Candidate: Ari B. Friedman, MD, PhD practices clinically as an emergency physician and conducts research as a health economist into how care systems affect older patients’ lives. He is passionate about improving the care and outcomes of the many older patients that he sees in the emergency department (ED) by improving the science underlying that care, especially those with Alzheimer’s Disease and Related Dementias (ADRD). Goal: The purpose of this GEMSSTAR is to gain knowledge and skills necessary to become an independent investigator focusing on how ED care affects physical frailty and cognitive impairment for patients, with a particular emphasis on patients with Alzheimer’s Disease or at risk of developing Alzheimer’s Disease. Research Context: Visits to hospital EDs are a growing source of care for older adults over 65, totaling 22.4 million visits in 2017. Cognitive frailty, the intersection of cognitive impairment and physical frailty, is hypothesized to result from dysregulation of multiple biological systems and curtails the length and quality of older adults’ lives. The impact of ED visits on trajectories of cognitive frailty is poorly characterized. Varying definitions of cognitive frailty include Alzheimer’s Disease patients or exclude Alzheimer’s Disease patients. Career Development Plan: Dr. Friedman seeks training in physical frailty and cognitive impairment, Medicare data analysis, Alzheimer’s Disease, and geriatric emergency medicine. This award will provide protected time and resources for Dr. Friedman to acquire the skills necessary to secure independent funding through a progressive, milestone-driven training plan that includes coursework, research, and guided independent study. Aims: The central hypothesis of this proposal is that ED visits resulting in discharge in patients with cognitive frailty represent an unrecognized opportunity for intervention. He will use the protected time funded by this GEMSSTAR to examine how cognitive frailty predicts ED visits and subsequent disposition for older adults, and to assess the relationship between ED discharges and subsequent outcomes in older adults. He will explore definitions of cognitive frailty which include Alzheimer’s Disease and exclude Alzheimer’s Disease. Research Plan: These Aims will be carried out in two datasets, the National Health and Aging Trends Study, and Medicare claims data. These databases can be linked by person identifiers, and provide annual measurements which can be used to calculate validated physical frailty phenotype and cognitive impairment indices. The databases also provide sociodemographic and health characteristics, including ED visits, Alzheimer’s Disease diagnoses and probable dementia. Multivariate regression will test the hypotheses above. Environment: Senior researchers with an established track record of mentoring scholars from their early career to independent and impactful work are committed to Dr. Friedman’s success. This team is embedded within a university environment with a track record of collaborative, pathbreaking scholarship in health economics, health services research, emergency medicine, Alzheimer’s Disease scholarship, and gerontology.

Frailty, cognitive impairment, and dementia, frequently curtail the length and quality of older adults' lives. This proposal seeks to understand how these phenomena both predict and are impacted by emergency department visits resulting in discharge rather than admission to the hospital, in order to help guide future interventions to improve care coordination and mitigate the impact of acute health shocks on the frailty and cognitive trajectories of older adults.