- [Show abstract] [Hide abstract] ABSTRACT: Importance: Treatment of chronic low back pain (LBP) in older adults is limited by the adverse effects of analgesics. Effective nonpharmacologic treatment options are needed. Objective: To determine the effectiveness of a mind-body program at increasing function and reducing pain in older adults with chronic LBP. Design, setting, and participants: This single-blind, randomized clinical trial compared a mind-body program (n = 140) with a health education program (n = 142). Community-dwelling older adults residing within the Pittsburgh metropolitan area were recruited from February 14, 2011, to June 30, 2014, with 6-month follow-up completed by April 9, 2015. Eligible participants were 65 years or older with functional limitations owing to their chronic LBP (≥11 points on the Roland and Morris Disability Questionnaire) and chronic pain (duration ≥3 months) of moderate intensity. Data were analyzed from March 1 to July 1, 2015. Interventions: The intervention and control groups received an 8-week group program followed by 6 monthly sessions. The intervention was modeled on the Mindfulness-Based Stress Reduction program; the control program, on the "10 Keys" to Healthy Aging. Main outcomes and measures: Follow-up occurred at program completion and 6 months later. The score on the Roland and Morris Disability Questionnaire was the primary outcome and measured functional limitations owing to LBP. Pain (current, mean, and most severe in the past week) was measured with the Numeric Pain Rating Scale. Secondary outcomes included quality of life, pain self-efficacy, and mindfulness. Intent-to-treat analyses were conducted. Results: Of 1160 persons who underwent screening, 282 participants enrolled in the trial (95 men [33.7%] and 187 women [66.3%]; mean [SD] age,74.5 [6.6] years). The baseline mean (SD) Roland and Morris Disability Questionnaire scores for the intervention and control groups were 15.6 (3.0) and 15.4 (3.0), respectively. Compared with the control group, intervention participants improved an additional -1.1 (mean, 12.1 vs 13.1) points at 8 weeks and -0.04 (mean, 12.2 vs 12.6) points at 6 months (effect sizes, -0.23 and -0.08, respectively) on the Roland and Morris Disability Questionnaire. By 6 months, the intervention participants improved on the Numeric Pain Rating Scale current and most severe pain measures an additional -1.8 points (95% CI, -3.1 to -0.05 points; effect size, -0.33) and -1.0 points (95% CI, -2.1 to 0.2 points; effect size, -0.19), respectively. The changes in Numeric Pain Rating Scale mean pain measure after the intervention were not significant (-0.1 [95% CI, -1.1 to 1.0] at 8 weeks and -1.1 [95% CI, -2.2 to -0.01] at 6 months; effect size, -0.01 and -0.22, respectively). Conclusions and relevance: A mind-body program for chronic LBP improved short-term function and long-term current and most severe pain. The functional improvement was not sustained, suggesting that future development of the intervention could focus on durability. Trial registration: clinicaltrials.gov Identifier: NCT01405716.
- [Show abstract] [Hide abstract] ABSTRACT: Introduction: This study investigated whether neuropsychological testing in primary care (PC) offices altered physician-initiated interventions related to cognitive impairment (CI) or slowed the rate of CI progression. Methods: This 24-month, cluster-randomized study included 11 community-based PC practices randomized to either treatment as usual (5 practices) or cognitive report (CR; 6 practices) arms. From 2005 to 2008, 533 patients aged ≥65 years and without a diagnosis of CI were recruited; 423 were retested 24 months after baseline. Results: CR physicians were significantly more likely to order cognitive-related interventions (P = .02), document discussions about cognition (P = .003), and order blood tests to rule out reversible CI (P = .002). At follow-up, significantly more CR patients had a medication for cognition listed in their chart (P = .02). There was no difference in the rate of cognitive decline between the groups. Discussion: Providing cognitive information to physicians resulted in higher rates of physician-initiated interventions for patients with CI.
- [Show abstract] [Hide abstract] ABSTRACT: Introduction. A family history of Alzheimer's disease is a significant risk factor for its onset, but the genetic risk associated with possessing multiple risk alleles is still poorly understood. Methods. In a sample of 95 older adults (Mean age = 75.1, 64.2% female), we constructed a genetic risk score based on the accumulation of risk alleles in BDNF, COMT, and APOE. A neuropsychological evaluation and consensus determined cognitive status (44 nonimpaired, 51 impaired). Logistic regression was performed to determine whether the genetic risk score predicted cognitive impairment above and beyond that associated with each gene. Results. An increased genetic risk score was associated with a nearly 4-fold increased risk of cognitive impairment (OR = 3.824, P = .013) when including the individual gene polymorphisms as covariates in the model. Discussion. A risk score combining multiple genetic influences may be more useful in predicting late-life cognitive impairment than individual polymorphisms.
- [Show abstract] [Hide abstract] ABSTRACT: Objective We hypothesized that among community-dwelling older adults without dementia with advanced chronic knee osteoarthritis (OA) pain: 1) higher levels of self-reported pain would be associated with decreased executive cognitive function and decreased physical function; and 2) decreased cognitive function would be associated with decreased physical function.Methods Substudy on 79 older adults who were participants in a Veterans Affairs clinical trial of periosteal stimulation therapy for advanced painful knee OA. Participants were ≥60 years, had radiographic evidence of Kellgren–Lawrence 3 or 4 knee OA on a standing anterior–posterior X-ray, had pain of at least moderate intensity and of at least 3 months' duration, and knee pain severity greater than pain severity in other parts of the body. Measures included computerized cognitive tests of executive function, pain, and physical function (gait speed and stair climbing).ResultsAs pain scores worsened, gait speed and stair climbing worsened (P = 0.007 and P = 0.035, respectively). Lower performance on the executive function tests was also significantly associated with decreased gait speed and stair climbing (P = 0.002 and P = 0.014, respectively). We did not find a significant relationship between pain and cognitive function. We explored the relationship between pain and physical function adjusted for executive functioning and found that pain was no longer associated with gait speed (P = 0.06).Conclusion Worse pain scores and executive function scores were associated with worse physical function in older adults with painful knee OA. This suggests that slower gait speed in patients could be an indication to clinicians to monitor their patient's cognitive function. Executive function in particular affected the relationship between gait speed and pain, suggesting a possible mediating relationship.
- [Show abstract] [Hide abstract] ABSTRACT: OBJECTIVE: To assess the relationship between cognitive decline of older patients (≥65 years) and utilization of primary care physician (PCP) services over 24-months. DESIGN: Retrospective analysis of prospectively collected data from a cluster randomized trial that took place from 2006 to 2010 and investigated the relationship between formal neuropsychological evaluation and patient outcomes in primary care. SETTING: Twenty-four PCPs in 11 practices in southwestern Pennsylvania. Most practices were suburban and included more than 5 PCPs. PARTICIPANTS: A sample of 423 primary care patients 65 years or older. MEASUREMENTS: The association between the number of PCP visits and a decline in cognitive status, as determined by multivariable analyses that controlled for patient-level, physician-level, and practice-level factors (e.g., patient age, comorbidities, and symptoms of depression; practice location and size; PCP age and sex) and used a linear mixed model with a random intercept to adjust for clustering. RESULTS: Over a two year follow-up, 199 patients (47.0%) experienced a decline in cognitive status. Patients with a cognitive decline had a mean of 0.69 more PCP visits than did patients without a cognitive decline (P<0.05). CONCLUSIONS: Early signs of cognitive decline may be an indicator of greater utilization of primary care. Given the demographic trends, more PCPs are likely to be needed to meet the increasing needs of the older population.
- [Show abstract] [Hide abstract] ABSTRACT: Mild cognitive deficits associated with HIV disease can affect activities of daily living, so interventions that reduce them may have a long-term effect on quality of life. We evaluated the feasibility of a cognitive stimulation program (CSP) to improve neuropsychological test performance in HIV disease. Sixty volunteers (30 HIV-infected) participated. The primary outcome was the change in neuropsychological test performance as indexed by the Global Impairment Rating; secondary outcomes included mood (Brief Symptom Inventory subscales) and quality of life rating (Medical Outcomes Survey-HIV) scales. Fifty-two participants completed all 24 weeks of the study, and 54% of the participants in the CSP group successfully used the system via internet access from their home or other location. There was a significant interaction between usage and study visit such that the participants who used the program most frequently showed significantly greater improvements in cognitive functioning (F(3, 46.4 = 3.26, p = 0.030); none of the secondary outcomes were affected by the dose of CSP. We found it possible to complete an internet-based CSP in HIV-infected individuals; ease of internet access was a key component for success. Participants who used the program most showed improvements in cognitive function over the 24-week period, suggesting that a larger clinical trial of CSP may be warranted.
- [Show abstract] [Hide abstract] ABSTRACT: Chronic low back pain (CLBP) is widespread among older adults (≥ 65 years) and is often treated inadequately. With a rapidly growing aging population, CLBP will increase and so will the demand for treatment. We believe that mind-body therapies can help to meet this demand. We present the methodology of a randomized, controlled clinical trial of 300 individuals with CLBP aged 65 years or older. The specific aims are, 1) to determine the effectiveness of a mindfulness meditation program in increasing function and reducing pain among older adults with CLBP, and 2) to evaluate the impact of mindfulness meditation on neuropsychological performance in older adults with CLBP. The intervention program is modeled on the Mindfulness-Based Stress Reduction Program (MBSR) and the control is adapted from the 10 Keys to Healthy Aging. We will measure self-reported and objectively measured physical function and include a variety of measures to assess pain intensity and pain interference and psychological function. Our primary hypothesis is that the MBSR program will be more effective than the 10 Keys program in increasing function and decreasing pain. The proposed study represents the first large, well-controlled, comprehensive examination of the effects of a mind-body program on older adults with chronic pain.
- [Show abstract] [Hide abstract] ABSTRACT: As the incidence of HIV-associated dementia has decreased, the survival of HIV-infected individuals with milder forms of cognitive impairment has increased. Detecting this milder impairment in its earliest stages has great clinical and research importance. We report here the results of an initial evaluation of the Computer Assessment of Mild Cognitive Impairment (CAMCI(®)), a computerized screening tool designed to assess abnormal cognitive decline with reduced respondent and test administrator burden. Fifty-nine volunteers (29 HIV infected; age=50.9 years; education=14.9 years; 36/59 males) completed the CAMCI(®) and a battery of neuropsychological tests. The CAMCI was repeated 12 and 24 weeks later. The results from the CAMCI were compared to Global and Domain Impairment scores derived from the full neuropsychological test battery. The CAMCI detected mild impairment (compared with normal and borderline test performance) with a sensitivity of 0.72, specificity of 0.97, positive predictive rate of 0.93, and a negative predictive rate of 0.89. Median stability over 12 and 24 weeks of follow-up was 0.32 and 0.46, respectively. These rates did not differ as a function of serostatus. A discriminant function analysis correctly classified 90% of the subjects with respect to their overall Global Impairment Rating from six of the CAMCI scores. This preliminary study demonstrates that the CAMCI is sensitive to mild forms of cognitive impairment, and is stable over 24 weeks of follow-up. A larger trial to obtain risk-group appropriate normative data will be necessary to make the instrument useful in both clinical practice and research (e.g., clinical trials).
- [Show abstract] [Hide abstract] ABSTRACT: This study examines how underrepresented older urban and rural-dwelling individuals conceptualize participation in cognitive impairment studies. Nine focus groups were held with urban and rural-dwelling older adults who had participated in a community-based memory screening study. Expected and experienced benefits of research participation were motivators for study participation in all focus groups. Results indicate that participation in memory research was believed to lead to an understanding of memory function. Focus group participants expressed an active interest in research on dementia, and viewed research participation as a way to address memory concerns and provide a benefit to society.
- [Show abstract] [Hide abstract] ABSTRACT: The primary aim of this pilot study was to identify structural and functional brain differences in older adults with self-reported disabling chronic low back pain (CLBP) compared with those who reported nondisabling CLBP. Cross-sectional. Sixteen cognitively intact older adults, eight with disabling CLBP and eight with nondisabling CLBP. Exclusions were psychiatric or neurological disorders, substance abuse, opioid use, or diabetes mellitus. Participants underwent: structural and functional brain MRI; neuropsychological assessment using the Repeatable Battery for the Assessment of Neuropsychological Status, Trail Making Tests A and B; and physical performance assessment using the Short Physical Performance Battery. In the disabled group, there was significantly lower white matter (WM) integrity (P < 0.05) of the splenium of the corpus callosum. This group also demonstrated activation of the right medial prefrontal cortex at rest whereas the nondisabled demonstrated activation of the left lateral prefrontal cortex. Combined groups analysis revealed a strong positive correlation (r(s) = 0.80, P < 0.0002) between WM integrity of the left centrum semiovale with gait-speed. Secondary analysis revealed a strong negative correlation between total months of CLBP and WM integrity of the SCC (r(s) = -0.59, P < 0.02). Brain structure and function is different in older adults with disabling CLBP compared with those with nondisabling CLBP. Deficits in brain morphology combining groups are associated with pain duration and poor physical function. Our findings suggest brain structure and function may play a key role in chronic pain related disability and may be important treatment targets.
- [Show abstract] [Hide abstract] ABSTRACT: Risk factors for cognitive decline in ageing are multifactorial, including medical co-morbidities and familial genetic risk. To assess the effect of medical co-morbidity and family history of dementia on cognitive performance in older outpatients of family practitioners. Analysis of 535 outpatients from 11 practices aged 65 and older, without a diagnosis of dementia. Information on medical co-morbidities, family history of dementia and cognitive test data were obtained. Patients were classified into high or low medical co-morbidities (<7 versus >8) and positive or negative family history of dementia. After controlling for age, education, gender and depression, global cognitive test scores, as well as memory, executive function, spatial ability and attention were significantly lower for persons having a high number of medical co-morbidities. Cognitive test scores were not significantly different for persons with or without a family history of dementia. A significant interaction between medical co-morbidities and family history of dementia was observed for the global cognitive score, executive function and spatial ability. Those persons with a high number of medical co-morbidities and positive family history of dementia had the lowest performance. Separate regression analysis assessing individual disease risk factors (e.g. hypertension and diabetes) did not find any relationship between specific medical variables and cognitive test scores for any of the subgroups. A high number of medical co-morbidities in addition to a reported family history of dementia are particularly detrimental to cognitive performance in elderly non-demented family practice patients.
- [Show abstract] [Hide abstract] ABSTRACT: Blood lead concentrations have been associated with increased risk of cardiovascular, cancer, and all-cause mortality in adults in general population and occupational cohorts. We aimed to determine the association between blood lead, all cause and cause specific mortality in elderly, community residing women. Prospective cohort study of 533 women aged 65-87 years enrolled in the Study of Osteoporotic Fractures at 2 US research centers (Baltimore, MD; Monongahela Valley, PA) from 1986-1988. Blood lead concentrations were determined by atomic absorption spectrometry. Using blood lead concentration categorized as < 8 microg/dL (0.384 micromol/L), and > or = 8 microg/dL (0.384 micromol/L), we determined the relative risk of mortality from all cause, and cause-specific mortality, through Cox proportional hazards regression analysis. Mean blood lead concentration was 5.3 +/- 2.3 microg/dL (range 1-21) [0.25 +/- 0.11 micromol/L (range 0.05-1.008)]. After 12.0 +/- 3 years of > 95% complete follow-up, 123 (23%) women who died had slightly higher mean (+/- SD) blood lead 5.56 (+/- 3) microg/dL [0.27(+/- 0.14) micromol/L] than survivors: 5.17(+/- 2.0) [0.25(+/- 0.1) micromol/L] (p = 0.09). Women with blood lead concentrations > or = 8 microg/dL (0.384 micromol/L), had 59% increased risk of multivariate adjusted all cause mortality (Hazard Ratio [HR], 1.59; 95% confidence interval [CI], 1.02-2.49) (p = 0.041) especially coronary heart disease (CHD) mortality (HR = 3.08 [CI], (1.23-7.70)(p = 0.016), compared to women with blood lead concentrations < 8 microg/dL(< 0.384 mumol/L). There was no association of blood lead with stroke, cancer, or non cardiovascular deaths. Women with blood lead concentrations of > or = 8 microg/dL (0.384 micromol/L), experienced increased mortality, in particular from CHD as compared to those with lower blood lead concentrations.
- [Show abstract] [Hide abstract] ABSTRACT: Many older individuals experience cognitive decline with aging. The causes of cognitive dysfunction range from the devastating effects of Alzheimer's disease (AD) to treatable causes of dysfunction and the normal mild forgetfulness described by many older individuals. Even mild cognitive dysfunction can impact medication adherence, impair decision making, and affect the ability to drive or work. However, primary care physicians do not routinely screen for cognitive difficulties and many older patients do not report cognitive problems. Identifying cognitive impairment at an office visit would permit earlier referral for diagnostic work-up and treatment. The Computer Assessment of Mild Cognitive Impairment (CAMCI) is a self-administered, user-friendly computer test that scores automatically and can be completed independently in a quiet space, such as a doctor's examination room. The goal of this study was to compare the sensitivity and specificity of the CAMCI and the Mini Mental State Examination (MMSE) to identify mild cognitive impairment (MCI) in 524 nondemented individuals > 60 years old who completed a comprehensive neuropsychological and clinical assessment together with the CAMCI and MMSE. We hypothesized that the CAMCI would exhibit good sensitivity and specificity and would be superior compared with the MMSE in these measures. The results indicated that the MMSE was relatively insensitive to MCI. In contrast, the CAMCI was highly sensitive (86%) and specific (94%) for the identification of MCI in a population of community-dwelling nondemented elderly individuals.
Conference Paper: Brain Morphology Differences in Older Adults with Disabling Chronic Pain
- [Show abstract] [Hide abstract] ABSTRACT: Lead is a neurotoxicant that accumulates in bone with a half life of 25-30 years. To evaluate the association of lead biomarkers and cognitive function, a cohort of exposed and nonexposed workers who had been previously assessed in 1982 was retested approximately 22 years later. For the current assessment, both blood lead and tibia bone lead levels were determined. In addition, cognitive function was tested with the Pittsburgh Occupational Exposures Test battery, which had previously been administered in 1982. In exposed workers, bone lead level predicted lower current cognitive performance and cognitive decline over 22 years. In those lead-exposed workers older than age 55, higher levels of bone lead predicted poorer cognitive scores, suggesting vulnerability for older workers with higher past lead exposure. Finally, there was no association with bone lead level and recency of exposure, suggesting that cumulative body burden is most likely responsible for the progressive cognitive decrement evidenced with vulnerability because of aging.
Article: Toxic dementias[Show abstract] [Hide abstract] ABSTRACT: This chapter reviews some of the toxic substances that have been associated with cognitive impairment, and describes the cognitive deficits associated with toxic dementias, their clinical characteristics, and potential for reversibility. A variety of toxic substances are known to cause cognitive impairment; the most prevalent of these is alcohol consumed in significant quantities over a long period. The chapter discusses the dementia of alcohol abuse and then considers the effects of exposure to heavy metals, industrial solvents, carbon monoxide poisoning, misuse of prescription medications, and illicit drug abuse on cognition and the development of dementia. The chapter concludes that the underlying cause of the cognitive impairment varies. There is evidence supporting the direct deleterious effect of toxins on cognition, as seen for example in cases of heavy metal poisoning and the use of anticholinergic medications; however, cognitive deficits are also the result of indirect consequences of toxic exposure such as stroke and vasculitis.
- [Show abstract] [Hide abstract] ABSTRACT: Subjective memory complaints (SMCs) are known to be inconsistently related to current memory impairment in older adults but this association has not been well investigated in primary care provider (PCP) settings. To characterize the complexity of the relationship between SMCs and objective memory in older outpatients of PCPs, we collected neuropsychological, subjective memory, depression and medical chart data from outpatients aged 65 and older, without documented dementia diagnoses, in eleven PCP offices in and around the Pittsburgh metropolitan area. Results indicated that self-estimates of current memory ability were most strongly associated with objective memory performance; in contrast, perception of worsening memory over the past year showed no association; and specific memory-related activities were only weakly associated. Women were more likely than men to show inconsistency between SMCs and objective memory performance. Only two of the 11 most significantly memory-impaired participants endorsed SMCs and only four had PCP chart documentation of memory problems. Eliciting SMCs in non-demented older adults can be of clinical value in a PCP setting, but significant limitations of patient self-report in more memory-impaired patients underscore the need to develop brief, objective indicators of memory impairment for PCP office use when there is suspicion of decline.