Search

Background/objectives Improving glycemic control in older African Americans with diabetes and mild cognitive impairment (MCI) is important as the population ages and becomes more racially diverse. Design Randomized controlled trial. Setting Recruitment from primary care practices of an urban academic medical center. Community-based treatment delivery. Participants Older African Americans with MCI, low medication adherence, and poor glycemic control (N = 101). Interventions Occupational therapy (OT) behavioral intervention and diabetes self-management education. Measurements The primary outcome was a reduction in hemoglobin A1c level of at least 0.5% at 6 months, with maintenance effects assessed at 12 months. Results At 6 months, 25 of 41 (61.0%) OT participants and 22 of 46 (48.2%) diabetes self-management education participants had a reduction in hemoglobin A1c level of at least 0.5%. The model-estimated rates were 58% (95% confidence interval [CI] = 45%-75%) and 48% (95% CI = 36%-64%), respectively (relative risk [RR] = 1.21; 95% CI = 0.84-1.75; P = .31). At 12 months, the respective rates were 21 of 39 (53.8%) OT participants and 24 of 49 (49.0%) diabetes self-management education participants. The model-estimated rates were 50% (95% CI = 37%-68%) and 48% (95% CI = 36%-64%), respectively (RR = 1.05; 95% CI = 0.70-1.57; P = .81). Conclusion Both interventions improved glycemic control in older African Americans with MCI and poor glycemic control. This result reinforces the American Diabetes Association's recommendation to assess cognition in older persons with diabetes and demonstrates the potential to improve glycemic control in this high-risk population. J Am Geriatr Soc 68:1015-1022, 2020.

Objective: To determine the incidence and remission rates of daytime urinary incontinence (UI) in a cohort of newly admitted nursing home (NH) residents. Design: Prospective cohort study. Setting: Eight proprietary NHs in Maryland. Subjects: Four hundred thirty new admissions age 65 or older who were participants in a larger prospective study of mental morbidity and adjustment to the NH. Measures: Nurses aides' reports of continence status, psychiatric examinations, and nursing staff assessments of mobility at 2 weeks, 2 months, and 1 year after NH admission. Results: The prevalence of daytime UI at admission was 39% in both females and males. Among the 293 members (68%) of the admission cohort remaining in the NHs 2 months after admission, the incidence of daytime UI was 27% (21% in females, 51% in males); daytime UI resolved in 23% (24% in females, 20% in males). Among the 178 members (41%) of the admission cohort remaining in the NHs 1 year after admission, the incidence of daytime UI between 2 months and 1 year after admission was 19% (16% in females, 46% in males); daytime UI resolved in 22% (23% in females, 14% in males). The continence status of about two-thirds of residents remaining in the NH at 1 year after admission was stable over time: 22% had daytime UI, and 42% were continent at all three data collection points. The development of daytime UI was associated with male sex, the diagnosis of dementia, fecal incontinence, and the inability to ambulate or transfer independently. Resolution of daytime UI was associated with the absence of these characteristics. Conclusions: Despite limitations attributable to the method of defining UI and potential biases related to the attrition of the admission cohort over time, this is the first large prospective study to examine the incidence and remission patterns of daytime UI among NH residents. The strong association between UI and dementia was validated for the first time by direct psychiatric examinations. Sex and mobility are also closely associated with the development and remission of UI in this setting. This study provides some valuable data that can be used to assess the impacts of the recently developed Resident Assessment Protocol for UI and Agency for Health Care Policy and Research Clinical Practice Guidelines.

OBJECTIVE: To assess how depression and impaired vision relate to disability in older people. DESIGN: An epidemiological survey of an age-stratified random community sample. SETTING: The rural mid-Monongahela Valley in Southwestern Pennsylvania. PARTICIPANTS: A total of 872 noninstitutionalized persons aged 68 and older, fluent in English, and with at least a grade 6 education. MEASUREMENTS: Demographics, self-reported vision impairment, OARS Instrumental Activities of Daily Living (IADL), and modified Center for Epidemiologic Studies-Depression scale to assess depression. RESULTS: Compared with subjects with intact vision, those with impaired vision were more likely to have five or more depressive symptoms (29.7% vs 8.5%; OR = 4.6, 95% CI = 2.2, 9.6) and to be more functionally impaired (OR = 9.7, 95% CI = 4.9, 19.2). The number of depressive symptoms (1–4: OR = 2.4, CI = 1.8,3.4) and (5 +: OR = 5.9, CI = 3.6, 9.8) was associated independently with IADL impairment after controlling for vision, age, and gender. CONCLUSIONS: Impaired vision and depression are both associated strongly with functional impairment in this community population of older adults. Depression, however, increases the odds of functional impairment independent of vision impairment. Treating depression may reduce excess disability associated with impaired vision. J Am Geriatr Soc 46:617–619, 1998.

OBJECTIVES: Age-related macular degeneration (AMD) is a common, disabling disorder of older age that is associated with depression. We investigated the incidence rate of depression and its risk factors and consequences in this 6-month longitudinal study. DESIGN: A prospective cohort study in which subjects were interviewed 6 weeks after the onset of bilateral vision loss and 6 months later. SETTING: The sample was recruited from the retinovascular clinic of a specialty eye hospital. PARTICIPANTS: Subjects were 5 1 patients with new onset bilateral AMD. MEASUREMENTS: We assessed depressive symptoms, personality traits, visual acuity, and vision and physical functioning. Additionally, we interviewed informants to obtain independent assessments of subjects' personality traits. RESULTS: The baseline prevalence rate of syndromal depression was 23.5% and high levels of depressive symptoms persisted over time. The 6-month incidence rate of depression was 27.8%. The strongest risk factors for incident depression were self-rated and informant-rated neuroticism. Patients who developed syndromal depression were 8.3 times (95% confidence interval = 1.1-63.4) more likely than nondepressed patients to become disabled in vision function, independent of change in visual acuity. CONCLUSION: AMD is associated with high rates of depression and visual disability independent of severity of vision loss. The personality trait of neuroticism is highly predictive of incident depression and identifies patients at high risk for excess disability. Psychotherapeutic treatments targeted to this group may prevent depression and reduce disability.

OBJECTIVE: To assess the relationship between sedative-hypnotic (S/H) utilization, severity of illness, length of stay, and hospital costs among older patients admitted to a tertiary care university hospital. DESIGN: Retrospective review of computerized hospital and pharmacy data bases. SUBJECTS: A total of 856 older consecutive medical and surgical admissions from November 1993 to March 1994. MEASUREMENTS: Sedative/hypnotic utilization in accord with the Health Care Financing Administration (HCFA) guidelines for S/H use in nursing homes. Jefferson Disease Staging to estimate severity of illness. Hospital records to obtain demographic characteristics, length of stay, and hospital costs. RESULTS: Patients whose S/H use exceeded HCFA guidelines, compared with those within the guidelines and those receiving no drugs, had longer lengths of stay (21.5 days vs 12.3 days vs 6.7 days, P < .001), increased hospital costs ($29,245 vs $15,219 vs $7,516, P < .001), and greater severity of illness (245.8 vs 189.5 vs 148.5, P < .001). S/H use exceeding and within HCFA guidelines were associated with increased length of stay (both P < .0001) and hospital costs (both P < . 0001). CONCLUSIONS: Older hospitalized patients receiving S/H have greater severity of illness, longer lengths of stay, and higher hospital costs compared with other patients. S/H use, and, in particular, S/H use exceeding the HCFA guidelines, are associated with increased hospital stay and cost. J Am Geriatr Soc 44:1371–1374, 1996.

OBJECTIVE: To determine the prevalence of depressive symptoms and their relationship to disability in older low vision patients. DESIGN: Panel study with 2-year follow-up. PARTICIPANTS: Community-residing older people (N = 31). MEASUREMENTS: Geriatric Depression Scale, Community Disability Scale, and Snellen visual acuity. RESULTS: Twelve of 31 patients (38.7%) had GDS scores ≥ 11 at baseline. Two years later, 10 of these 12 patients remained depressed, and three of the 19 (15.8%) previously nondepressed patients had become depressed. Depressed patients tended to be more disabled functionally than nondepressed patients at follow-up. The correlation of disability with depression and with vision were examined for the entire sample and revealed a strong correlation between disability and depression (r = .40; P = .013) compared with that of disability and vision (r = .34; P = .032) at baseline and at follow-up: depression (r = .68; P = .001), vision (r = .45; P = .006). There was no significant correlation between depression and vision at baseline (r = .06; P = .383), but there was a trend toward correlation at follow-up (r = .28; P = .067). CONCLUSION: Depressive symptoms are prevalent and persistent among low vision patients and appear more highly related to disability than is vision. The frequent occurrence of depression and the availability of effective treatment argue for its recognition and treatment as possible ways to reduce disability in older persons with low vision. J Am Geriatr Soc 44:181–184, 1996.

Objective This study investigated the association between physical restraint use and decline in cognition. Design Cohort analytic study describing changes in resident characteristics. Setting Eight nursing homes, both urban and suburban, operated by a proprietary corporation in a large metropolitan area. Participants 437 nursing home admissions, with 201 remaining at 1 year. Main Outcome Measures Cognitive status was measured by geropsychiatrists, using the Folstein Mini-Mental State Exam, during a psychiatric evaluation of the resident. Daily restraint use was documented from nursing orders. Observations were made at 2 weeks, 10 weeks, and 1 year. Results Restraint use alone and in combination with neuroleptic use was associated with poor cognition. Other variables associated with poor cognitive scores were: ADL impairment, poor adaptive behavior, and longer time in the nursing home. The use of neuroleptics alone was not significant. Variables which were associated with good cognitive status were: being non-ambulatory but without dementia and having strong social support. Conclusions These findings raise the possibility that restraint use may contribute to cognitive impairment, specifically among residents who have moderate to no cognitive impairment at admission; however, the findings do not exclude an alternative explanation that residents undergoing cognitive decline are more likely to be put in restraints. Further research is needed to understand whether factors which can be manipulated contribute to cognitive decline.

To examine the quality of mental health research in nursing homes, 130 articles published in six geriatric specialty and health care delivery journals were reviewed. Thirty-nine (30%) articles used a mental health measure. Measures of cognitive function were most common, being used in 32 (25%) of the articles reviewed. Twenty-three (18%) studies measured abnormal mental experiences and 17 (13%) articles measured behavioral disorder. Many articles used measures or determinations with no established reliability. Twenty-six of the articles which used a mental health measure also used a measure of activities of daily living or physical function. Retrospective and prospective studies were similar in number. A minority of articles used control groups, random samples, or prepost measures while a majority (64%) identified an outcome measure. We conclude that nursing home research can be improved by the increased use of reliable measures of cognition and abnormal mental experiences and by the development of reliable measures of behavioral disorder. Study design can be improved by identifying a priori hypotheses and by the increased use of random sampling and control/comparison groups.