses on reducing suffering and improving quality of life by attending to themulti-dimensional sources of distress for seriously ill individuals and families. Evidence for quality palliativecare for advanced ADRD comes primarily from research in nursing homes. For the more than 700,000 olderadults with advanced Alzheimer?s disease who die at home each year, clinicians lack population-level evidenceto guide caregivers and patients in anticipating and planning for disease changes. The proposed K01 willaddress critical knowledge gaps and develop a toolkit of resources to support basic palliative care provided byneurologists. Dr. Harrison will first use a nationally-representative dataset to longitudinally examine factorsassociated with mortality and nursing home stay among people living at home with severe and advancingADRD. Second, she will use semi-structured interviews with older adults living at home with ADRD, currentand bereaved caregivers to understand palliative and end-of-life experiences and opportunities to improvepalliative care for ADRD. Third, Dr. Harrison will work with multiple stakeholders to refine and assess thefeasibility of a toolkit of basic palliative care resources for use in neurology clinical practice (such as anassessment checklist, evidence-based strategies for discussing serious illness prognosis and advance careplanning adapted for ADRD, referral and billing guides, and summarized evidence from Aims 1 and 2 on livingat home with ADRD to inform anticipatory guidance). The goal of this toolkit is to improve neurologists?communication with older adults living at home with advancing ADRD and/or their informal caregivers. Theproposed research will provide Dr. Harrison with the preliminary data, training, and experience to supportfuture competitive independent R-series applications to test the efficacy and effectiveness of her intervention.
    NIH K76AG054862 / (2017-2021)
  PROJECT SUMMARY ABSTRACTThis K76 Paul B. Beeson Emerging Leaders Career Development Award in Aging proposes to provide Dr.Caroline Stephens, a newly promoted Associate Professor in the UCSF School of Nursing, with mentorshipand training in translational qualitative research, implementation science, clinical trials, and leadershipdevelopment. The proposed training and support will provide her with the necessary additional skills to becomea transformative interdisciplinary leader in aging and palliative care research who examines and promoteschanges at the junctures of healthcare systems to improve access to palliative care services and supports for hard toreach nursing home (NH) populations. She has assembled an excellent multidisciplinary team of mentors andscientific advisors with the following areas of expertise: clinical geriatrics and palliative care (Drs. ChristineRitchie and Sei Lee); implementation science (Drs. C. Ritchie and S. Lee); integrated care delivery models forfrail elders (Dr. C. Ritchie and L. Branagan); measuring and improving health care quality in NHs (Drs. S. Lee,Charlene Harrington, Joseph Ouslander); developing/evaluating patient-centered technologies, such as telehealth,for improving care for medically complex older adults (Drs. C. Ritchie and L. Branagan); statistical expertise onclinical trial design and analysis of complex datasets (Dr. J. Neuhaus); long term care health policy (Dr. C.Harrington); translational qualitative research methods (Dr. J. Shim); developing, testing and evaluating multi-component interventions in the NH setting (Dr. J. Ouslander).Suboptimal communication and lack of access to appropriate and timely palliative care expertise and supportin the NH setting often leads to burdensome transitions, particularly at the end of life. Dr. Stephens' researchwill focus on developing, optimizing and pilot-testing a multi-component Improving Access ThroughTechnology (ImPAcTT) intervention that leverages existing telehealth technologies to provide staff education;family outreach, engagement and support; care coordination; and resident symptom management andfacilitation of goals-of-care discussion. ImPAcTT employs a secure communications platform that permits multi-person live video, audio, and text message consultations; real-time document sharing and documentation foradvanced care planning discussions; and remote virtual assessment capabilities. In Aim 1, she will conductsemi-structured interviews with NH staff, residents and families to explore potential barriers and facilitators tousing telehealth for increasing upstream access to PC expertise, support, and education. In Aim 2, she willassess the technical feasibility of telehealth to provide NH palliative care education and support, and developand refine study protocols with up to 10 NH residents, families and staff. In Aim 3, she will conduct a pilotimplementation trial in 3 NHs to evaluate the feasibility and acceptability of the multi-component ImPAcTTintervention. These studies will provide the scientific foundation for a compelling R01 application to evaluatethe outcomes of this ImPAcTT intervention in a multi-site RCT.
    NIH K76AG057016 / (2018-2021)
  PROJECT SUMMARY/ABSTRACT The ability to live comfortably, safely, and independently in one?s home and community ? often called?aging in place? ? is a key component of quality of life for older adults. Yet the ability to age in place is severelycompromised among the nearly 3 million older adults living in federally-subsidized housing, whose risk fornursing home admission is seven times that of the general population. Although some resources are availableto help these vulnerable older adults to age in place, existing programs have not been found to decrease ratesof nursing home placement or to improve other key aspects of aging in place, including function and quality oflife. Thus, there is a need to develop more effective strategies to identify at-risk individuals in subsidizedhousing and deliver targeted interventions to improve aging in place. The aims of the parent grant for thisapplication are to determine barriers and facilitators to a two-component intervention to improve aging in placefor older adults living in subsidized housing, including (a) case-finding to identify high-risk individuals and (b)Function-Focused Care to improving function and aging in place (Aim 1); and to pilot test the feasibility andpreliminary effectiveness of this intervention for improving function and aging in place for older adults living insubsidized housing (Aims 2 and 3). Subsidized housing residents have a disproportionate prevalence ofcognitive impairment, with nearly 30% screening positive for dementia. However, the parent award focuses onaddressing the needs of individuals with functional impairment and does not recruit sufficient participants withdementia nor perform the assessments needed to understand their unique needs. The objective of thisadministrative supplement is to address this gap by adapting and refining the parent intervention to meet theneeds of people with Alzheimer?s disease and related dementias (ADRD) and determining the feasibility andpreliminary effectiveness of this adapted intervention for people with ADRD. We propose the following specificaims: first, to expand the qualitative parent study to identify the unique needs of people with ADRD, allowing usto adapt and refine the intervention for older adults with ADRD living in subsidized housing (Aim 1); andsecond, to expand the parent case-finding and Function-Focused Care pilot intervention to include rigorouscognitive assessments and increased enrollment of people with ADRD, allowing us to determine its feasibilityand preliminary effectiveness for people with ADRD. Relevance/public health significance: Completing theseaims will provide valuable preliminary data which will inform an R01 application employing this intervention, tobe submitted in Year 3 of the K76 award. If successful, this intervention could have a transformative impact forvulnerable older adults with ADRD living in subsidized housing, enhancing their freedom to live in the leastrestrictive setting while also decreasing costs for long-term care.
    NIH K76AG059931 / (2019-2024)
  PROJECT SUMMARY / ABSTRACT This application for the Paul B. Beeson Emerging Leaders Career Development Award in Aging (K76)describes the five-year career development plan of Dr. Victoria Tang, a geriatrician and young physician-scientist in the Division of Geriatrics at the University of California, San Francisco. Dr. Tang?s long-term careergoal is to develop a research niche that bridges the field of aging and surgery to improve the care of oldersurgical patients. The specific career development goals outlined in this application include developing expertise inimplementation science, intervention development, clinical trial design/analysis, and building a research nichethat bridges the field of aging and surgery to improve the care of older surgical patients at the national level.The primary mentor for accomplishing these career development goals is Dr. Ken Covinsky, Professor ofMedicine at UCSF and Principle Investigator of the UCSF Older Americans Independence Center. Dr.Covinsky will be assisted by co-mentor Dr. Emily Finlayson, Professor of Surgery and Director of UCSF?sCenter for Surgery in Older Adults. The career development plan of Dr. Tang includes individualizedmentorship with her mentorship team, formal coursework, one-on-one tutorials, and leadership training. The overall objective of the research plan is to understand the role of psychosocial vulnerability in post-operative outcomes with the largest cohort of older surgical patients to date and to develop a pilot test apsychosocial intervention to improve depressive symptoms, coping skills, and social support. The centralhypothesis of this project is that preoperative psychosocial vulnerability is associated with post-operativefunctional recovery, and a greater understanding of psychosocial vulnerability and interventions designed tomitigate its effects will improve post-operative outcomes, such functional recovery. The specific aims of theproject include (1) determining the independent association between pre-operative psychosocial vulnerabilitywith 2-year overall mortality and functional decline following major surgery; (2) understanding howpsychosocial vulnerability impacts post-operative recovery in older surgical patients through semi-structuredinterviews with older surgical patients and caregivers; and (3) comparing 6-month functional recoveryoutcomes between those randomized to a psychosocial intervention (navigator-led social support and problemsolving therapy) versus usual care. These aims will permit a better understanding of psychosocial vulnerability,a geriatric-specific risk factor, in older adults that may be especially important in a time of major surgery. Theapplication is relevant to NIH and NIA because Dr. Tang?s career goal is to leverage an understanding of thegeriatric-specific risk factors to elucidate potential aspects needing interventions and to improve sharedsurgical decision-making among older adults and their physicians.
  Leader(s): WONG, MELISA L
    NIH K76AG064431 / (2019-2024)
  PROJECT SUMMARY/ABSTRACTThis is a Beeson K76 career development award for Dr. Melisa Wong, a thoracic oncology clinician-investigator dually trained in medical oncology and aging research. Dr. Wong?s long-term goal is to become anational leader in geriatric oncology research, improving cancer care for older adults by aligning treatmentswith individualized patient goals. More than 72% of older adults with cancer report that they would not choosea treatment that results in functional impairment, even if it improves survival. Yet, oncologists traditionally maketreatment decisions based on cancer characteristics, often without discussing how treatment might affectfunction or eliciting patients? goals and values. To move from cancer-centered to patient-centered decisionmaking, oncologists must both predict which older adults are at highest risk for functional decline andcommunicate complex information about benefits and harms to patients in a way that aligns treatments withtheir goals for function, quality of life, longevity, and other priorities. This proposal aims to 1) identify risk factorsfor functional decline in daily activities, physical performance, and life-space mobility during chemotherapyand/or immunotherapy in older adults with metastatic lung cancer; 2A) adapt the Best Case/Worst Case(BC/WC) communication tool; and 2B) test its feasibility for use during treatment discussions with older adultswith lung cancer. In Aim 1?s multi-site cohort study, patients age 65 and older with metastatic lung cancer willundergo serial geriatric assessments to measure functional status during chemotherapy and/orimmunotherapy. In Aim 2A?s focus group study, older adults with lung cancer, caregivers, and oncologists willparticipate in focus groups to elicit feedback aimed at adapting the BC/WC tool to incorporate function andother patient priorities into patient-centered decision making. In Aim 2B?s pre-post pilot study, oncologists willbe trained to use the adapted BC/WC tool; treatment discussions with older adults with lung cancer before andafter training will be analyzed. Dr. Wong?s exceptional multidisciplinary mentoring team is led by Dr. LouiseWalter, an internationally recognized expert on individualized decision making for cancer screening in olderadults. This award will support Dr. Wong?s transition to research independence through dedicated training in 1)longitudinal modeling and risk prediction for functional decline in older adults with cancer; 2) shared decisionmaking and decision-making interventions for older adults with functional or cognitive impairment; 3) clinicaltrial design to test decision-making interventions for older adults with cancer; and 4) leadership skills to directmulticenter research to transform geriatric oncology care. The results from this proposal will serve as thefoundation for a multicenter cohort study to develop and validate a risk prediction score for functional declineduring lung cancer treatment in older adults and a cluster-randomized trial to test the effect of the adaptedBC/WC tool on communication, shared decision making, and receipt of goal-concordant care.
    NIH K76AG064545 / (2019-2024)
  PROJECT SUMMARY/ABSTRACTDue in large part to the successful development of antiretroviral therapy, adults with HIV infection are livinglonger; in the United States, 47% of all people living with HIV are age 50 and older. This aging populationincreasingly experiences multimorbidity, polypharmacy, and significant mental health and psychosocialchallenges. Older HIV-positive adults also experience a high frequency of geriatric conditions including falls,frailty, and functional impairment. Geriatric assessment and management could help address this medical andsocial complexity. Supporting a role for geriatric assessment, studies show that assessments can predicthospitalization and mortality among older HIV-positive adults and geriatric conditions are associated withpoorer quality of life. Yet little is known on how to best integrate geriatric assessment and management in HIVcare settings. Strategies developed need to be efficient, able to be administered by non-geriatrics trainedclinicians, and also tailored to the unique aging issues that are influenced by HIV infection. Our proposaladdresses this knowledge gap by developing and testing a tailored Geriatric Assessment and InitialManagement guide focused on the needs of older HIV-positive adults, also referred to as G-AIM HIV.Specifically, the objectives of this proposal are to 1) develop G-AIM HIV by incorporating patient and expertperspectives on the most important geriatric assessment domains and initial management steps; 2) examineHIV providers? and staff attitudes towards G-AIM HIV and identify facilitators and barriers to its use; and 3) pilotG-AIM HIV in two HIV outpatient settings to evaluate feasibility, acceptability and preliminary patient reportedoutcomes such as quality of life. The objectives of this proposal support the career development activities ofthe PI Dr. Meredith Greene focused on 1) Delphi methodology and stakeholder engagement, 2) qualitativeresearch methods, 3) intervention and clinical trial research with vulnerable populations, and 4) ongoingleadership development. Dr. Greene will conduct all work at the University of California, San Francisco with anexceptional mentoring team, led by Dr. Kenneth Covinsky. This K76 Beeson proposal will advance ourknowledge of how to integrate geriatric principles into HIV care to improve quality of life for older HIV-positiveadults. It will also provide advanced research skills and valuable data to launch Dr. Greene?s career as anindependent investigator and leader at the intersection of HIV and geriatric medicine.
  Leader(s): SUSKIND, ANNE M.
    NIH R01AG058616 / (2018-2022)
  PROJECT ABSTRACT:There is a fundamental gap in our understanding of outcomes related to surgery for bladder and boweldysfunction, which are ubiquitous conditions among nursing home residents. Despite these proceduresbeing relatively ?low risk?, they are not without risk, particularly in an already functionally and cognitivelylimited cohort. Currently, the only available information on such outcomes are from studies conducted inyounger and healthier individuals and they lack important functional and cognitive outcomes that aremeaningful to older adults. Our overarching research objective is to improve care for nursing homeresidents with bladder and bowel dysfunction by providing them and their healthcare providers with realisticexpectations about the risks and benefits of surgical treatment for these conditions. The objective for theproposed study is to better understand the surgical and functional outcomes of these procedures in thenursing home population and to provide patients and their providers with a prognostic tool to assist in thesurgical decision-making process. The central hypothesis is that there are substantial and significantimmediate and long-term complications resulting from these procedures, spanning from high rates ofsurgical morbidity and mortality (compared to community-dwelling controls) and poor functional outcomesmeasured by activities of daily living, cognition and specific bowel and bladder functional outcomes. Thishypothesis will be tested by leveraging Minimum Data Set (MDS) for Nursing Home Resident Assessmentand Medicare claims data (inpatient and outpatient) by the following three specific aims: 1) to compareshort-term (30-day mortality, surgical complications, length of stay, readmission) and long-term (1-yearmortality and intensity of care) surgical outcomes between nursing home residents and age-, sex- andcomorbidity-matched community-dwelling older adults undergoing elective surgery for bladder and boweldysfunction, 2) to determine longitudinal changes in functional status, cognition, and bladder and bowelfunction among nursing home residents following elective surgery for bladder and bowel dysfunction, and3) to develop and internally validate a prognostic tool for nursing home residents considering electivesurgery for bladder and bowel dysfunction to predict surgical morbidity, mortality and postoperativefunction, cognition and bladder and bowel function. This study is innovative because it will measure andapply longitudinal functional and cognitive outcomes data to a prognostic tool for surgical proceduresperformed to improve function among an already functionally impaired population. The proposed researchis significant because there is no information about outcomes for these common conditions in this large andvulnerable population. Development of a prognostic tool to aid in this decision-making process will serve tominimize the risks of potentially unsuccessful, unnecessary and even harmful procedures, while promotingthe use of such procedures among individuals who are more likely to receive benefit.
  Leader(s): LAI, JENNIFER C.
    NIH R01AG059183 / (2018-2023)
  PROJECT SUMMARYThe decision to proceed with liver transplantation in a patient with end-stage liver disease depends not just onthe risk of death without transplant but the risk of adverse outcomes after it. The transplant clinician's assess-ment of a cirrhotic patient's global functional health ? which we have conceptualized as his or her vulnerabilityto health stressors ? is a critical factor (oftentimes the sole factor) in this decision. Yet at the current time, nostandardized, objective criteria for poor global functional health exist to define who is ?too frail for transplant?.Rather, assessment of functional status in transplant is subjective and is applied to decision-making ad hoc,resulting in unequal transplant access and potential denial of otherwise suitable candidates. To facilitatetransplant decision-making, a precise understanding of how pre-transplant functional status impacts post-transplant outcomes is needed to inform prediction of who will not regain excellent global functional health aftertransplant. We have demonstrated that tools to quantify frailty and functional status in older adults have provenvaluable to measure global functional health in cirrhotic patients and have developed an objective Liver FrailtyIndex, consisting of a composite of performance-based tests (grip strength, chairs stands, and balancetesting), to capture longitudinal changes in functional status specifically for use in the pre- and post-transplantsettings. Building logically upon this work, we propose to determine the impact of pre-transplant functionalstatus on 1-year post-transplant mortality and global functional health and develop/validate clinical predictionrules for these outcomes that incorporate pre-transplant functional status. To accomplish these goals, we willleverage our existing Multi-center Functional Assessment in Liver Transplantation Study, consisting of 5 USliver transplant centers (UCSF, Johns Hopkins, Columbia, Baylor, and Duke) with a track record ofcollaboration and high-impact research to obtain data on a minimum of 1,300 liver transplant recipients withassessments of functional status pre-transplantation and assessments of global functional health (including theLiver Frailty Index, disability, and quality of life) 1-year post-transplantation. These data will be used to developand validate clinical prediction rules that incorporate both pre-transplant functional status, patient and donorcharacteristics to predict death, functional status, disability, and quality of life 1-year after transplantation. Thisproject will positively impact the field by expanding our ability to measure the benefit of transplant both by howlong a recipient will live as well as by how well a recipient will live after liver transplantation. Importantly, thisproject will facilitate clinical decision-making for patients and their clinicians through the precise understandingof how functional status impacts outcomes and what patients can expect after liver transplantation with respectto functional recovery. Given that functional status is modifiable in cirrhotic patients, our data will also supportfuture investigations to develop effective strategies to improve pre-transplant functional status with the goal ofreducing mortality and optimizing post-transplant functional health.
  Leader(s): GARDNER, RAQUEL C.
    NIH R01NS110944 / (2019-2024)
  PROJECT SUMMARY / ABSTRACTSome 2.8 million Americans seek medical attention for traumatic brain injury (TBI) annually, resulting inestimated annual costs of over $75 billion. Older adults have the highest and fastest rising rate of TBI of anyother age-group, with 1 in 50 adults age =75y seeking medical attention for TBI in 2013. Older adults with TBIexperience higher mortality, slower recovery, worse outcomes, and may be at especially high risk for post-TBIdementia. There are few evidence-based guidelines for management, no tools to provide patients and familieswith reliable estimates of prognosis, and few proven treatments. Progress has been limited by: 1. systematicexclusion of older disabled patients from most prior prospective TBI studies, and 2. lack of age-appropriate TBIresearch tools. The overall objective is to launch a 2-site prospective geriatric TBI cohort study that will directlyaddress these barriers by applying state-of-the-art geriatric research methods to the field of TBI to improverepresentation of older patients in TBI research, and to develop a novel approach to measuring age-appropriate TBI predictors, outcomes, blood-based biomarkers, and neuropathology. The approach rests on 2foundational concepts: 1. Geriatric TBI is different from TBI in younger patients and will require a targeted age-appropriate approach. 2. Baseline health status ? including comorbidities/polypharmacy, physical frailty,functional status, and brain structure ? is recognized as a key predictor of outcome in the field of geriatrics butis not systematically measured in TBI research. The central hypothesis is that pre-injury health will beextremely heterogeneous in geriatric TBI and will be a key predictor of outcome in this population. Anoutstanding team of experts in TBI and aging research will achieve these Aims: Aim 1: Assemble a prospectivecohort of patients age =65y presenting to the Emergency Department =72h after TBI who underwent CT. Enroll270 TBI patient/study-partner dyads and 90 controls; perform baseline assessments and blood draws, andassess longitudinal outcomes at 2wk, 3mo, 6mo (primary endpoint) and 12mo; offer enrollment in a braindonation program. Aim 2: Develop and validate optimized geriatric TBI predictor and outcome assessments:2a: Systematically measure apolipoprotein E allele and pre-injury comorbidities/polypharmacy, physical frailty,and multi-domain functional status via detailed patient and study partner interviews using validated geriatricinstruments and assess association of these predictors with outcome after TBI. 2b: Describe the natural historyof geriatric TBI using validated TBI and geriatric outcomes and then use data-driven analytics to identify themost parsimonious set of measures for longitudinal outcome assessment in this population. 2c (exploratory):Measure pre-injury brain structure (atrophy/white matter disease of uninjured brain visualized on baseline CT)and explore association with outcome after TBI. Aim 3: Identify age-appropriate diagnostic and prognosticblood-based biomarkers. This work will directly inform design of large-scale age-appropriate geriatric TBIclinical trials that are urgently needed to improve care and outcomes in this vulnerable population.
    NIH R03AG059822 / (2018-2020)
  Project Summary/Abstract:Elders undergoing cardiac surgery are at particular risk of postoperative cognitive dysfunction (POCD), anacute decline in cognition persisting days, weeks, or months following surgery. Nonetheless, thousands ofelders undergo coronary artery bypass grafting (CABG) each year in the United States in hopes of improvingtheir health and function. Percutaneous coronary intervention (PCI) offers coronary revascularization thatavoids major surgery and anesthetic exposure, which may be an attractive alternative to CABG for elderlypatients concerned about durable cognitive decline following CABG despite inferior revascularization outcomesfor certain coronary lesions. It is not known whether long-term cognition, on the timescale of anticipatedclinical benefit of CABG, is impacted differently by CABG versus PCI, and whether cognitive change is trulynew or a continuation of preoperative cognitive trajectory. We propose an analysis of biennial cognitive testingin the Health and Retirement Study (HRS) linked with Medicare claims data to investigate population-levelcognitive trajectories spanning up to 20 years in elderly patients undergoing CABG or PCI. Using linear mixed-effects models, we will model raw and adjusted pre- and post-revascularization cognitive trajectories for eldersundergoing CABG and PCI to evaluate whether long-term population-level pre- and post-procedural cognitivetrajectory for patients undergoing CABG differs from that for patients undergoing PCI. Furthermore, under thehypothesis that there is heterogeneity among post-procedure cognitive trajectories beyond that predicted bypre-procedure trajectory, we will identify subpopulations of patients united by clinical characteristics who are atelevated risk of POCD. Finally, to complement results derived from objective cognitive testing, we will alsostudy the impact of CABG versus PCI on patient-reported (subjective) cognitive function and ability of therespondent to complete cognitively-intensive instrumental activities of daily living, like medication and financialmanagement. This study will shed new light on the clinical relevance of POCD after coronaryrevascularization, providing data from a novel and patient-relevant perspective which will help cliniciansreconcile the potential risks of cognitive change with the medical necessity of these interventions in elders athigh risk for catastrophic coronary occlusive events.
  Leader(s): SHAH, SACHIN J
    NIH R03AG060090 / (2019-2021)
  Project Summary/AbstractDecades of research establish that social determinants of older adults affect their health, yet, we lack ways toimplement this knowledge. We fall short without a coherent synthesis: What basic social determinants shouldan investigator include in their aging cohort study? How can a Medicare accountable care organization includesocial determinants to identify at-risk patients in the population for which they are accountable? Lackingpractical ways to incorporate social risk factors, risk models often exclude social risk factors, and in doing so,risk creating biased estimates. For practical applications in research, population health, and policy settings it isuseful to identify a subset for social determinants that predict risk efficiently. Prior attempts have fallen short bynot accounting for the unique social determinant of older adults. To address this gap, we propose a study todevelop a social vulnerability index ? a summary measure reflective of the social risk factors of older adults.We will test the social vulnerability index?s ability to predict medical hospitalization, a common health eventamong older adults, and assess the index?s ability to improve traditional risk models. The central hypothesisis that social risk factors ? specifically aging-associated social risk factors ? will significantly improve thepredictive model discrimination of traditional risk models. This hypothesis will be tested using the nationally-representative sample of older adults in the Health and Retirement Study Medicare-linked cohort. We have twospecific aims: 1) Develop a social vulnerability index to predict medical hospitalization and 2) Assess theability of the social vulnerability index to improve upon traditional comorbidity-based prediction models. Thisproject is innovative and significant because it will develop a summary measure of social vulnerability thatcan be used to improve prediction. This will, in turn, will improve the quality of risk models used in research,population health, and health policy.
    NIH R03AG060098 / (2018-2020)
  PROJECT SUMMARY/ABSTRACTFor the 5.3 million older Americans with Alzheimer?s disease and related dementias (ADRD), end-of life-care isincreasingly marked by intensive medical treatments that are goal-discordant, confer no benefit, and likelycauses harm. Compared to a decade ago, older adults with advanced dementia in the United States (US) aretwice as likely to receive mechanical ventilation and be admitted to the ICU without substantial improvement insurvival. There is a lack of research describing the systemic and cultural drivers of burdensome ICU care,which we define as ICU admission, ICU level treatments such as vasopressors or mechanical ventilation, andresuscitation amongst older adults with ADRD near the end of life. Comparisons between the US and theUnited Kingdom (UK), a country that has significantly lower rates of terminal ICU hospitalization than the US,are useful in determining modifiable drivers of burdensome ICU care. By identifying practices that are commonor accepted in the UK, but not found in the US, we can bring a different perspective onto typical practices in theUS and identify innovative practices that exist in the UK that could be introduced in the US context to modifythe American culture of burdensome ICU care. The long-term goal is to design, pilot, and implement hospitalsystems-level interventions that successfully shift institutional culture to mitigate burdensome treatments forolder adults with ADRD near the end of life. The objective of this project is to identify factors at the institutionallevel that contribute to burdensome ICU treatments in older adults with ADRD near the end of life. The first aimof this project is to identify institutional, clinician, patient, and family factors that contribute to burdensome ICUtreatments in older adults with ADRD near the end of life in the US and United Kingdom (UK). This will beaccomplished through a comparative ethnography (observations) at two hospitals in the US (UCSF andUCLA), and two in the UK (King?s College Hospital and Princess Royal University Hospital). The observationswill focus on of the day-to-day activities and behaviors of individuals involved in the care of older adults withADRD such as ward rounds, family meetings, and treatment discussions. The project?s second aim identifiespromoter and inhibitors of burdensome ICU treatments in older adults with ADRD near the end of life throughsemi-structured in-depth interviews with key stakeholders at all levels of the healthcare system. The proposedresearch is innovative because it will be the first rigorously designed, in-depth qualitative study examiningcultural and systemic factors related to burdensome ICU care between the US and UK. This study is significantbecause it will uncover previously uncharacterized cultural and systemic factors that contribute to burdensomeICU care, which can be used to develop targeted interventions to mitigate burdensome care in older adults withADRD.
    NIH R03AG060354 / (2018-2020)
  ABSTRACTAfrican Americans are twice as likely to have Alzheimer?s disease than Whites, yet they are underrepresentedin dementia research. The low rate of participation among African Americans hinders the understanding of themechanisms of dementia in this population, further widening health disparities. To date, partnerships with faith-based organizations are the most common strategy used to recruit African Americans into dementia research.However, estimates suggest that only half of African Americans regularly attend religious services, which limitsthe effectiveness of this strategy. Thus, there is an urgent need to develop additional culturally relevant andscalable strategies for recruiting African Americans with cognitive impairment into dementia research. Todevelop such strategies, we will leverage the expertise of the research team in recruiting older adults who areunderrepresented in research studies. Because older adults with cognitive impairment are likely to be wary ofstrangers, identifying trusted community-based organizations (CBOs) who are also culturally relevant is critical.Therefore, the goal of this study is to examine how CBOs with national reach could be used as a culturallyrelevant and scalable approach to facilitate recruitment of African Americans with cognitive impairment. Inorder to identify these partnerships, we will use qualitative methods of analysis. We will interview AfricanAmericans with cognitive impairment, caregivers, and administrators of selected CBOs with national reach(total n=100). Interviews and focus groups will be audio-recorded, transcribed, and analyzed using contentanalysis. We will include two sites with whom we have established partnerships and have a highrepresentation (= 25%) of African Americans: Oakland, CA and Detroit, MI. Interviews and focus groups willoccur at two time points: Timepoint 1 will be used to collect initial data. We will return to the same participantsin Timepoint 2 to obtain feedback on specific guidelines to help standardize recruitment strategies for AfricanAmericans with cognitive impairment nationwide. The proposed research has three specific aims: (1) to identifybarriers and facilitators to recruit African Americans with cognitive impairment into research using CBOs withnational reach; (2) to examine factors related to trust and cultural relevance of CBOs to facilitate recruitment,and; (3) to examine barriers and facilitators of developing partnerships with CBOs with national reach tofacilitate recruitment. The proposed project will address the need to increase the participation of AfricanAmericans with cognitive impairment into research. The methods developed as part of this project can beapplied to future studies recruiting African Americans with cognitive impairment. These methods can also beused to identify strategies and guidelines to recruit other ethnic/racial minorities with cognitive impairment aswell as other vulnerable groups into research. Findings of this study will create the foundation for a larger R01study to finalize and test the effectiveness of national guidelines for standardized strategies with selectedCBOs to recruit African Americans with cognitive impairment into dementia research.
    NIH R03AG064373 / (2019-2021)
  PROJECT SUMMARY/ABSTRACTOlder adults accounted for over 12 million hospitalizations in 2015. During hospitalization, blood pressure (BP)may fluctuate as a result of acute illness, stress, and new medication exposures. Though the long-termbenefits of strict BP control on older adults? cardiovascular risk are well established, no research has shown ashort-term benefit to treating asymptomatic elevated BPs during hospitalization. Despite this evidence gap,single-center studies indicate older adults commonly receive intensive BP treatments during hospitalization fornon-cardiac conditions. Older adults are at increased risk of medication-related adverse events while beingtreated for and recovering from acute illness, therefore, understanding the benefits and harms of intensivelytreating elevated BPs during hospitalization is critically important. While hospitalized for conditions unrelated tohypertension, older adults may be particularly susceptible to harms resulting from BP overtreatment, includingsymptomatic orthostasis, falls, and acute kidney injury. To date, prior studies have not assessed the effect ofintensive inpatient BP treatment on clinical outcomes during hospitalization. The importance of addressing theknowledge gaps surrounding inpatient BP management is highlighted by prior research on inpatient bloodglucose management which demonstrated that applying outpatient blood glucose treatment targets to thehospital setting results in increased risks of in-hospital hypoglycemia and mortality. The objective of thisapplication is to characterize the epidemiology and outcomes of intensively treating elevated BPs in olderadults during hospitalization. We propose a retrospective cohort study of all older adults hospitalized for non-cardiac conditions in the national Veteran?s Affairs Health System between 2013 and 2015. First, we willdescribe how often elevated inpatient BPs are treated intensively among hospitalized older adults and evaluatepatient characteristics associated with intensive BP management. We will use log binominal or Poissonregression to obtain direct estimates of relative risks of intensive BP treatment by key patient characteristicsincluding prior outpatient BP control, polypharmacy, multi-morbidity, dementia, and limited life expectancy.Second, we will evaluate the impact of intensive inpatient BP treatment on in-hospital clinical outcomesincluding potential harms (e.g. falls, acute kidney injury) and potential benefits (reduction in acute CV events).We will compare in-hospital outcomes of older adults who did and did not receive intensive BP treatment usingpropensity score matching to control for confounding by indication. We will conduct pre-specified subgroupanalyses to determine whether patients with multi-morbidity, dementia, or limited life expectancy haveincreased risk of in-hospital harms. This study will fill a vital knowledge gap and provide key guidance to informinpatient BP treatment decisions for older adults. These data will serve as the foundation for future studies todesign and test a pilot intervention to guide the individualization of elevated BP treatment decisions during theperi-hospitalization period based upon older adults? likelihood to benefit and risk of adverse outcomes.
  C. PILOT/EXPLORATORY PROJECTS (3 Pilot Projects Listed)
1. Project Title: Functional Impairment and Advance Care Planning among Older Adults Transferred to Long-Term Acute Care Hospitals: An Analysis of the Health and Retirement Study
  Leader: Anil Makam, MD

Each year, over 120,000 hospitalized older adults survive an acute or critical illness and are transferred to a long-term acute care hospital (LTAC) to recover. LTACs are distinct from acute care hospitals and skilled nursing facilities (SNFs) in their focus on treating patients who require extended inpatient care, typically for 3-5 weeks following the initial hospitalization. While most commonly understood as the post-acute care setting of choice for chronically critically ill patients, three-quarters of LTAC patients are not mechanically ventilated, but rather, require other medically complex inpatient care, such as antibiotics, complex wound care, and dialysis.


The intended goal of LTACs is to help patients recover and regain independence; however, using national Medicare claims data, we found that older adults transferred to an LTAC have poor prognoses. Fewer than 20% of older adults transferred to an LTAC were alive at 5 years. Patients spent on average two-thirds of their remaining time alive after transfer as an inpatient. Over one-third were confined to an inpatient setting and never returned home before dying. One-third received an artificial life-prolonging procedure. Lastly, half experienced a minimal definition of recovery, defined as achieving 60 consecutive days alive without inpatient care. Though half make it back home at some point after their LTAC stay, actual functional recovery is unknown. Maintaining functional independence is an important health care goal for older adults.

Despite this bleak prognosis, there is extremely low use of specialty palliative care and hospice among older adults transferred to LTACs. Using national Medicare data, we found that only 16% of older adults transferred to LTACs in the Medicare program ever enrolled into hospice with a median of 10 days, which is far lower than for the overall Medicare program, where 48% of decedents enrolled in hospice for a median of 24 days, and only 1% were ever seen by a palliative care physician during the initial episode of care. While patients in LTACs may represent a distinct population who desired to pursue life-sustaining and intensive care, we do not know if patients participated in advance care planning—whether goals of care discussions occurred or if patients expressed desire for life-sustaining treatment. Understanding advance care planning actions in this population could uncover a critical gap in LTACs, which are intended to be post-acute care settings that specialize in the care of older adults with serious illness.


The objective of this Dr. Makam's study is to develop a novel, robust, and nationally representative cohort of older adults which will include detailed assessments on functioning and advance care planning both before and after LTAC transfer, and will generate compelling preliminary data for a R01 grant application to explore these areas in greater depth. His central hypothesis is that geriatric syndromes and unmet palliative care needs are highly prevalent in this vulnerable population. In subsequent years, Dr. Makam will be using this work to support his future application for a R01 grant.

2. Project Title: Understanding the Context of Patient Medication Practices among Diverse Older Adults with Multiple Chronic Conditions
  Leader: Jan Jih, MD

By 2050, 42% of the older U.S. adult population will be racial/ethnic minorities. Older minorities bear a substantial burden of multiple chronic conditions (MCC) and polypharmacy and receive poorer quality of chronic disease management. Patient-clinician communication barriers are important contributors to disparities in care and outcomes of MCC including polypharmacy. In particular, clinic visit communication about the context of people’s lives (i.e., contextual factors such as food availability, culture, home safety, etc.) optimally informs MCC management including medication management and is essential to delivering patient-centered healthcare. As the World Health Organization succinctly states: “The context of people’s lives determine their health.” Yet, few patient-clinician communication interventions focused on medication practices have included diverse populations and have centered on patient activation and engagement in clinical communication about medication use. Furthermore, most do not address the interactions of aging, MCC, polypharmacy and contextual factors that enhance or reduce health.


Type 2 diabetes is one of the most common conditions among patients with MCC. A common scenario is the minority older adult with diabetes and concurrent comorbid conditions with significant polypharmacy. The burden of self-management tasks related to diabetes (e.g., checking glucose, taking multiple medications, optimizing exercise, adhering to diet) while simultaneously following care plans for other conditions can be overwhelming, particularly when care plans do not account for culture, language and the context of patients’ daily lived experiences. We need clinically feasible, patient-centered interventions, particularly among those with racial/ethnic, cultural or non-English language diversity, to support person-centered communication between patients and clinicians about the complexities of chronic disease care including medication use.


The goal of Dr. Jih’s study is to better understand the multi-level contextual factors that influence the medication practices of older minorities with MCC in order to develop a patient-centered technology-enabled, photo-based communication intervention to promote optimal medication management called medPhoto+Care. The premise of a medPhoto+Care is that a picture is worth a thousand words, meaning that photos can promote efficient information exchange and activate patients to communicate their lived experiences to their clinicians, so they can develop patient-centered care plans together.39-41 Using smartphone cameras as a tool, medPhoto+Care will elicit and integrate contextual factors relevant to medication practices into primary care for older minorities with MCC. medPhoto+Care will consist of a patient component, which will comprise: 1) brief training on photo-taking with a smartphone camera; 2) photo-taking guided by standardized structured and open-ended prompts to elicit contextual factors relevant to medication practices; and 3) sharing of photos from the smartphone and their accompanying oral narratives in a clinic visit; and a clinician component, which will include training to 1) respond to the photos and 2) discuss the contextual factors elicited by the photos with patients.


Through this pilot, Dr. Jih seeks to prove that medPhoto+Care will improve patient-clinician communication about the contextual factors affecting medication practices within MCC management and lead to realistic care plans that align with patient goals and preferences. She aims to conduct her study with older African American, Latino and Asian patients who speak English, Spanish or Chinese (Cantonese/Mandarin) from the UCSF primary care clinics. Since the start of her study, Dr. Jih has been setting up her study to conduct observations in patients’ homes (n=10) to directly observe medication practices and explore contextual factors related to medication use within the context of MCC in these levels: 1) individual factors, behaviors and preferences (e.g., diet and physical activity practices); 2) clinical factors (e.g., comorbid conditions, geriatric syndromes); and 3) family and community factors (e.g., culture, social support).


Currently, Dr Jih and her team have completed 4 home visit interviews to explore patients’ practices, beliefs and preferences on medication use among diverse older adults with multiple chronic conditions. They are in the process of rescheduling 3 home visits through Zoom during the COVID19 pandemic. They have learned a range of patients' medication practices and preferences through these home visits, some of which were easily communicated through photos.

3. Project Title: Sleep medication use and cognitive aging in a biracial cohort of community-dwelling elderly
  Leader: Yue Leng, PhD

Older adults frequently report sleep disturbances, making sleep medications one of the most commonly used medications in the elderly. Sleep medications can be broadly divided into over-the-counter (OTC) and prescription medication, with different subtypes included in each category. Growing evidence suggested that the use of both OTC and prescription sleep medications in the elderly could lead to a range of adverse events, including high risk of falls and short-term memory loss. However, the effects of sleep medication use on cognitive aging outcomes, including cognitive decline and risk of Alzheimer’s disease and related dementias (ADRD) in the long term are poorly understood. While most previous studies have examined the association between benzodiazepine use and risk of dementia and have found inconsistent results, almost nothing is known about non-benzodiazepine type of sleep medications or if different types of sleep medications influence long-term cognitive trajectory differently. Since different types of sleep medications have different mechanisms of action and different drug detection times, they might also affect cognition differently. Given the high prevalence of both sleep medication use and ADRD in older adults, understanding the link between the two has large public health implications. Characterization of users of different types of sleep medications is a critical first step in understanding their health implications.


The overall objective of this study is to characterize older sleep medication users, determine the association between the use of different types of sleep medications and cognitive decline and impairment, and elucidate the role of sleep disturbances, sex and race. Dr. Yue is leveraging the existing data infrastructure of a biracial longitudinal cohort of aging, the Health ABC Study, in order to characterize users of sleep medications, determine the association between sleep medication use and cognitive decline and impairment, and explore the role of sleep disturbances, sex and race in this association. She is developing her analysis to compare baseline characteristics between users and non-users of each sleep medication in univariable analysis. Multivariable logistic regression will be used to identify independent correlates of sleep medication users. Linear regression will be used to estimate the cross-sectional association between sleep medication use and scores of each cognitive test. Mixed effect models will be used to examine the longitudinal effects of sleep medication use on change in cognitive scores over time. She will also use logistic regression to model sleep as a predictor for the development of MCI and dementias. In order to address the independent effects of sleep medication use, we will carefully construct multivariable models to account for potential confounders, determined a-priori. We will also model the interaction to decide if the association between sleep medication use and risk of adverse cognitive outcomes will be modified by sleep disturbances and other factors, such as sex and race.

  D. DEVELOPMENT PROJECTS (2 Development Projects Listed)
1. Project Title: Methods with Survey Data
  Leader: Grisell Diaz-Ramirez, MS, Bocheng Jing, MS

Currently there are no clear methods or best practice guidelines regarding analysis of survey data to support all survey topics ranging from surgery prediction to cognition. There are currently no software packages available, thus creating an issue of no standardized methods in calculations to perform analysis. The aims of this development project were to explore survey data issues from three main aspects: survival prediction (cox model, competing risk), propensity score methods, and linear mixed model.


Since the start of this project, Ms. Diaz-Ramirez and Mr. Jing have been actively disseminating their findings, of note:


1.     The following proceeding paper was accepted to SAS Global: “Mixed-Effects Models and Complex Survey Data with the GLIMMIX Procedure”


2.     The following proceeding paper was also accepted to SAS Global: “Propensity Score Matching with Survey Data”


3. SAS proceedings papers on mixed model and propensity score were presented at the Virtual SAS Global meeting. They are both now published on the Proceedings of the SAS Global Forum 2020 and also accessible online to reach the a global audience


Mixed model download link:


Propensity score download link:

2. Project Title: Statistical Harmonization of Two Nationally Representative Data Sets: HRS and NHATS
  Leader: Sun Jeon, PhD

Dr. Sun Jeon seeks to develop a harmonized coding of ADL/IADL and other functional measures using the Health Retirement Study (HRS) and the National Health Aging Trends Study (NHATS).

Through her analysis of the prevalence of disabilities in those two data sets, NHATS showed higher prevalence across ADL/IADL measures than that in HRS. Currently there is a lack of an understanding of whether the NHATS cohort consists of generally sicker people or the discrepancy was derived from the way the questions were asked or the survey is done.


From observation of work that UCSF Pepper Center Investigators are engaging in, she has seen great overlap their interests in and demands for this work.

Dr. Jeon will be dedicating her effort to further study in this area to get a deeper understanding of NHATS/HRS cohorts, survey design, and of course as well as some statistical tests.

REC Scholar, Research & Grants Funded During Pepper Supported Time Years Publications
Lindsey Hampson, MD
Assistant Professor of Urology / UCSF
Evaluating Quality of Life and Decisional Regret Among Older Men Undergoing Treatment for Stress Urinary Incontinence
  • GEMSSTAR R03 Grant Funder: NIA Funding Period: 9/1/2019 - 5/31/2021
  • Doris Duke Award to Retain Clinical Scientists Grant Funder: Doris Duke Charitable Foundation Funding Period: 7/1/2019 - 6/30/2020

2019-2020  1 (0 1st/Sr)
Elizabeth (Liz) Whitlock, MD, MS
Assistant Professor, Anesthesia / UCSF
Cognitive Change Before and After Total Joint Arthroplasty in Older Adults
  • GEMSSTAR R03 - R03AG059822 Title: Impact of Coronary Revascularization on Longitudinal Cognitive Change in the Elderly Grant Funder: NIH/NIA Funding Period: 08/01/2019- 07/31/2020
  • UCSF KL2 Scholar Award (KL2TR001870) Title: Impact of Elective Total Joint Arthroplasty on Longitudinal Cognitive Change in Older Adults Grant Funder: National Center for Advancing Translational Sciences KL2 Scholar Program Funding Period: 08/01/2019- 07/31/2022

2019-2020  4 (3 1st/Sr)
Lauren Hunt, PhD, RN, FNP
Assistant Professor, Physiological Nursing / UCSF
Live Discharge from Hospice: Impact on Burdensome Transitions in the Last Month of Life in Persons with Dementia
  • UCSF KL2 Scholar Award (KL2 TR001870) Title: The Impact of Live Discharge from Hospice on Burdensome Transitions in the Last Month of Life for Persons with Dementia Grant Funder: National Center for Advancing Translational Sciences KL2 Scholar Program Funding Period: 7/1/2019-6/30/2022
  • NPCRC Award Title: Potentially Burdensome Health Care Use Following Live Discharge from Hospice for Patients with Dementia Grant Funder: National Palliative Care Research Center Funding Period: 7/1/2019-6/30/2021

2019-2020  6 (1 1st/Sr)
Ashwin Kotwal, MD
Assistant Professor, Geriatrics / UCSF
Evaluating Explanations for the Association between Sensory Impairments, Cognitive Decline, and Dementia
  • GEMSSTAR R03 - R03AG064323 Grant Title: Loneliness and Social Isolation among Older Adults in the Last Years of Life Grant Funder: NIA Funding Period: 8/01/2019-5/31/2021
  • NPCRC Award Title: Social Health among Older adults in the Last Years of Life Grant Type: Foundation Grant Grant Funder: National Palliative Care Research Center Funding Period: 7/01/2019-6/31/2021

2019-2021  2 (2 1st/Sr)
Sachin Shah, MD, MPH
Assistant Professor, Medicine / UCSF
Anticoagulation in Vulnerable, Older Adults with Atrial Fibrillation
  • UCSF KL2 Scholar Award (KL2TR001870) Title: Anticoagulation in Vulnerable, Older Adults with Atrial Fibrillation Grant Funder: National Center for Advancing Translational Sciences KL2 Scholar Program Funding Period: 8/1/2019-6/30/2022
  • GEMSSTAR R03 Title: Social Vulnerability of Older Adults and the Risk of Medical Hospitalization Grant Funder: NIH/NIA Funding Period: 9/15/2019-5/31/2021
  • UCSF Pilot Award for Junior Investigators in Basic and Clinical/Translational Sciences Title: Anticoagulation in Vulnerable, Older Adults with Atrial Fibrillation Grant Funder: UCSF Resource Allocation Program Funding Period: 7/1/2019-6/30/2020
  • CADC Scholar Award Title: Anticoagulation in Vulnerable, Older Adults with Atrial Fibrillation Grant Funder: Center for Aging in Diverse Communities Funding Period: 7/1/2019-6/30/2020

2019-2020  2 (2 1st/Sr)
Scott Bauer, MD, MS
Assistant Professor, Medicine / UCSF
Prevalence of Frailty Among Older Men with Lower Urinary Tract Symptoms
  • UCSF-CTSI K Scholars Program Team Science Award Title: Incorporating pharmacokinetics/pharmacodynamics into n-of-1 trials of tamsulosin deprescribing in older men Funding Period: Mar 1, 2020 - Feb 28, 2021 Role: PI

2019-2020  2 (2 1st/Sr)
Willa Brenowitz, PhD, MPH
Assistant Professor, Psychiatry / UCSF
Evaluating Explanations for the Association between Sensory Impairments, Cognitive Decline, and Dementia
  • K01 (1K01AG062722-01A1) Title: Sensory Impairments, Cognitive Decline, and Dementia: What Explains the Association? Grant Funder: NIH/NIA Funding Period: 9/01/2019-4/30/2020

2019-2020  9 (3 1st/Sr)

  1. Patient-reported measures of well-being in older multiple myeloma patients: use of secondary data source.
    Cenzer I, Berger K, Rodriguez AM, Ostermann H, Covinsky KE
    Aging Clin Exp Res, 2020 Jan 22, 32(6): 1153-1160 | PMID: 31970671 | PMCID: PMC7260254
    Citations: | AltScore: 0.25
  2. Frailty Is Associated With Increased Rates of Acute Cellular Rejection Within 3 Months After Liver Transplantation.
    Fozouni L, Mohamad Y, Lebsack A, Freise C, Stock P, Lai JC
    Liver Transpl, 2020 Mar, 26(3): 390-396 | PMID: 31655014 | PMCID: PMC7036016
    Citations: | AltScore: NA
  3. Transforming Undergraduate Student Perceptions of Dementia through Music and Filmmaking.
    Gubner J, Smith AK, Allison TA
    J Am Geriatr Soc, 2020 May, 68(5): 1083-1089 | PMID: 32372442
    Citations: | AltScore: 62.78
  4. Hospice Staff Perspectives on Caring for People with Dementia: A Multisite, Multistakeholder Study.
    Harrison KL, Allison TA, Garrett SB, Thompson N, Sudore RL, Ritchie CS
    J Palliat Med, 2020 Mar 4 | PMID: 32130076
    Citations: | AltScore: 2.35
  5. Community-Based Palliative Care Consultations: Comparing Dementia to Nondementia Serious Illnesses.
    Harrison KL, Bull JH, Garrett SB, Bonsignore L, Bice T, Hanson LC, Ritchie CS
    J Palliat Med, 2020 Jan 22 | PMID: 31971857
    Citations: | AltScore: 4.85
  6. What's Happening at Home: A Claims-based Approach to Better Understand Home Clinical Care Received by Older Adults.
    Harrison KL, Leff B, Altan A, Dunning S, Patterson CR, Ritchie CS
    Med Care, 2020 Apr, 58(4): 360-367 | PMID: 31876645 | PMCID: PMC7071951
    Citations: | AltScore: 1.85
  7. Barriers and Solutions to Advance Care Planning among Homeless-Experienced Older Adults.
    Kaplan LM, Sudore RL, Cuervo IA, Bainto D, Olsen P, Kushel M
    J Palliat Med, 2020 Mar 17 | PMID: 32182155
    Citations: | AltScore: NA
  8. Advance Care Planning Prior to Death in Older Adults with Hip Fracture.
    Kata A, Cenzer I, Sudore RL, Covinsky KE, Tang VL
    J Gen Intern Med, 2020 May 4 | PMID: 32367390
    Citations: | AltScore: 1.75
  9. Time Spent Away from Home in the Year Following High-Risk Cancer Surgery in Older Adults.
    Suskind AM, Zhao S, Boscardin WJ, Smith A, Finlayson E
    J Am Geriatr Soc, 2020 Mar, 68(3): 505-510 | PMID: 31981366 | PMCID: PMC7161704
    Citations: | AltScore: 22.75
  1. Smoking and Smoking Cessation Among Criminal Justice-Involved Older Adults.
    Ahalt C, Buisker T, Myers J, Williams B
    Tob Use Insights, 2019, 12: 1179173X19833357 | PMID: 30890860 | PMCID: PMC6416677
    Citations: | AltScore: 2.45
  2. Assessing Risk for Adverse Outcomes in Older Adults: The Need to Include Both Physical Frailty and Cognition.
    Aliberti MJR, Cenzer IS, Smith AK, Lee SJ, Yaffe K, Covinsky KE
    J Am Geriatr Soc, 2019 Mar, 67(3): 477-483 | PMID: 30468258 | PMCID: PMC6510389
    Citations: 4 | AltScore: 37.95
  3. Comparison of Pharmacy Database Methods for Determining Prevalent Chronic Medication Use.
    Anderson TS, Jing B, Wray CM, Ngo S, Xu E, Fung K, Steinman MA
    Med Care, 2019 Oct, 57(10): 836-842 | PMID: 31464843 | PMCID: PMC6742560
    Citations: 1 | AltScore: 8.95
  4. A systematic review of methods for determining cross-sectional active medications using pharmacy databases.
    Anderson TS, Xu E, Whitaker E, Steinman MA
    Pharmacoepidemiol Drug Saf, 2019 Apr, 28(4): 403-421 | PMID: 30761662 | PMCID: PMC7050409
    Citations: 3 | AltScore: 2.6
  5. Trajectories of functional impairment in homeless older adults: Results from the HOPE HOME study.
    Brown RT, Guzman D, Kaplan LM, Ponath C, Lee CT, Kushel MB
    PLoS One, 2019, 14(8): e0221020 | PMID: 31408488 | PMCID: PMC6692032
    Citations: | AltScore: 8.45
  6. An integrative group movement program for people with dementia and care partners together (Paired PLI?): initial process evaluation.
    Casey JJ, Harrison KL, Ventura MI, Mehling W, Barnes DE
    Aging Ment Health, 2019 Feb 12, 24(6): 971-977 | PMID: 30744387 | PMCID: PMC6690798
    Citations: | AltScore: 1.25
  7. \Looking Forward\: a qualitative evaluation of a physical activity program for middle-aged and older adults with serious mental illness.
    Dobbins S, Hubbard E, Leutwyler H
    Int Psychogeriatr, 2019 Aug 28 1-8 | PMID: 31455434 | PMCID: PMC7047554
    Citations: | AltScore: NA
  8. Oral health and access to dental care among older homeless adults: results from the HOPE HOME study.
    Freitas DJ, Kaplan LM, Tieu L, Ponath C, Guzman D, Kushel M
    J Public Health Dent, 2019 Dec, 79(1): 3-9 | PMID: 30295922 | PMCID: PMC6420347
    Citations: | AltScore: 12.45
  9. Physician Perspectives on Deprescribing Cardiovascular Medications for Older Adults.
    Goyal P, Anderson TS, Bernacki GM, Marcum ZA, Orkaby AR, Kim D, Zullo A, Krishnaswami A, Weissman A, Steinman MA, Rich MW
    J Am Geriatr Soc, 2020 Jan, 68(1): 78-86 | PMID: 31509233 | PMCID: PMC7061460
    Citations: | AltScore: 83.25
  10. Dying With Dementia: Underrecognized and Stigmatized.
    Harrison KL, Hunt LJ, Ritchie CS, Yaffe K
    J Am Geriatr Soc, 2019 Aug, 67(8): 1548-1551 | PMID: 30908605 | PMCID: PMC6684346
    Citations: | AltScore: 108.55
  11. Care Settings and Clinical Characteristics of Older Adults with Moderately Severe Dementia.
    Harrison KL, Ritchie CS, Patel K, Hunt LJ, Covinsky KE, Yaffe K, Smith AK
    J Am Geriatr Soc, 2019 Sep, 67(9): 1907-1912 | PMID: 31389002 | PMCID: PMC6732035
    Citations: 2 | AltScore: 149.27
  12. Who Will Care for the Caregivers? Increased Needs When Caring for Frail Older Adults With Cancer.
    Huang LW, Smith AK, Wong ML
    J Am Geriatr Soc, 2019 May, 67(5): 873-876 | PMID: 30924526 | PMCID: PMC6488360
    Citations: 1 | AltScore: 63.5
  13. Psychoactive Medications and Adverse Outcomes among Older Adults Receiving Hemodialysis.
    Ishida JH, McCulloch CE, Steinman MA, Grimes BA, Johansen KL
    J Am Geriatr Soc, 2019 Mar, 67(3): 449-454 | PMID: 30629740
    Citations: 1 | AltScore: 19.9
  14. Food Insecurity Is Associated with Behavioral Health Diagnosis Among Older Primary Care Patients with Multiple Chronic Conditions.
    Jih J, Nguyen TT, Jin C, Seligman H, Boscardin WJ, Ritchie CS
    J Gen Intern Med, 2019 Dec 5 | PMID: 31808129
    Citations: | AltScore: 8.25
  15. Feasibility and Acceptability of Technology-Based Exercise and Posture Training in Older Adults With Age-Related Hyperkyphosis: Pre-Post Study.
    Katzman WB, Gladin A, Lane NE, Wong S, Liu F, Jin C, Fukuoka Y
    JMIR Aging, 2019 Jan-Jun, 2(1): e12199 | PMID: 31363712 | PMCID: PMC6664796
    Citations: | AltScore: NA
  16. Geriatric oncology research at the 2019 American Geriatrics Society (AGS) annual meeting: Joint perspectives from the Young International Society of Geriatric Oncology (SIOG) and AGS Cancer and Aging Special Interest Group.
    Kotwal AA, Presley CJ, Loh KP, Huang LW, Lam V, Wong ML
    J Geriatr Oncol, 2019 Nov, 10(6): 994-997 | PMID: 31272896 | PMCID: PMC6814544
    Citations: | AltScore: 7.5
  17. Frailty Associated With Waitlist Mortality Independent of Ascites and Hepatic Encephalopathy in a Multicenter Study.
    Lai JC, Rahimi RS, Verna EC, Kappus MR, Dunn MA, McAdams-DeMarco M, Haugen CE, Volk ML, Duarte-Rojo A, Ganger DR, O'Leary JG, Dodge JL, Ladner D, Segev DL
    Gastroenterology, 2019 May, 156(6): 1675-1682 | PMID: 30668935 | PMCID: PMC6475483
    Citations: 6 | AltScore: 29.5
  18. Often Off-label: Questionable Gabapentinoid Use Noted at Hospital Admission Warrants Deprescribing.
    Lam K, Rochon PA, Steinman MA
    J Hosp Med, 2019 Sep, 14(9): 579-580 | PMID: 31507352 | PMCID: PMC6716494
    Citations: | AltScore: NA
  19. Making Function Part of the Conversation: Clinician Perspectives on Measuring Functional Status in Primary Care.
    Nicosia FM, Spar MJ, Steinman MA, Lee SJ, Brown RT
    J Am Geriatr Soc, 2019 Mar, 67(3): 493-502 | PMID: 30506667 | PMCID: PMC6402957
    Citations: 2 | AltScore: 13.35
  20. Goals-of-Care Conversations for Older Adults With Serious Illness in the Emergency Department: Challenges and Opportunities.
    Ouchi K, George N, Schuur JD, Aaronson EL, Lindvall C, Bernstein E, Sudore RL, Schonberg MA, Block SD, Tulsky JA
    Ann Emerg Med, 2019 Aug, 74(2): 276-284 | PMID: 30770207 | PMCID: PMC6714052
    Citations: 1 | AltScore: 26.35
  21. Walking the Tightrope between Study Participant Autonomy and Researcher Integrity: The Case Study of a Research Participant with Alzheimer's Disease Pursuing Euthanasia in Switzerland.
    Portacolone E, Covinsky KE, Johnson JK, Rubinstein RL, Halpern J
    J Empir Res Hum Res Ethics, 2019 Dec, 14(5): 483-486 | PMID: 31179811 | PMCID: PMC6884661
    Citations: | AltScore: 0.5
  22. The Precarity of Older Adults Living Alone With Cognitive Impairment.
    Portacolone E, Rubinstein RL, Covinsky KE, Halpern J, Johnson JK
    Gerontologist, 2019 Mar 14, 59(2): 271-280 | PMID: 29373676 | PMCID: PMC6417768
    Citations: 4 | AltScore: NA
  23. Stability of Symptom Clusters in Patients With Lung Cancer Receiving Chemotherapy.
    Russell J, Wong ML, Mackin L, Paul SM, Cooper BA, Hammer M, Conley YP, Wright F, Levine JD, Miaskowski C
    J Pain Symptom Manage, 2019 May, 57(5): 909-922 | PMID: 30768960 | PMCID: PMC6486424
    Citations: 1 | AltScore: NA
  24. Recurrent Urinary Tract Infections are Associated With Frailty in Older Adults.
    Tang M, Quanstrom K, Jin C, Suskind AM
    Urology, 2019 Jan, 123: 24-27 | PMID: 30296501
    Citations: | AltScore: NA
  25. Advance Care Planning in Older Adults With Multiple Chronic Conditions Undergoing High-Risk Surgery.
    Tang VL, Dillon EC, Yang Y, Tai-Seale M, Boscardin J, Kata A, Sudore RL
    JAMA Surg, 2019 Mar 1, 154(3): 261-264 | PMID: 30516794 | PMCID: PMC6439627
    Citations: | AltScore: 77.19
  26. Cognitive Change After Cardiac Surgery Versus Cardiac Catheterization: A Population-Based Study.
    Whitlock EL, Diaz-Ramirez LG, Smith AK, Boscardin WJ, Avidan MS, Glymour MM
    Ann Thorac Surg, 2019 Apr, 107(4): 1119-1125 | PMID: 30578068 | PMCID: PMC6707506
    Citations: 2 | AltScore: 124.496
  27. Age-related differences in patient-reported and objective measures of chemotherapy-induced peripheral neuropathy among cancer survivors.
    Wong ML, Cooper BA, Paul SM, Abrams G, Topp K, Kober KM, Chesney MA, Mazor M, Schumacher MA, Conley YP, Levine JD, Miaskowski C
    Support Care Cancer, 2019 Oct, 27(10): 3905-3912 | PMID: 30770977 | PMCID: PMC6697247
    Citations: | AltScore: 13.4
  28. Geriatric oncology health services research: Cancer and Aging Research Group infrastructure core.
    Wong ML, Lichtman SM, Morrow GR, Simmons J, Hargraves T, Gross CP, Lund JL, Lowenstein LM, Walter LC, McDermott CL, Mohile SG, Cohen HJ
    J Geriatr Oncol, 2020 Mar, 11(2): 350-354 | PMID: 31326392 | PMCID: PMC6980419
    Citations: | AltScore: 0.25

Jean Kutner, MD, MPH/MSPH
School of Medicine, University of Colorado
Serving since 2013 (7 years)

Mark S. Lachs, MD
Weil Cornell Medicine
Serving since 2013 (7 years)

Seth Landefeld, MD
School of Medicine, University of Alabama at Birmingham
Serving since 2013 (7 years)

Recognition and Awards not specified.

General Brief Description of Minority Activities:
Not defined.

Minority Trainee(s):
  • Jennifer E. James, PhD, MSW, MS, Assistant Professor, Institute for Health & Aging at UCSF
    Incarceration and the health of currently and formerly incarcerated individuals was highlighted as an important social determinant of health in Healthy People 2020. Individuals with a history of incarceration report more chronic health problems after incarceration than before (Schnittker & John, 2007), in many cases regardless of the length of time served (Schnittker & John, 2007; Massoglia, 2008). Compared to the general population, incarcerated persons are more likely to have high blood pressure, asthma, cancer, arthritis and infectious diseases (Healthy People 2020) and studies have shown that women with a history of incarceration face a greater disease burden than men with a history of incarceration (Healthy People 2020; Covington, 2007). Ninety percent of recently released women have chronic medical, mental health, or substance use disorders, which is significantly higher than the general population (Mallik-Kane & Visher, 2005; Schnittker, Massoglia & Uggen, 2012). Additionally, within the first two weeks after release, recently released individuals have a 12.7 times higher mortality rate than the general population and that relative risk is higher for women than men (Binswanger et al., 2007). Being Black, being a woman, being poor and having a history of incarceration each confer serious health risks (Braithwaite, Treadwell, & Arriola, 2008). The overall goal of this study is to use interviews and ethnographic observation to better understand the intersection of these interconnected forms of risk. Dr. James will use a novel qualitative interview approach called “collective dialogue”, grounded in Black Feminist Epistemology, that engages participants in the analysis of the data they produce with the researcher over the course of open-ended interviews about their lives. This method, which Dr. James developed and piloted in her dissertation, enables her to center the lived experience of older, formerly incarcerated Black women and enables the women to participate in the production of knowledge about themselves. These interviews, combined with ethnographic observations of organizations advocating for the health and welfare of currently and formerly incarcerated women, will produce a multi-faceted and multilayered account of post-incarceration experiences of women with chronic disease and how they access healthcare. Currently, she is continuing to recruit participants for interviews. Her interviews to date have produced incredibly rich data. She is currently working with two research assistants to analyze the data, and have submitted abstracts based on preliminary findings to four conferences, and have been invited to present at two conferences this summer. However, attendance for conferences have been placed on hold due to COVID 19 safety protocols.
Minority Grant(s):