Temitope Olatunji-Bello, MD, MSc | Global Clinical Scholars Research Training
An internist, geriatrician, and cardiology fellow at University of Florida Health, in Jacksonville, Temitope Olatunji-Bello strives to provide optimal care to elderly patients with heart disease. Toward that end, she recently bolstered her research skills and used them to propose and design a clinical trial investigating whether the assessment of geriatric syndromes improves outcomes for older adults in cardiac intensive care units (CICUs).
Thanks to advances in medicine and public health, more people are living longer. And along with that demographic shift has come an increase in the proportion of older adults afflicted by heart disease. Older people are susceptible to so-called geriatric syndromes that include frailty, delirium, multiple drug prescriptions, and co-occurring health problems. These syndromes can potentially worsen among patients admitted for intensive care treatment.
However, patients admitted into cardiac intensive care units are rarely assessed for geriatric syndromes, even though many of them are over the age of 65. "The CICU staff are focused mainly on a patient's heart and how to make it better, but they often overlook things like how to prevent delirium and how many medications a patient is on," Olatunji-Bello says. "And delirium is usually treated by giving sedatives that can make things worse, instead of trying non-pharmacological methods."
Responding to a need for Evidence
Clinical trials in all fields typically exclude older, sicker people and that leaves cardiologists hamstrung by inadequate data on which to base clinical decisions in older adults. Expert medical societies have responded by calling for more research into how to manage geriatric syndromes in heart disease patients. Among them, the American Heart Association recently issued a statement highlighting that need specifically for patients in cardiac ICUs.
Olatunji-Bello developed the framework for her clinical trial last year while she was enrolled in Harvard Medical School's Global Clinical Scholars Research Training program, which was designed to help clinicians and clinician-scientists sharpen their research skills. Scholars in the program concentrate either in Advanced Epidemiology or Clinical Trials, and Olatunji-Bello chose the latter track. "I was really looking for in-depth formal training that would allow me to reach the goal of having the knowledge and skills to conduct clinical research," she says. "There isn't a lot of published research in geriatric cardiology, which is what I want to pursue in my career." Olatunji-Bello says the program taught her how to analyze data and come up with valid hypotheses to test. Scholars work together and in teams, and "we spend a lot of time bouncing ideas off each other," Olatunji-Bello says.
A Distinguished Capstone
During the second half of the program, scholars write a proposal for a capstone project based on an original research question. This is when Olatunji-Bello developed the concept for her clinical trial. Titled "The Effects of Geriatric Syndrome Assessments on the Care of Older Adults in the Cardiac Intensive Care Unit," and selected as among the top three capstones in her class, the proposal drew from Olatunji-Bello's experiences as a medical resident. Elderly patients in the cardiac ICU, she says, typically lie in beds hooked up to beeping machines and behind shuttered windows, deprived of normal day-night cycles that can help to ward off delirium. Few clinicians take steps to prevent geriatric syndromes, or manage the disorientation, sensory impairments, and other varied stressors that can make them worse.
The Proposed Strategy
Olatunji-Bello's clinical trial will randomize older CICU patients into two groups—a treatment group that is regularly assessed for geriatric syndromes, and a control group that is not. Her hypothesis is that implementing a geriatric syndrome assessment protocol will have benefits such as decreased length of stay in the CICU, lower rehospitalization rates, better quality of life, and improved functional status. The approach relies on a comprehensive geriatric assessment score tool that is already validated and used in other settings. "This is all about early identification and prevention," Olatunji-Bello explains, adding that clinicians have a number of non-pharmacological options to prevent worsening symptoms. For instance, delirium can be addressed by making sure patients wear eye glasses for visual stimulation, and opening windows in the morning and closing them at night to maintain proper day-night cycles. To address frailty, clinicians can encourage patients to mobilize as soon as possible, in order to prepare them for physical therapy and the next phase of care.
"The intervention also applies to polypharmacy," Olatunji-Bello says. "We want pharmacists to round daily with the team and proactively look every day at the medications patients are taking, along with their interactions, and then cut out the ones that are unnecessary. We should also spend more time with our patients discussing and understanding their goals of care."
Olatunji-Bello says the provider-driven protocol will require her to train clinicians, nurses, pharmacists, case managers, physical therapists, and other specialists on how to prevent, identify and manage geriatric syndromes. She is currently looking for funding and hopes to launch the study as soon as possible.
Throughout the proposal development process, Harvard faculty provided Olatunji-Bello with critical support. "It's not like we were thrown into the water and told to go write a capstone," she says. "We had training in how to develop a hypothesis, choose appropriate statistical methods, and how to write and organize a research proposal. I'm sure that if I need any support in the future, all I have to do is ask."
Olatunji-Bello comes from Nigeria and completed medical school at Lagos State University, before coming to Atlanta for her residency. She says her aim is to return and practice medicine in her home country. "I'd like to contribute to the Nigerian health care system, particularly as a geriatric cardiologist," she says. "I'm grateful for the opportunity to have gone through such a rigorous program at Harvard. It made me a better researcher and a better clinician too. It was a long year, but I'm glad I did it."
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Written by Lisa D. Ellis