[Show abstract][Hide abstract] ABSTRACT: Objective. To understand older primary care patients’ perceptions of the risks and benefits of dementia screening and to measure the association between attitudes and screening behaviors. Methods. Eligible patients completed the Perceptions Regarding Investigational Screening for Memory in Primary Care (PRISM-PC) questionnaire and then were asked to undergo dementia screening by a telephone screening instrument. Results. Higher scores on the PRISM-PC questionnaire items that measure attitudes about benefits of screening were associated with decreased odds of refusing screening. Participants who refused screening had significantly lower PRISM-PC questionnaire scores on the items that measure perceived benefits compared to those who agreed to screening. Participants who refused screening were less likely to agree on screening for other conditions, such as depression and cancer. Participants who know someone with Alzheimer’s disease (AD) were less likely to refuse screening. Discussion. Patients’ attitudes about the benefits of dementia screening are associated with their acceptance of dementia screening.
Journal of aging research 05/2015; 2015:1-7. DOI:10.1155/2015/423265
[Show abstract][Hide abstract] ABSTRACT: We examined the provision of behavioral health services to youths detained in Indiana between 2008 and 2012 and the impact of services on recidivism.
We obtained information about behavioral health needs, behavioral health treatment received, and recidivism within 12 months after release for 8363 adolescents (aged 12-18 years; 79.4% male). We conducted survival analyses to determine whether behavioral health services significantly affected time to recidivating.
Approximately 19.1% of youths had positive mental health screens, and 25.3% of all youths recidivated within 12 months after release. Of youths with positive screens, 29.2% saw a mental health clinician, 16.1% received behavioral health services during detention, and 30.0% received referrals for postdetention services. Survival analyses showed that being male, Black, and younger, and having higher scores on the substance use or irritability subscales of the screen predicted shorter time to recidivism. Receiving a behavior precaution, behavioral health services in detention, or an assessment in the community also predicted shorter time to recidivating.
Findings support previous research showing that behavioral health problems are related to recidivism and that Black males are disproportionately rearrested after detention. (Am J Public Health. Published online ahead of print May 14, 2015: e1-e7. doi:10.2105/AJPH.2014.302529).
American Journal of Public Health 05/2015; 105(7):e1-e7. DOI:10.2105/AJPH.2014.302529 · 4.55 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: In the intensive care unit (ICU), delirium is routinely measured with the widely-used, validated Confusion Assessment Method for the ICU (CAM-ICU), but CAM-ICU has not been studied in patients with cirrhosis. We studied a group of patients with cirrhosis to determine the relationship between delirium measured by CAM-ICU and clinical outcomes. Consecutive patients with cirrhosis admitted to the ICU from 2009 to 2012 were included in a retrospective cohort study. Patients were screened twice daily for coma and delirium during their ICU stay using the Richmond Agitation Sedation Scale (RASS) and CAM-ICU. The association between delirium/coma and mortality was determined using multiple logistic regression. RASS and CAM-ICU were also compared to a retrospective assessment of hepatic encephalopathy (HE). Of 91 patients with cirrhosis, 26 (28.6 %) developed delirium/coma. RASS/CAM-ICU had fair agreement with the HE assessment (κ 0.38). Patients with delirium/coma had numerically greater mortality in-hospital (23.1 vs. 7.7 %, p = 0.07) and at 90 days (30.8 vs. 18.5 %, p = 0.26), and they also had longer hospital length of stay (median 19.5 vs. 6 days, p < 0.001). Delirium/coma was associated with increased inpatient mortality, independent of disease severity (unadjusted OR 3.6; 95 % CI, 0.99-13.1; MELD-adjusted OR 5.4; 95 % CI, 1.3-23.8; acute physiology score-adjusted OR 2.2; 95 % CI, 0.53-8.9). Delirium/coma was also associated with longer length of stay after adjusting for disease severity. In critically ill patients with cirrhosis, delirium/coma as measured by the RASS and CAM-ICU is associated with increased mortality and hospital length of stay. For these patients, these measures provide valuable information and may be useful tools for clinical care. RASS and CAM-ICU need to be compared to HE-specific measures in future studies.
[Show abstract][Hide abstract] ABSTRACT: As part of the debate about screening for dementia, it is critical to understand why patients agree or disagree to diagnostic assessment after a positive screening test. We used the Perceptions Regarding Investigational Screening for Memory in Primary Care (PRISM-PC) questionnaire to measure the characteristics of patients who screened positive for dementia but refused further diagnostic assessment.
Survey of patients ≥65 years old without a diagnosis of dementia attending primary care clinics in Indianapolis, IN, in 2008 and 2009.
Five hundred and fifty-four individuals completed the PRISM-PC and 63 screened positive. Of those, 21 (33%) accepted and 42 (67%) refused diagnostic assessment. In adjusted models, having larger stigma domain scores and living alone were significantly associated with increased odds of refusing the diagnostic assessment.
Despite screening positive, many patients refused a diagnostic assessment. Living alone and the perceived stigmas of dementia are associated with the refusal of diagnostic assessment for dementia.
[Show abstract][Hide abstract] ABSTRACT: To determine the frequency of pharmacogenomic variants and concurrent medications that may alter the efficacy and tolerability of acetylcholinesterase inhibitors (AChEIs).
A multisite cross-sectional study was carried out across four memory care practices in the greater Indianapolis area. Participants were adults aged 65 years and older with a diagnosis of probable or possible Alzheimer's disease (AD) (n=105). Blood samples and self-reported medication data were collected. Since two of the three AChEIs are metabolized by cytochrome P450 (CYP)-2D6, we determined the frequency of functional genetic variants in the CYP2D6 gene and calculated their predicted CYP2D6-activity scores. Concurrent medication data were collected from self-reported medication surveys, and their predicted effect on the pharmacokinetics of AChEIs was determined based on their known effects on CYP2D6 and CYP3A4/5 enzyme activities.
Among the 105 subjects enrolled, 72% were female and 36% were African American. Subjects had a mean age of 79.6 years. The population used a mean of eight medications per day (prescription and nonprescription). The CYP2D6 activity score frequencies were 0 (3.8%), 0.5 (4.8%), 1.0 (36.2%), 1.5-2.0 (51.4%), and >2.0 (3.8%). Nineteen subjects (18.1%) used a medication considered a strong or moderate inhibitor of CYP2D6, and eight subjects (7.6%) used a medication considered a strong or moderate inhibitor of CYP3A4/5. In total, 28.6% of the study population was predicted to have reduced activity of the CYP2D6 or CYP3A4/5 enzymes due to either genetic variants or concomitant medications.
Both pharmacogenetic variants and concurrent drug therapies that are predicted to alter the pharmacokinetics of AChEIs should be evaluated in older adults with AD. Pharmacogenetic and drug-interaction data may help personalize AD therapy and increase adherence by improving tolerability.
[Show abstract][Hide abstract] ABSTRACT: Objectives:
We describe a statewide effort to implement detention-based mental health screening and assess follow-up services offered to detained youths in Indiana.
A total of 25,265 detention stays (15,461 unique youths) occurred between January 1, 2008, and December 31, 2011, across 16 detention centers participating in the Indiana Juvenile Mental Health Screening Project. We collected screening results and reports of detention-based follow-up mental health services and referrals from justice system records.
Approximately 21% of youths screened positive for mental health issues requiring follow-up. A positive screen significantly predicted that youths would receive a follow-up mental health service or referral while detained or upon detention center discharge, compared with youths who did not screen positive (61% vs 39%). Logistic regression models indicated that a positive screen was associated with (1) contact with a mental health clinician within 24 hours of detention center intake and (2) a mental health referral upon discharge. White youths were more likely than minorities to receive both follow-up services.
Future statewide efforts to improve the mental health of detained youths should incorporate standards for providing appropriate follow-up services in detention centers.
American Journal of Public Health 08/2014; 104(10):e1-e7. DOI:10.2105/AJPH.2014.302054 · 4.55 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Background
Dementia affects over 4 million people in the US and is frequently unrecognized and underdiagnosed in primary care. Routine dementia screening in primary care is not recommended by the US Preventive Services Task Force due to lack of empirical data on the benefits and harms of screening. This trial seeks to fill this gap and contribute information about the benefits, harms, and costs of routine screening for dementia in primary care.
Single-blinded, parallel, randomized controlled clinical trial with 1:1 allocation. A total of 4,000 individuals aged ≥65 years without a diagnosis of dementia, cognitive impairment, or serious mental illness receiving care at primary care practices within two cities in Indiana. Subjects will be randomized to either i) screening for dementia using the Memory Impairment Screen Telephone version or ii) no screening for dementia. Subjects who screen positive for dementia will be referred to the local Aging Brain Care program that delivers an evidence-based collaborative care model for dementia and depression. Research assistants will administer the 15-item Health Utility Index, Patient Health Questionnaire, Generalized Anxiety Disorder Scale, and Medical Outcomes Study at baseline, 1, 6, and 12 months. Information about advanced care planning will be collected at baseline and 12 months. All enrollees’ medical records will be reviewed to collect data on health care utilization and costs.
We have two primary hypotheses; first, in comparison to non-screened subjects, those who are screened and referred to a dementia collaborative care program will have a higher health-related quality of life as measured by the Health Utility Index at 12 months post-screening. Second, in comparison to non-screened subjects, those who are screened and referred to a dementia collaborative care program will not have higher depression or anxiety at one month post-screening as measured by the Patient Health Questionnaire and Generalized Anxiety Disorder Scale scales. Our secondary hypothesis is that screened subjects will have an Incremental Cost-Effectiveness Ratio below the maximum acceptable threshold of $60,000 per quality adjusted life year saved at 12 months.
Ongoing; registered on September 19, 2012. ClinicalTrials.gov Identifier: 2012 NCT01699503.
[Show abstract][Hide abstract] ABSTRACT: To evaluate whether race influences agreement between screening results and documentation of cognitive impairment and delirium.
Secondary data analysis.
An urban, public hospital and healthcare system.
Hospitalized older adults aged 65 and older admitted to general inpatient medical services evaluated for cognitive impairment (n = 851) and evaluated for delirium (n = 424).
Cognitive impairment and delirium were measured in each participant using the Short Portable Mental Status Questionnaire (SPMSQ) and the Confusion Assessment Method (CAM), respectively, as the reference identification method. Clinical documentation of cognitive impairment and delirium was defined according to the presence of International Classification of Diseases, Ninth Revision (ICD-9), codes from within 1 year before hospitalization through discharge for cognitive impairment or from hospital admission through discharge for delirium.
Two hundred ninety-four participants (34%) had cognitive impairment based on SPMSQ performance, and 163 (38%) had delirium based on CAM results. One hundred seventy-one (20%) of those with cognitive impairment had an ICD-9 code for cognitive impairment, whereas 92 (22%) of those with delirium had an ICD-9 code for delirium. After considering age, sex, education, socioeconomic status, chronic comorbidity, and severity of acute illness, of those who screened positive on the SPMSQ, African Americans had a higher adjusted odds ratio (AOR) than non-African Americans for clinical documentation of cognitive impairment (AOR = 1.66, 95% confidence interval (CI) = 0.95-2.89), and of those who screened negative on the SPMSQ, African Americans had higher odds of clinical documentation of cognitive impairment (AOR = 2.10, 95% CI = 1.17-3.78) than non-African Americans. There were no differences in clinical documentation rates of delirium between African Americans and non-African Americans.
Racial differences in coding for cognitive impairment may exist, resulting in higher documentation of cognitive impairment in African Americans screening positive or negative for cognitive impairment.
Journal of the American Geriatrics Society 02/2014; 62(3). DOI:10.1111/jgs.12691 · 4.57 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Background:
Caregivers of persons with dementia are stressed. Stressors not related to care recipients' needs impact caregiver outcomes, yet are seldom reported. The purpose of this study was to report the most stressful events experienced by spouse caregivers of older adults with Alzheimer s disease during a 6-month period.
31 caregivers completed the Most Stressful Event form, Patient Health Questionnaire (PHQ-9) and the Revised Memory Behavioral Problem Checklist (R-MBPC). Fisher's exact test and two-sample t-test were used to compare Most Stressful Events between caregivers. ANOVA model tested whether the PHQ-9 and R-MBPC subscales differed by stressor.
Caregivers reported no stressors 21.5% of the time, 1-2 stressors 25% of the time, and 3 stressors 53% of the time with 318 stressors reported in total. Care recipient needs (30.2%), caregiver needs (26.7%), and decision-making (16.7%) were the most frequently reported stressors. Using a mixed effects model, there were associations between the Most Stressful Events and depression (p = 0.016), mobility (p = 0.024) and caregiver issues (p = 0.009) subscales of R-MBPC.
Results can be used to develop targeted intervention and support strategies for spouse caregivers experiencing non-caregiving related stressorsas well as the traditional challenges with caregiving related issues.
American Journal of Alzheimer s Disease and Other Dementias 01/2014; 29(5). DOI:10.1177/1533317513518652 · 1.63 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Objective
Although depression is a risk and prognostic factor for cardiovascular disease (CVD), depression trials involving cardiac patients have not observed the anticipated cardiovascular benefits. To test our hypothesis that depression treatment delivered before clinical CVD onset reduces risk of CVD events, we conducted an 8-year follow-up study of the Indiana sites of the Improving Mood-Promoting Access to Collaborative Treatment (IMPACT) randomized controlled trial.Methods
Participants were 235 primary care patients 60 years or older with major depression or dysthymia who were randomized to a 12-month collaborative care program involving antidepressants and psychotherapy (85 without and 35 with baseline CVD) or usual care (83 without and 32 with baseline CVD). Hard CVD events (fatal/nonfatal) were identified using electronic medical record and Medicare/Medicaid data.ResultsA total of 119 patients (51%) had a hard CVD event. As hypothesized, the treatment × baseline CVD interaction was significant (p = .021). IMPACT patients without baseline CVD had a 48% lower risk of an event than did usual care patients (28% versus 47%, hazard ratio = 0.52, 95% confidence interval = 0.31-0.86). The number needed to treat to prevent one event for 5 years was 6.1. The likelihood of an event did not differ between IMPACT and usual care patients with baseline CVD (86% versus 81%, hazard ratio = 1.19, 95% confidence interval, 0.70-2.03).Conclusions
Collaborative depression care delivered before CVD onset halved the excess risk of hard CVD events among older, depressed patients. Our findings raise the possibility that the IMPACT intervention could be used as a CVD primary prevention strategy.Trial Registrationclinicaltrials.gov Identifier: NCT01561105.
Psychosomatic Medicine 12/2013; 76(1). DOI:10.1097/PSY.0000000000000022 · 3.47 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Currently, there are no valid and reliable biomarkers to identify delirious patients predisposed to longer delirium duration. We investigated the hypothesis that elevated S100 calcium binding protein B (S100β) levels will be associated with longer delirium duration in critically ill patients.
A prospective observational cohort study was performed in the medical, surgical, and progressive intensive care units (ICUs) of a tertiary care, university affiliated, and urban hospital. Sixty-three delirious patients were selected for the analysis, with two samples of S100β collected on days 1 and 8 of enrollment. The main outcome measure was delirium duration. Using the cutoff of <0.1 ng/mL and ≥0.1 ng/mL as normal and abnormal levels of S100β, respectively, on day 1 and day 8, four exposure groups were created: Group A, normal S100β levels on day 1 and day 8; Group B, normal S100β level on day 1 and abnormal S100β level on day 8; Group C, abnormal S100β level on day 1 and normal on day 8; and Group D, abnormal S100β levels on both day 1 and day 8.
Patients with abnormal levels of S100β showed a trend towards higher delirium duration (P=0.076); Group B (standard deviation) (7.0 [3.2] days), Group C (5.5 [6.3] days), and Group D (5.3 [6.0] days), compared to patients in Group A (3.5 [5.4] days).
This preliminary investigation identified a potentially novel role for S100β as a biomarker for delirium duration in critically ill patients. This finding may have important implications for refining future delirium management strategies in ICU patients.
International Journal of General Medicine 12/2013; 6:855-861. DOI:10.2147/IJGM.S51004
[Show abstract][Hide abstract] ABSTRACT: Minnesota's Performance-Based Incentive Payment Program uses a collaborative, provider-initiated approach to nursing home quality improvement: up-front funding of evidence-based projects selected and designed by participating facilities, with accountable performance targets. During the first 4 rounds of funding (2007-10), 66 projects were launched at 174 facilities. Using a composite quality measure representing multiple dimensions of clinical care, we found that facilities participating during this period exhibited significantly greater gains than did nonparticipating facilities, in both targeted areas and overall quality, and maintained their quality advantage after project completion. Participating and nonparticipating facilities were similar at baseline with respect to quality scores and improvement trends, as well as acuity-adjusted payment, operating costs, and nurse staffing. Although self-selection precludes firm conclusions regarding the program's impacts, early findings indicate that the program shows promise for incentivizing nursing home quality improvement, both in facility-identified areas of concern and overall.
Health Affairs 09/2013; 32(9):1631-8. DOI:10.1377/hlthaff.2013.0294 · 4.97 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Background
The class of acetylcholinesterase inhibitors (ChEI), including donepezil, rivastigmine, and galantamine, have similar efficacy profiles in patients with mild to moderate Alzheimer’s disease (AD). However, few studies have evaluated adherence to these agents. We sought to prospectively capture the rates and reasons for nonadherence to ChEI and determine factors influencing tolerability and adherence.
We designed a pragmatic randomized clinical trial to evaluate the adherence to ChEIs among older adults with AD. Participants include AD patients receiving care within memory care practices in the greater Indianapolis area. Participants will be followed at 6-week intervals up to 18 weeks to measure the primary outcome of ChEI discontinuation and adherence rates and secondary outcomes of behavioral and psychological symptoms of dementia. The primary outcome will be assessed through two methods, a telephone interview of an informal caregiver and electronic medical record data captured from each healthcare system through a regional health information exchange. The secondary outcome will be measured by the Healthy Aging Brain Care Monitor and the Neuropsychiatric Inventory. In addition, the trial will conduct an exploratory evaluation of the pharmacogenomic signatures for the efficacy and the adverse effect responses to ChEIs. We hypothesized that patient-specific factors, including pharmacogenomics and pharmacokinetic characteristics, may influence the study outcomes.
This pragmatic trial will engage a diverse population from multiple memory care practices to evaluate the adherence to and tolerability of ChEIs in a real world setting. Engaging participants from multiple healthcare systems connected through a health information exchange will capture valuable clinical and non-clinical influences on the patterns of utilization and tolerability of a class of medications with a high rate of discontinuation.
[Show abstract][Hide abstract] ABSTRACT: Background Elderly patients with cognitive impairment are at increased risk of developing delirium, especially in the intensive care unit. Objective To evaluate the efficacy of a computer-based clinical decision support system that recommends consulting a geriatrician and discontinuing use of urinary catheters, physical restraints, and unnecessary anticholinergic drugs in reducing the incidence of delirium. Methods Data for a subgroup of patients enrolled in a large clinical trial who were transferred to the intensive care units of a tertiary-care, urban public hospital in Indianapolis were analyzed. Data were collected on frequency of orders for consultation with a geriatrician; discontinuation of urinary catheterization, physical restraints, or anticholinergic drugs; and the incidence of delirium. Results The sample consisted of 60 adults with cognitive impairment. Mean age was 74.6 years; 45% were African American, and 52% were women. No differences were detected between the intervention and the control groups in orders for consultation with a geriatrician (33% vs 40%; P = .79) or for discontinuation of urinary catheters (72% vs 76%; P = .99), physical restraints (12% vs 0%; P=.47), or anticholinergic drugs (67% vs 36%; P=.37). The 2 groups did not differ in the incidence of delirium (27% vs 29%; P = .85). Conclusion Use of a computer-based clinical decision support system may not be effective in changing prescribing patterns or in decreasing the incidence of delirium.
American Journal of Critical Care 05/2013; 22(3):257-262. DOI:10.4037/ajcc2013447 · 2.12 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Objective:
We examined the (a) influence of nursing facility characteristics on resident quality of life and (b) the impact of cognitive impairment and residence on a dementia special care unit(SCU) on QOL after controlling for resident and facility characteristics.
Multilevel models (resident and facility) were estimated for residents with and without cognitive impairment on conventional units and dementia SCU. Data came from the 2007 Minnesota Nursing Home Resident Quality of Life and Consumer Satisfaction Survey (N = 13,983).
Level of resident CI was negatively related to QOL, although residing on a dementia SCU was positively related to QOL. Certified Nursing Assistant and activity personnel hours per resident day had a positive relationship with resident QOL.
Our results highlight the need to ensure adequate levels of paraprofessional direct care staff and the availability of dementia-focused (SCU)s despite current constraints on long-term care funding.
Journal of Aging and Health 03/2013; 25(4). DOI:10.1177/0898264313480240 · 1.56 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Objective:
To evaluate an online disease management system supporting patients with uncontrolled type 2 diabetes.
Materials and methods:
Engaging and Motivating Patients Online With Enhanced Resources for Diabetes was a 12-month parallel randomized controlled trial of 415 patients with type 2 diabetes with baseline glycosylated hemoglobin (A1C) values ≥7.5% from primary care sites sharing an electronic health record. The intervention included: (1) wirelessly uploaded home glucometer readings with graphical feedback; (2) comprehensive patient-specific diabetes summary status report; (3) nutrition and exercise logs; (4) insulin record; (5) online messaging with the patient's health team; (6) nurse care manager and dietitian providing advice and medication management; and (7) personalized text and video educational 'nuggets' dispensed electronically by the care team. A1C was the primary outcome variable.
Compared with usual care (UC, n=189), patients in the intervention (INT, n=193) group had significantly reduced A1C at 6 months (-1.32% INT vs -0.66% UC; p<0.001). At 12 months, the differences were not significant (-1.14% INT vs -0.95% UC; p=0.133). In post hoc analysis, significantly more INT patients had improved diabetes control (>0.5% reduction in A1C) than UC patients at 12 months (69.9 (95% CI 63.2 to 76.5) vs 55.4 (95% CI 48.4 to 62.5); p=0.006).
A nurse-led, multidisciplinary health team can manage a population of diabetic patients in an online disease management program. INT patients achieved greater decreases in A1C at 6 months than UC patients, but the differences were not sustained at 12 months. More INT than UC patients achieved improvement in A1C (>0.5% decrease). Trial registered in clinical trials.gov: #NCT00542204.
Journal of the American Medical Informatics Association 11/2012; 20(3). DOI:10.1136/amiajnl-2012-001263 · 3.50 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: OBJECTIVES: Prevention and public reporting of falls have suffered due to inadequate attention given to the association of falls and cognitive impairment (CI) among nursing home (NH) residents. This study examines the relationship between CI, residence on dementia special care units (SCUs) and other resident characteristics and likelihood of residents experiencing new falls in NHs. DESIGN: Retrospective cohort study. SETTING AND PARTICIPANTS: A total of 21,587 residents from 381 Minnesota NHs. MEASUREMENTS: The NH Minimum Data Set (MDS) for 21,587 residents from 381 Minnesota NHs in the first calendar quarter of 2008 were analyzed. New falls, (fall noted on a current MDS assessment but not on a prior assessment); cognitive status, (as defined by Cognitive Performance Scale); residence on an SCU, and health and functional status covariates were recorded. A random effects logistic regression model was used to examine relationships between new falls and the resident's cognitive status, type of unit, and covariates. RESULTS: The likelihood of a new fall had a nonlinear association with CI. Compared with residents with normal or mild CI, the likelihood of a new fall was significantly higher among residents with moderate CI (OR = 1.43). The risk decreased slightly (OR = 1.34) for residents with more advanced CI, whereas the presence of severe CI was not significantly associated with new falls. Overall the likelihood of new falls was significantly higher for residents on SCUs compared with those on conventional units (OR = 1.27). CONCLUSIONS: Severity of CI and residence on SCU impact fall incidence and should be accounted for in future fall- prevention interventions and quality-reporting indicators and measures.
Journal of the American Medical Directors Association 09/2012; 13(9). DOI:10.1016/j.jamda.2012.07.018 · 4.94 Impact Factor