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This study explored the relationship between trust in physicians and telehealth use during the COVID pandemic in 162 African Americans with diabetes. More than 90% of patients had internet-capable devices and internet service but only 61 patients (39%) had a telehealth visit. Compared to the latter, participants with no telehealth visits had less trust in physicians' ability to diagnose COVID, less trust in physicians' ability to treat via telehealth, and resided in more deprived neighborhoods. There were no differences in age, sex, education, nor literacy. For African Americans with diabetes, health disparities may increase unless fundamental issues such as trust are addressed.

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.

Diabetic retinopathy (DR) is more prevalent in blacks than whites because, compared to whites, blacks on average have worse glycemic control. Both of these racial disparities reflect differences in sociocultural determinants of health, including physician mistrust. This randomized, controlled 6-month pilot trial compared the efficacy of a culturally tailored behavioral health/ophthalmologic intervention called Collaborative Care for Depression and Diabetic Retinopathy (CC-DDR) to enhanced usual care (EUC) for improving glycemic control in black patients with DR (n = 33). The mean age of participants was 68 years (SD 6.1 years), 76% were women, and the mean A1C was 8.7% (SD 1.5%). At baseline, 14 participants (42%) expressed mistrust about ophthalmologic diagnoses. After 6 months, CC-DDR participants had a clinically meaningful decline in A1C of 0.6% (SD 2.1%), whereas EUC participants had an increase of 0.2% (SD 1.1%) (f[1, 28] = 1.9; P = 0.176). Within CC-DDR, participants with trust had a reduction in A1C (1.4% [SD 2.5%]), whereas participants with mistrust had an increase in A1C (0.44% [SD 0.7%]) (f[1, 11] = 2.11; P = 0.177). EUC participants with trust had a reduction in A1C (0.1% [SD 1.1%]), whereas those with mistrust had an increase in A1C (0.70% [SD 1.1%]) (f[1, 16] = 2.01; P = 0.172). Mistrust adversely affected glycemic control independent of treatment. This finding, coupled with the high rate of mistrust, highlights the need to target mistrust in new interventions to improve glycemic control in black patients with DR.

OBJECTIVE The purpose of the cross-sectional study was to identify associations of diabetes distress, physical functioning, and cognition with A1C in older Black individuals with diabetes and mild cognitive impairment. METHODS The investigators analyzed previously collected data from 101 older Black individuals with diabetes and mild cognitive impairment. Participants were administered surveys at baseline to assess diabetes distress, physical functioning, and cognitive functioning and had A1C testing. RESULTS The mean age of participants was 68.4 years, and 62% were women. Participants with higher A1C showed worse self-reported daily functioning (r = −0.28, P CONCLUSION Regimen-related diabetes distress and self-reported daily functioning were found to compromise glycemic control in Black individuals with mild cognitive impairment and diabetes. This finding suggests that diabetes interventions should be multifaceted to improve glycemic control in the high-risk population of Black individuals with diabetes.

Aims Dementia, diabetes, and African American race are three factors that are independently associated with emergency department (ED) use. This study tested the hypothesis that ED use is associated with worse cognitive function in African Americans with Mild Cognitive Impairment (MCI) and poorly controlled diabetes. Methods This study examined differences in ED use among African Americans with MCI and diabetes in a secondary data analysis of baseline data from a one-year randomized controlled trial (N = 101). Results Over one year, 49/92 participants (53.3%) had at least one ED visit. At baseline, participants who had an incident ED visit had significantly fewer years of education; lower scores on neuropsychological tests assessing working memory, psychomotor speed, and complex scanning; higher diabetes-related interpersonal distress scores; lower adherence to a diabetes medication; and higher hemoglobin A1c levels compared to participants with no ED visits (p ≤ 0.05 for all comparisons). Conclusions This study identified multiple risk factors for ED visits in older African Americans with MCI and diabetes. Targeted interventions may be necessary to reduce the need for ED care in high risk populations.

Objectives To evaluate determinants of medication adherence and glycemic control in black patients with diabetes and mild cognitive impairment (MCI). Methods Cross-sectional study of 143 participants with mean age of 68.8 (SD: 6.7) years; 66.4% were women. Results Eighty-seven participants (60.8%) self-reported medication nonadherence; they had more negative beliefs about medicines, greater diabetes-related distress, and more difficulty with daily living activities and affording medications than adherent participants. There were no group differences in cognition, depressive symptoms, or glycemic control. Glycemic control negatively correlated with regimen distress, emotional burden, interpersonal distress, beliefs that physicians overprescribe medications, and beliefs that medications are harmful. Conclusions Beliefs about medications, diabetes-related distress, functional disability, and medication affordability are associated with medication nonadherence in black individuals with diabetes and MCI. Interventions that respect personal health beliefs and compensate for impaired cognition may improve medication adherence and glycemic control in this population.

(Reprinted with permission from American Psychiatric Association, http://psychiatryonline.org/guidelines).

Objective Amnestic mild cognitive impairment (aMCI) has an uncertain course. Valid methods to evaluate memory change will best identify predictors of course. This issue is especially relevant to older persons in minority groups, who may have encountered life course factors that adversely affect cognition. Methods/design Growth curve mixture models were used to identify trajectories of memory test scores obtained every 6 months over 2 years in 221 African Americans with aMCI. Results Participants sorted into two classes, with clinically and statistically significant differences in memory scores over time. Class 1 (n = 28 [14.7%]) had sustained improved scores. Class 2 (n = 162 [85.3%]) scores remained low, fluctuated, or declined. Class 1 had better baseline cognition and daily function than class 2. Conclusions The observed rate of improved memory is lower than reported reversion rates from aMCI to normal cognition. Evaluating trajectories of memory test scores rather than changes in categorical diagnoses of aMCI, which may depend on recalling (or not recalling) one or two words, may yield a more valid indicator of cognitive change. These approaches require further study in minority groups.

Importance Mild cognitive impairment (MCI) is a transition state between normal cognitive aging and dementia that increases the risk for progressive cognitive decline. Preventing cognitive decline is a public health priority. Objective To determine whether behavioral activation prevents cognitive and functional decline over 2 years in black individuals with MCI. Design, Setting, and Participants Single-center, single-masked, attention-controlled randomized clinical trial. Participants were enrolled from June 21, 2011, to October 3, 2014, and follow-up ended December 13, 2016. Community-based recruitment and treatment of black individuals older than 65 years with amnestic MCI. Volunteer sample of 1390 persons with memory complaints were screened. Overall, 536 individuals had baseline assessment, and 315 (58.8%) were ineligible, most often owing to normal cognition (205 of 315 [65%]) or dementia (59 of 315 [18.7%]); 221 fully eligible participants were randomized. Analyses were intention to treat. Interventions Participants were randomized to behavioral activation, which aimed to increase cognitive, physical, and social activity (111 [50.2%]), or supportive therapy, an attention control treatment (110 [49.8%]). Main Outcomes and Measures The prespecified primary outcome was a decline of 6 or more recalled words on the total recall score of the Hopkins Verbal Learning Test–Revised assessed at 6, 12, 18, and 24 months. The secondary outcome was functional decline. Results Of 221 randomized participants (mean [SD] age, 75.8 [7.0] years, 175 women [79%]), 77 behavioral activation participants (69.4%) and 87 supportive therapy participants (79.1%) had 2-year outcome assessments. After baseline, behavioral activation participants engaged in significantly more cognitive activities than supportive therapy participants. The 2-year incidence of memory decline was 1.2% (95% CI, 0.2-6.4) for behavioral activation vs 9.3% (95% CI, 5.30-16.4) for supportive therapy (relative risk, 0.12; 95% CI, 0.02-0.74;P = .02). Behavioral activation was associated with stable everyday function, whereas supportive therapy was associated with decline (difference in slopes, 2.71; 95% CI, 0.12-5.30;P = .04). Rates of serious adverse events for behavioral activation and supportive therapy, respectively, were: falls (14 [13%] vs 28 [25%]), emergency department visits (24 [22%] vs 24 [22%]), hospitalizations (36 [32%] vs 31 [28%]), and deaths (7 [5%] vs 3 [4%]). Conclusions and Relevance Behavioral activation prevented cognitive and functional decline, but this finding requires further investigation. Black individuals have almost twice the rate of dementia as white individuals; behavioral activation may reduce this health disparity. Trial Registration ClinicalTrials.gov Identifier:NCT01299766

Purpose To compare the efficacy of behavior activation (BA) + low vision rehabilitation (LVR) with supportive therapy (ST) + LVR to prevent depressive disorders in patients with age-related macular degeneration (AMD). Design Single-masked, attention-controlled, randomized, clinical trial with outcome assessment at 4 months. Participants Patients with AMD and subsyndromal depressive symptoms attending retina practices (n = 188). Interventions Before randomization, all subjects had 2 outpatient LVR visits, and were then randomized to in-home BA+LVR or ST+LVR. Behavior activation is a structured behavioral treatment that aims to increase adaptive behaviors and achieve valued goals. Supportive therapy is a nondirective, psychological treatment that provides emotional support and controls for attention. Main Outcome Measures The Diagnostic and Statistical Manual IV defined depressive disorder based on the Patient Health Questionnaire-9 (primary outcome), Activities Inventory, National Eye Institute Vision Function Questionnaire–25 plus Supplement (NEI-VFQ), and NEI-VFQ quality of life (secondary outcomes). Results At 4 months, 11 BA+LVR subjects (12.6%) and 18 ST+LVR subjects (23.4%) developed a depressive disorder (relative risk [RR], 0.54; 95% CI, 0.27–1.06; P = 0.067). In planned adjusted analyses the RR was 0.51 (95% CI, 0.27–0.98; P = 0.04). A mediational analysis suggested that BA+LVR prevented depression to the extent that it enabled subjects to remain socially engaged. In addition, BA+LVR was associated with greater improvements in functional vision than ST+LVR, although there was no significant between-group difference. There was no significant change or between-group difference in quality of life. Conclusions An integrated mental health and low vision intervention halved the incidence of depressive disorders relative to standard outpatient LVR in patients with AMD. As the population ages, the number of persons with AMD and the adverse effects of comorbid depression will increase. Promoting interactions between ophthalmology, optometry, rehabilitation, psychiatry, and behavioral psychology may prevent depression in this population.

Perceived functional vision refers to the self-reported ability to perform vision-dependent activities, and is often an outcome in epidemiological studies of vision loss and clinical trials of ophthalmologic and rehabilitative treatments to improve vision and everyday functioning. Functional vision is distinct from visual function, which more properly refers to the physiologic activity and function of the eyes and the visual system (Colenbrander, 2005). In principle, functional vision ought to be closely tied to objective measures of visual function, but the correlation with visual acuity, for example, ranges from 0.5 to 0.68 (Massof & Fletcher, 2001; Revicki, Rentz, Harnam, Thomas, & Lanzetta, 2010). This range suggests that nonophthalmologic factors may contribute to the relationship. One of those factors may be the characteristic way patients perceive and report difficulty in their lives. Functional vision is assessed by asking patients to rate the difficulty they experience when performing various activities like reading newsprint or doing housework. Their responses reflect their perceived difficulty, the value they place on the activity, their mood, and their personality. Depressed mood is known to impair functional vision, perhaps through loss of interest, low self-efficacy, and low motivation (Casten & Rovner, 2008; Horowitz, Reinhardt, & Kennedy, 2005; Owsley & McGwin, 2004; Rovner, Casten, Hegel, & Tasman, 2006; Zhang, Bullard, & Saaddine, 2013). Only a few studies have evaluated the impact of personality, which shapes an individual's style of perceiving, responding to, and reporting visual difficulties (Boerner, Reinhardt, & Horowitz, 2006; Rovner & Casten, 2001; Tabrett & Latham, 2012; Warrian, Spaeth, Lankaranian, Lopes, & Steinmann, 2009). In fact, personality provides a more stable and enduring representation of a person than depression, which tends to be transient and dependent on situations (McCrae & Costa, 1990). One facet of personality is the trait of neuroticism, which refers to the increased tendency to experience negative, distressing emotions (McCrae & Costa, 1990). This trait is distributed normally in the population without a threshold indicative of disorder, and is moderately inheritable (Wray et al., 2008). Individuals on the extremes of the distribution get upset easily by life events and stay upset longer than others who face similar difficulties. They tend to be temperamental, anxious, and inflexible, and to hold pessimistic views of themselves and their circumstances. Thus, given the same degree of vision loss, people high and low in neuroticism might vary substantially in their reporting of functional vision. If their scores on the National Eye Institute Visual Function Questionnaire (NEI VFQ) differ, we cannot assume that the person who reports worse functional vision (that is, has a lower NEI VFQ score) has worse visual acuity than a person with a higher score (Mangione et al., 2001). The former person may simply have a perceptual bias that conveys greater distress and disability. The extent to which this phenomenon occurs in patients with AMD is uncertain because no studies, to our knowledge, have investigated it. If the extent is substantial, it may confound the results of studies on vision loss and disability or on the efficacy of ophthalmologic and rehabilitative treatments. In the study presented here, we tested the hypothesis that personality traits would influence self ratings of functional vision independently of objective measures of vision (that is, visual acuity, contrast sensitivity) in older persons with bilateral age-related macular degeneration (AMD). The subjects were enrolled in the Low Vision Depression Prevention TriAL (VITAL), which is a randomized controlled clinical trial that compares the efficacy of a combined mental health and low vision rehabilitation intervention with standard low vision rehabilitation to prevent depression (Casten & Rovner, n. …

Purpose To compare the efficacy of problem-solving therapy (PST) with supportive therapy (ST) to improve targeted vision function (TVF) in age-related macular degeneration (AMD). Design Single-masked, attention-controlled, randomized clinical trial with outcome assessments at 3 months (main trial endpoint) and 6 months (maintenance effects). Participants Patients with AMD (n = 241) attending retina practices. Interventions Whereas PST uses a structured problem-solving approach to reduce vision-related task difficulty, ST is a standardized attention-control treatment. Main Outcome Measures We assessed TVF, the 25-item National Eye Institute Vision Function Questionnaire plus Supplement (NEI VFQ), the Activities Inventory (AI), and vision-related quality of life (QoL). Results There were no between-group differences in TVF scores at 3 ( P = 0.47) or 6 ( P = 0.62) months. For PST subjects, mean ± standard deviation TVF scores improved from 2.71±0.52 at baseline to 2.18±0.88 at 3 months ( P = 0.001) and were 2.18±0.95 at 6 months (change from 3 to 6 months, P = 0.74). For ST subjects, TVF scores improved from 2.73±0.52 at baseline to 2.14±0.96 at 3 months ( P = 0.001) and were 2.15±0.96 at 6 months (change from 3 to 6 months, P = 0.85). Similar proportions of PST and ST subjects had less difficulty performing a TVF goal at 3 months (77.4% vs 78.6%, respectively; P = 0.83) and 6 months (76.2% vs 79.1%, respectively; P = 0.61). There were no changes in the NEI VFQ or AI. Vision-related QoL improved for PST relative to ST subjects at 3 months ( F (4, 192) = 2.46; P = 0.05) and at 6 months ( F (4, 178) = 2.55; P = 0.05). The PST subjects also developed more adaptive coping strategies than ST subjects. Conclusions We found that PST was not superior to ST at improving vision function in patients with AMD, but that PST improved their vision-related QoL. Despite the benefits of anti-vascular endothelial growth factor treatments, AMD remains associated with disability, depression, and diminished QoL. This clinical reality necessitates new rehabilitative interventions to improve the vision function and QoL of older persons with AMD. Financial Disclosure(s) The authors have no proprietary or commercial interest in any of the materials discussed in this article.

This review updates the literature on depression in age-related macular degeneration (AMD). Treatment for AMD has been revolutionized since the 2004 review of depression and AMD. New data describing the prevalence of depression in AMD, as well as novel interventions for managing depression in AMD, are discussed.Depression continues to be prevalent in AMD and new information is available on the pathways by which impaired vision leads to depression. Strategies for the treatment of depression in patients with impaired vision have evolved.AMD is still a major risk factor for depression and people with activity restriction due to vision loss are at greatest risk. An integrated approach to depression management in older adults with impaired vision may be the best course of action.

Objective. The purpose of this observational study was to describe the associations between cultural beliefs that are prevalent in older African Americans and adherence to diabetes self-management (DSM) behaviors. Methods. In a community population of 110 older African Americans with type 2 diabetes, the investigators administered surveys that assess present time orientation (PTO), future time orientation (FTO), and religiosity, as well as exercising habits, reading food labels, and checking blood glucose. Results. Participants who reported regularly exercising had significantly lower PTO scores and higher FTO and religiosity scores than participants who did not regularly exercise. Similarly, participants who reported reading food labels had lower PTO scores and higher FTO scores but did not differ in religiosity. Participants who reported checking blood glucose levels tended to have higher FTO scores but did not differ in PTO or religiosity. Participants who engaged in all three DSM behaviors had significantly lower PTO scores and higher FTO and religiosity scores. Conclusion. These data indicate that cultural diversity within older African Americans may influence DSM behaviors and contribute to disparities in diabetes outcomes in this high-risk population. Efforts to prevent complications of diabetes might benefit from consideration of these cultural factors.

Mild Cognitive Impairment (MCI) affects 25% of older African Americans and predicts progression to Alzheimer's disease. An extensive epidemiologic literature suggests that cognitive, physical, and/or social activities may prevent cognitive decline. We describe the methods of a randomized clinical trial to test the efficacy of Behavior Activation to prevent cognitive decline in older African Americans with the amnestic multiple domain subtype of MCI. Community Health Workers deliver 6 initial in-home treatment sessions over 2-3 months and then 6 subsequent in-home booster sessions using language, materials, and concepts that are culturally relevant to older African Americans during this 24 month clinical trial. We are randomizing 200 subjects who are recruited from churches, senior centers, and medical clinics to Behavior Activation or Supportive Therapy, which controls for attention. The primary outcome is episodic memory as measured by the Hopkins Verbal Learning Test-Revised at baseline and at months 3, 12, 18, and 24. The secondary outcomes are general and domain-specific neuropsychological function, activities of daily living, depression, and quality-of-life. The negative results of recent clinical trials of drug treatments for MCI and Alzheimer's disease suggest that behavioral interventions may provide an alternative treatment approach to preserve cognition in an aging society.

The purpose of this study was to determine how clinical interpretations of the (18)F-amyloid tracer florbetapir compares diagnostically with (18)F-FDG PET when evaluating patients with Alzheimer disease (AD) and controls.Nineteen patients with a clinical diagnosis of AD and 21 elderly controls were evaluated with both (18)F-florbetapir and (18)F-FDG PET scans. Scans were interpreted together by 2 expert readers masked to any case information and were assessed for tracer binding patterns consistent with AD. The criteria for interpreting the (18)F-florbetapir scan as positive for AD was the presence of binding in the cortical regions relative to the cerebellum. (18)F-FDG PET scans were interpreted as positive if they displayed the classic pattern of hypometabolism in the temporoparietal regions. Scans were interpreted as either positive or negative for AD. In addition, a relative scoring system was used to assess the degree of either hypometabolism or amyloid binding in specified regions. The metabolism and amyloid binding scores for each region were compared across subjects. An overall ratio was calculated on the basis of values in regions expected to be affected by AD and those not expected to be affected. The metabolic ratio and amyloid ratio were then correlated with the mini-mental status examination (MMSE) score.The sensitivity and specificity, compared with the clinical diagnosis of AD or controls, for the (18)F-florbetapir scans were 95% and 95%, respectively, and for the (18)F-FDG scans 89% and 86%, respectively. When a comparison with MMSE scores was made, (18)F-FDG significantly correlated with MMSE when both controls and AD patients were included (r = 0.79, P0.0001) and in AD patients alone (r = 0.70, P = 0.001). The (18)F-florbetapir scores significantly correlated with MMSE scores only when both controls and AD patients were included (r = 0.62, P0.001) but not in the AD group alone (r = 0.12, P = 0.66).Overall, both scans performed well in detecting AD in patients with known clinical AD. Both scans correlated well with cognitive status as determined by MMSE when the entire cohort of controls and AD patients was evaluated. However, only the (18)F-FDG scans correlated with cognitive status when AD patients were evaluated separately.

Age-Related Macular Degeneration (AMD) is the leading cause of severe vision loss in older adults and impairs the ability to read, drive, and live independently and increases the risk for depression, falls, and earlier mortality. Although new medical treatments have improved AMD's prognosis, vision-related disability remains a major public health problem. Improving Function in AMD (IF-AMD) is a two-group randomized, parallel design, controlled clinical trial that compares the efficacy of Problem-Solving Therapy (PST) with Supportive Therapy (ST) (an attention control treatment) to improve vision function in 240 patients with AMD. PST and ST therapists deliver 6 one-hour respective treatment sessions to subjects in their homes over 2 months. Outcomes are assessed masked to treatment assignment at 3 months (main trial endpoint) and 6 months (maintenance effects). The primary outcome is targeted vision function (TVF), which refers to specific vision-dependent functional goals that subjects highly value but find difficult to achieve. TVF is an innovative outcome measure in that it is targeted and tailored to individual subjects yet is measured in a standardized way. This paper describes the research methods, theoretical and clinical aspects of the study treatments, and the measures used to evaluate functional and psychiatric outcomes in this population.

Objective: The measurement of affective symptoms in older persons who decline cognitively is uncertain. The authors investigated whether mood variability predicts dementia in patients with age-related macular degeneration (AMD). Design: Three-year observational study after a clinical trial. Setting: Community follow-up of outpatients ascertained from retina clinics. Participants: One hundred sixty patients with AMD. Measurements: Geriatric Depression Scale (GDS) administered every 2 weeks for 6 months to subjects; Informant Questionnaire for Cognitive Decline in the Elderly (IQCODE) administered to subjects' knowledgeable informants. Results: Twenty-three subjects (14.4%) declined cognitively. Age, education, baseline GDS score ≥5, and variability in GDS scores (i.e., fluctuations between adjacent time points) were associated with cognitive decline. For GDS variability, each 1 unit increase in the residual standard deviation (SD) of the GDS increased the risk for cognitive decline by 93% (IDR = 1.92; 95% CI [1.27–2.91]). Thus, subjects with a residual SD of 1 were nearly twice as likely to become demented as subjects with no variability in GDS scores. The risk for subjects with SDs of 2 increased more than threefold (IDR = 3.68; 95% CI [1.61–8.47]). A multiple regression analysis showed that GDS variability was a significant risk factor for dementia after controlling for significant covariates. Conclusion: These data suggest a useful approach to conceptualizing and measuring depressive symptoms in older persons. Variability in self-reported mood may be an early sign of dementia and may offer new insights into the neurobiological mechanisms linking depression and cognition.

Age-related macular degeneration (AMD) is a major cause of disability in the elderly, substantially degrades the quality of their lives, and is a risk factor for depression. Rates of depression in AMD are substantially greater than those found in the general population of older people, and are on par with those of other chronic and disabling diseases. This article discusses the effect of depression on vision-related disability in patients with AMD, suggests methods for screening for depression, and summarizes interventions for preventing depression in this high-risk group.

Objective To determine whether problem-solving treatment (PST) can prevent depressive disorders in patients with age-related macular degeneration (AMD). Design Two hundred six patients with AMD were randomly assigned to PST (n = 105) or usual care (n = 101). PST therapists delivered six PST sessions over 8 weeks in subjects' homes. Measurements Diagnostic and Statistical Manual of Mental Disorders – Fourth Edition Diagnoses of Depressive Disorders, Hamilton Depression Rating Scale scores, and rates of relinquishing valued activities were assessed at 2 months for short-term effects and 6 months for maintenance effects. Results The 2-month incidence rate of depressive disorders in PST-treated subjects was significantly lower than controls (11.6% versus 23.2%, respectively; OR=0.43; 95% CI [0.20, 0.95]). PST also reduced the odds of relinquishing a valued activity (OR = 0.48; 95% CI [0.25, 0.96]); this effect mediated the relationship between treatment group and depression. By 6 months most earlier observed benefits had diminished. Secondary analyses showed that a minimal level of depressive symptoms were disabling and predicted incident depressive disorders. Conclusion PST prevented depressive disorders and loss of valued activities as a short-term treatment but these benefits were not maintained over time. To sustain PST's effect, an intervention that uses a problem-solving framework to enhance rehabilitative skills may be necessary.

Objective. The purpose of this study is to describe the impact of depression on perceptions of risks to health, diabetes self-management practices, and glycemic control in older African Americans with type 2 diabetes. Methods. The authors analyzed data on depression, risk perceptions, diabetes self-management, and A1C in African Americans with type 2 diabetes. T-tests, χ2, and multivariate regression were used to analyze the data. Results. The sample included 177 African Americans (68% women) whose average age was 72.8 years. Thirty-four participants (19.2%) met criteria for depression. Compared to nondepressed participants, depressed participants scored significantly higher on Personal Disease Risk (the perception of being at increased risk for various medical problems), Environmental Risk (i.e., increased risk for environmental hazards), and Composite Risk Perception (i.e., overall perceptions of increased risk); adhered less to diabetes self-management practices; and had marginally worse glycemic control. Depression and fewer years of education were independent predictors of overall perception of increased health risks. Conclusion. Almost 20% of older African Americans with type 2 diabetes in this study were depressed. Compared to nondepressed participants, they tended to have fewer years of education, perceived themselves to be at higher risk for multiple health problems, and adhered less to diabetes self-management practices. It is important for diabetes educators to recognize the impact of low education and the fatalistic perceptions that depression engenders in this population.

This review centers on the development of diagnostic criteria for depression of Alzheimer's disease. It describes: risk-factors and neurobiological correlates, epidemiology, clinical characteristics and course, assessment, treatment, economics, a description of the criteria and future research directions. Overall, there is substantial evidence for depression of Alzheimer's disease. Further research is needed to better define core symptoms, clinical course and efficacy of treatments.

Engaging in cognitive, social, and physical activities may prevent cognitive decline. In a sample of older African Americans with Mild Cognitive Impairment (N=221), we investigated the cross-sectional relationships between activity levels and participants’ demographic, clinical, and neuropsychological characteristics. The average age of participants was 75.4 years (standard deviation [SD] 7.0); 177 (80.1 %) were women. Participation in cognitive/social activities was positively associated with education, depression, literacy, mobility, instrumental activities of daily living (IADL), verbal learning, and subcomponents of executive function. A linear regression identified IADLs, education, depression, and verbal learning as independent predictors. Participation in physical activities was positively associated with gender, depression, IADLs, and subcomponents of executive function. An ordinal regression identified executive function and depression as independent correlates. These data suggest that unique characteristics are associated with cognitive/social and physical activities in older African Americans with MCI. These characteristics, coupled with low activity levels, may increase the risk of progression from Mild Cognitive Impairment to dementia. Culturally relevant behavioral interventions to reduce cognitive decline in this high risk population are needed.

Background: Depression is the most prevalent disabling psychiatric syndrome of aging and may lead to important decrements in the elderly depressed patient's health-related quality of life (HRQL). The goal of this study was to determine whether severity of chronic illness at admission, severity of depressive symptoms at admission, or living alone before admission was associated with lack of improvement in HRQL at 3 months postdischarge among elderly depressed inpatients. Methods: Subjects were 100 consecutive patients admitted to a 26-bed inpatient geriatric psychiatry unit from 1994 through 1997, who were residing in the community and were not demented. At admission, severity of depressive symptoms was assessed using the Geriatric Depression Scale and severity of chronic physical illness was measured using the Cumulative Illness Rating Scale (Geriatrics). HRQL was assessed at admission and again at 3 months postdischarge using the Medical Outcomes Study (MOS) 6-Item General Health Survey. Results: This study found large improvements in all MOS items between admission and 3 months postdischarge. Severity of chronic physical disease was negatively associated with the probability of improvement in three MOS items (role functioning, psychological functioning, and general health perceptions) whereas the severity of depressive symptoms on admission was negatively associated with the probability of improvement in role functioning, social functioning, and bodily pain. Living alone was negatively associated with social functioning but not with any of the other MOS items. Conclusion: The results of this study suggest that the inpatient treatment of depression in the elderly brings about improvements in quality of life that persist for at least 3 months follwing discharge. The patient's initial level of depression and initial level of physical health may be important factors to be considered when evaluating a patient's prognosis.

Caregiver support is an important factor in recovery from depression among older patients. We examined whether caregivers' perceptions regarding patients' ability to control depressive symptoms were related to depression recovery. Depression treatment, demographics, number of depressive symptoms, and health were controlled. The sample comprised 51 geriatric psychiatry inpatients who met DSM-IV criteria for major depression and who had a primary caregiver. Depression was assessed at both admission and discharge. Caregivers were asked to indicate whether they believed their patient-relatives could control their depressive symptoms. At discharge, 33 patients (64.7%) were “remitted” and 18 (35.3%) were “nonremitted.” Multivariate analyses indicated that receiving electroconvulsive treatment, having fewer depressive symptoms caregivers perceived to be within patient control, and being female predicted depression remission at discharge. This study highlights the important relationship between family dynamics and course of depression.

Purpose To compare the efficacy of behavioral activation (BA) plus low vision rehabilitation with an occupational therapist (OT-LVR) with supportive therapy (ST) on visual function in patients with age-related macular degeneration (AMD). Methods Single-masked, attention-controlled, randomized clinical trial with AMD patients with subsyndromal depressive symptoms (n = 188). All subjects had two outpatient low vision rehabilitation optometry visits, then were randomized to in-home BA + OT-LVR or ST. Behavioral activation is a structured behavioral treatment aiming to increase adaptive behaviors and achieve valued goals. Supportive therapy is a nondirective, psychological treatment that provides emotional support and controls for attention. Functional vision was assessed with the activity inventory (AI) in which participants rate the difficulty level of goals and corresponding tasks. Participants were assessed at baseline and 4 months. Results Improvements in functional vision measures were seen in both the BA + OT-LVR and ST groups at the goal level (d = 0.71; d = 0.56 respectively). At the task level, BA + OT-LVR patients showed more improvement in reading, inside-the-home tasks and outside-the-home tasks, when compared to ST patients. The greatest effects were seen in the BA + OT-LVR group in subjects with a visual acuity ≥20/70 (d = 0.360 reading; d = 0.500 inside the home; d = 0.468 outside the home). Conclusions Based on the trends of the AI data, we suggest that BA + OT-LVR services, provided by an OT in the patient's home following conventional low vision optometry services, are more effective than conventional optometric low vision services alone for those with mild visual impairment. (ClinicalTrials.gov number, NCT00769015.).

Importance This study provides further evidence from a national sample to generalize the relationship between depression and vision loss to adults across the age spectrum. Better recognition of depression among people reporting reduced ability to perform routine activities of daily living due to vision loss is warranted. Objectives To estimate, in a national survey of US adults 20 years of age or older, the prevalence of depression among adults reporting visual function loss and among those with visual acuity impairment. The relationship between depression and vision loss has not been reported in a nationally representative sample of US adults. Previous studies have been limited to specific cohorts and predominantly focused on the older population. Design The National Health and Nutrition Examination Survey (NHANES) 2005-2008. Setting A cross-sectional, nationally representative sample of adults, with prevalence estimates weighted to represent the civilian, noninstitutionalized US population. Participants A total of 10 480 US adults 20 years of age or older. Main Outcome Measures Depression, as measured by the 9-item Patient Health Questionnaire depression scale, and vision loss, as measured by visual function using a questionnaire and by visual acuity at examination. Results In 2005-2008, the estimated crude prevalence of depression (9-item Patient Health Questionnaire score of ≥10) was 11.3% (95% CI, 9.7%-13.2%) among adults with self-reported visual function loss and 4.8% (95% CI, 4.0%-5.7%) among adults without. The estimated prevalence of depression was 10.7% (95% CI, 8.0%-14.3%) among adults with presenting visual acuity impairment (visual acuity worse than 20/40 in the better-seeing eye) compared with 6.8% (95% CI, 5.8%-7.8%) among adults with normal visual acuity. After controlling for age, sex, race/ethnicity, marital status, living alone or not, education, income, employment status, health insurance, body mass index, smoking, binge drinking, general health status, eyesight worry, and major chronic conditions, self-reported visual function loss remained significantly associated with depression (overall odds ratio, 1.9 [95% CI, 1.6-2.3]), whereas the association between presenting visual acuity impairment and depression was no longer statistically significant. Conclusions and Relevance Self-reported visual function loss, rather than loss of visual acuity, is significantly associated with depression. Health professionals should be aware of the risk of depression among persons reporting visual function loss.

Cultural constructs prevalent in older African Americans may influence their risk perceptions and knowledge of Alzheimer’s disease (AD). To examine this issue, we administered 3 sociocultural scales, the Alzheimer’s Disease Knowledge Scale, and a Risk Perception questionnaire to 271 older African Americans who were recruited from a large community senior center and local churches. Higher Present Time Orientation was significantly related to perceptions of having little control over risks to health (p = .004), God’s Will in determining AD (p = .001), and lower AD knowledge (p < .0001), and marginally related to having little control over developing AD (p = .052). Religiosity was marginally related to having little control over risks to health (p = .055) and getting AD″ (p =.057). Post hoc inter-group comparisons found significant differences in the highest vs. lowest scoring Religiosity groups. There were no significant differences by Future Time Orientation. Most subjects (57.6%) were unaware that African Americans were at higher risk for AD than whites. These data indicate that cultural diversity within older African Americans may shape health perceptions and knowledge of AD. This diversity may contribute to disparities in the detection and treatment of AD in this high risk population.

This article discusses a longitudinal study of change in disruptive behaviors among nursing home residents treated with neuroleptics compared with those not treated with neuroleptics. Observations were made of 201 participants on admission to and after 1 year in eight skilled nursing facilities. Nine disruptive behaviors were measured using the Psychogeriatric Dependency Rating Scale with nursing assistants. Neuroleptic use was documented from medication records. Odds ratios are reported for the association of behavior at baseline and use of neuroleptics on nine problem behaviors. For those who received neuroleptics during the year, there was greater change in both developing and resolving disruptive behaviors than for those not receiving neuroleptics. For both groups, restless or pacing behavior and belligerent behavior manifested by refusing instructions changed the most, both in developing and in apparently resolving. Our results show that change in disruptive behaviors occurs among nursing home residents regardless of neuroleptic use, but it occurs more frequently among those who receive neuroleptic medication. Knowledge of which disruptive behaviors are most likely to resolve or develop is important in training nursing home staff to cope with the behaviors as well as in planning interventions that may modify such behaviors.

Objective: To investigate predictors of missing data in a longitudinal study of Alzheimer disease (AD). Methods: The Alzheimer9s Disease Neuroimaging Initiative (ADNI) is a clinic-based, multicenter, longitudinal study with blood, CSF, PET, and MRI scans repeatedly measured in 229 participants with normal cognition (NC), 397 with mild cognitive impairment (MCI), and 193 with mild AD during 2005–2007. We used univariate and multivariable logistic regression models to examine the associations between baseline demographic/clinical features and loss of biomarker follow-ups in ADNI. Results: CSF studies tended to recruit and retain patients with MCI with more AD-like features, including lower levels of baseline CSF Aβ 42 . Depression was the major predictor for MCI dropouts, while family history of AD kept more patients with AD enrolled in PET and MRI studies. Poor cognitive performance was associated with loss of follow-up in most biomarker studies, even among NC participants. The presence of vascular risk factors seemed more critical than cognitive function for predicting dropouts in AD. Conclusion: The missing data are not missing completely at random in ADNI and likely conditional on certain features in addition to cognitive function. Missing data predictors vary across biomarkers and even MCI and AD groups do not share the same missing data pattern. Understanding the missing data structure may help in the design of future longitudinal studies and clinical trials in AD.

To compare the efficacy of problem-solving therapy (PST) with supportive therapy (ST) to improve targeted vision function (TVF) in age-related macular degeneration (AMD).Single-masked, attention-controlled, randomized clinical trial with outcome assessments at 3 months (main trial endpoint) and 6 months (maintenance effects).Patients with AMD (n = 241) attending retina practices.Whereas PST uses a structured problem-solving approach to reduce vision-related task difficulty, ST is a standardized attention-control treatment.We assessed TVF, the 25-item National Eye Institute Vision Function Questionnaire plus Supplement (NEI VFQ), the Activities Inventory (AI), and vision-related quality of life (QoL).There were no between-group differences in TVF scores at 3 (P = 0.47) or 6 (P = 0.62) months. For PST subjects, mean ± standard deviation TVF scores improved from 2.71±0.52 at baseline to 2.18±0.88 at 3 months (P = 0.001) and were 2.18±0.95 at 6 months (change from 3 to 6 months, P = 0.74). For ST subjects, TVF scores improved from 2.73±0.52 at baseline to 2.14±0.96 at 3 months (P = 0.001) and were 2.15±0.96 at 6 months (change from 3 to 6 months, P = 0.85). Similar proportions of PST and ST subjects had less difficulty performing a TVF goal at 3 months (77.4% vs 78.6%, respectively; P = 0.83) and 6 months (76.2% vs 79.1%, respectively; P = 0.61). There were no changes in the NEI VFQ or AI. Vision-related QoL improved for PST relative to ST subjects at 3 months (F(4, 192) = 2.46; P = 0.05) and at 6 months (F(4, 178) = 2.55; P = 0.05). The PST subjects also developed more adaptive coping strategies than ST subjects.We found that PST was not superior to ST at improving vision function in patients with AMD, but that PST improved their vision-related QoL. Despite the benefits of anti-vascular endothelial growth factor treatments, AMD remains associated with disability, depression, and diminished QoL. This clinical reality necessitates new rehabilitative interventions to improve the vision function and QoL of older persons with AMD.The authors have no proprietary or commercial interest in any of the materials discussed in this article.

The authors interviewed the families of 420 nursing home admissions to examine the relationship between patients' need for nursing and mental health services and their use of these services prior to nursing home placement. Although the majority of demented and nondemented patients needed help with activities of daily living, and many needed help with behavioral disorders, fewer than one-third of the families of these patients used community nursing and mental health services for these problems. Increased awareness of the potential value of and improved access to these services may postpone or prevent nursing home placement.

Background/Methods The objective of this study was to determine whether relinquishing cognitive, physical, and social activities is associated with an increased risk of cognitive decline in patients with age-related macular degeneration (AMD). We conducted a 3-year longitudinal study of 206 nondemented patients with AMD. Results Twenty-three subjects (14.4%) declined cognitively. Age, sex, education, decline in visual acuity, and number of dropped activities were associated with cognitive decline; each additional dropped activity increased the risk by 58%. Subjects who relinquished three activities were 3.87 times (95% confidence interval, 1.95–7.76) more likely to become demented than subjects who relinquished no activities; those who relinquished five activities were 9.54 times (95% confidence interval, 3.05–30.43) more likely. A multivariate model demonstrated that number of dropped activities was a powerful predictor of cognitive decline after controlling for relevant risk factors, particularly for subjects younger than 80 years of age. Conclusions Relinquishing valued activities is associated with an increased risk of cognitive decline in older patients with vision loss caused by AMD. These data suggest the importance of promoting optimal cognitive and physical health in patients with AMD and perhaps other chronic diseases.

African American individuals are at high risk of diabetes mellitus and diabetic retinopathy but have suboptimal rates of dilated fundus examinations (DFEs). Early intervention is crucial for the prevention of diabetic retinopathy in this high-risk population.To test the efficacy of behavioral activation for diabetic retinopathy prevention on rates of DFEs in older African American individuals with diabetes mellitus.Masked randomized clinical trial at 2 urban medical centers from October 1, 2010, to May 31, 2014. Participants included 206 African American individuals 65 years and older with diabetes mellitus who had not obtained a DFE in the preceding 12 months.Participants were randomized to either behavioral activation for diabetic retinopathy prevention, a behavioral intervention designed to provide education, facilitate identifying and addressing health care barriers, and promote goal setting to improve rates of DFEs, or supportive therapy, a control condition.The primary outcome was medical documentation of a DFE at 6 months' follow-up. Secondary outcomes included the Risk Perceptions and Risk Knowledge Survey of Diabetes Mellitus, Diabetes Self-Care Inventory, Patient Health Questionnaire 9, and National Eye Institute Vision Function Questionnaire 25 scores and hemoglobin A1c levels.More participants in the behavioral activation for diabetic retinopathy prevention group (87.9%) obtained a DFE compared with those in the supportive therapy group (34.1%) by the 6-month follow-up assessment (P .001). Overall, participants in the behavioral activation for diabetic retinopathy prevention group were 2.5 times more likely to obtain a DFE compared with those in the supportive therapy group (risk ratio = 2.58; 95% CI, 1.91-3.48; P .001). The intervention had no short-term effect on secondary outcomes of hemoglobin A1c levels, depression, or the Risk Perceptions and Risk Knowledge Survey of Diabetes Mellitus or National Eye Institute Vision Function Questionnaire 25 composite scores; however, both groups had improved adherence to diabetes mellitus self-care behaviors from baseline to 6-month follow-up.Behavioral activation for diabetic retinopathy prevention significantly increased rates of DFEs in older African American individuals with diabetes mellitus. Behavioral interventions may have the potential to positively affect screening for diabetic retinopathy in at-risk populations.clinicaltrials.gov Identifier: NCT01179555.

Zhang et al 1 recently reported that visual function loss but not visual acuity was associated with depression. In an accompanying editorial, Morse 2 further described how the loss of functional vision (ie, actual task-related visual performance) leads to depression. The article and editorial raise important questions about the terminology of vision and function. To explore understanding of these terms, we informally discussed the abstract with 20 ophthalmologist colleagues. Based solely on the abstract, 6 participants (30%) believed that the study focused on conversion symptoms (ie, a somatoform disorder). According to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSMIV-TR), “The common feature of somatoform disorders is the presence of physical symptoms that suggest a general medical condition… and are not fully explained by a general medical condition, by the direct effects of a substance, or by another mental disorder.” 3 Psychiatrists have replaced the term functional with the more specific DSM-IV-TR classification. Ophthalmologists appear to lack a clear sense of the term functional when describing vision and function. How should loss of visual function (ie, physical decline in the ocular system), self-reported loss of function due to poor vision, and functional vision loss (ie, perceived vision loss in the absence of organic pathology) be described? The disablement literature provides a unique framework for separating organic and somatoform loss of vision, and their functional sequelae. Verbrugge and Jette posited in 1994 the “disablement process,” a sociomedical model of disability that describes “how chronic and acute conditions affect functioning” 4 and how “personal and environmental factors speed or slow disablement.” 4 In this model, pathology leads to impairment (dysfunctions and structural abnormalities in specific body systems), which leads to functional limitations (restrictions in basic physical and mental actions) and then disability (difficulty performing activities of daily life). Ophthalmologists might best adhere to this model when describing eye disease and its consequences, invoking vision loss, visual impairment, loss of visual function, and visual disability. This schema will improve communication between clinicians and in the medical literature and provide a clearer conception of the impact of vision loss on function. As to our patients who report high levels of disability due to vision loss, perhaps beyond what we might expect based on what we see in their eyes, we should abandon any deprecatory terms, recognize their distress, and direct treatment to the whole person. 5

Objective: To validate a shorter version of the Geriatric Depression Scale (GDS) for older, visually impaired patients. Participants: Subjects were 70 visually impaired adults over age 65 who were presenting for services at a low vision clinic. Method: Subjects were interviewed by a geriatric nurse practitioner. A structured clinical interview was used to ascertain major depression, and the 15-item GDS was used to assess depressive symptoms. A multiple logistic regression was performed in which the dependent variable was clinical diagnosis of major depression and the independent variables were the 15 GDS items. Four items were significant, and were used to form the GDS-Abbreviated (GDS-A) scale. Sensitivity and specificity analyses were performed on various combinations of these four items to generate an effective cutoff score. Results: Endorsing any two or more of the following four items—(a) dissatisfied with life, (b) feeling helpless, (c) reporting problems with memory, and (d)lost activities and interests—yielded the best results with a sensitivity of .71 and a specificity of .88. This GDS-A cutoff score better differentiates depressed from nondepressed individuals than the cutoff score of 5 that is recommended for the GDS-15. Conclusion: The GDS-A's short format and strong discriminating ability make it an effective convenient tool for screening visually impaired, older patients for depression.

In the early part of this century, Alzheimer described a 51-year-old woman who experienced a rapidly increasing loss of memory. She could no longer find her way around her home. She carried objects back and forth, and hid them. At times, she thought someone wanted to kill her and began shrieking loudly. This type of behavior certainly would have been a strain for the woman's husband. If he could no longer care for his wife, his principal option was to place her in a mental hospital. Today, patients with Alzheimer's disease who require institutionalization are more likely to be admitted to a nursing home. However, because most patients in nursing homes have some type of mental illness, nursing homes, by default, serve as mental hospitals. The increasing number of nursing home residents with dementia prompted the author and colleagues to examine behavioral disturbances in this patient population.

Objective: To investigate the effect of coping strategies, depression, physical health, and cognition on National Eye Institute Visual Function Questionnaire scores obtained at baseline in a sample of older patients with age-related macular degeneration (AMD) enrolled in the Improving Function in AMD Trial, a randomized controlled clinical trial that compares the efficacy of problemsolving therapy with that of supportive therapy to improve vision function in patients with AMD. Methods: Baseline evaluation of 241 older outpatients with advanced AMD who were enrolled in a clinical trial testing the efficacy of a behavioral intervention to improve vision function. Vision function was characterized as an interval-scaled, latent variable of visual ability based on the near-vision subscale of the National Eye Institute Vision Function Questionnaire-25 plus Supplement. Results: Visual ability was highly correlated with visual acuity. However, a multivariate model revealed that patient coping strategies and cognitive function contributed to their ability to perform near-vision activities independent of visual acuity. Conclusions: Patients with AMD vary in their coping strategies and cognitive function and in their visual acuity, and that variability determines patients’ self-report of vision function. Understanding patient coping mechanisms and cognition may help increase the precision of vision rating scales and suggest new interventions to improve vision function and quality of life in patients with AMD. Trial Registration: clinicaltrials.gov Identifier: NCT00572039

The prevalence of psychiatric disorders among new admissions to nursing homes is unknown. Such data are needed to estimate the psychiatric needs of this population. We report the prevalence of specific psychiatric disorders in 454 consecutive new nursing home admissions who were evaluated by psychiatrists and diagnosed according to the Diagnostic and Statistical Manual of Mental Disorders, third edition, revised. Eighty percent had a psychiatric disorder. The commonest were dementia syndromes (67.4%) and affective disorders (10%). Also, 40% of demented patients had additional psychiatric syndromes such as delusions or depression, and these patients constituted a distinct subgroup that predicted frequent use of restraints and neuroleptics, and the greatest consumption of nursing time. These data demonstrate that the majority of nursing home residents have psychiatric disorders on admission, and that their management is often quite restrictive. Research is now needed to determine the best methods of treatment for nursing home patients with mental disorders.

Context Age-related macular degeneration is a prevalent disease of aging that may cause irreversible vision loss, disability, and depression. The latter is rarely recognized or treated in ophthalmologic settings. Objective To determine whether problem-solving treatment can prevent depressive disorders in patients with recent vision loss. Design Randomized, controlled trial. Setting Outpatient ophthalmology offices in Philadelphia, Pennsylvania. Patients Two hundred six patients aged 65 years or older with recent diagnoses of neovascular age-related macular degeneration in one eye and pre-existing age-related macular degeneration in the fellow eye. Intervention Patients were randomly assigned to problem-solving treatment (n = 105) or usual care (n = 101). Problem-solving treatment therapists delivered 6 sessions during 8 weeks in subjects' homes. Main Outcome Measures Outcomes were assessed at 2 months for short-term effects and 6 months for maintenance effects. These included DSM-IV –defined diagnoses of depressive disorders, National Eye Institute Vision Function Questionnaire–17 scores, and rates of relinquishing valued activities. Results The 2-month incidence rate of depressive disorders in problem-solving–treated subjects was significantly lower than controls (11.6% vs 23.2%, respectively; odds ratio, 0.39; 95% confidence interval, 0.17-0.92; P = .03). Problem-solving treatment also reduced the odds of relinquishing a valued activity (odds ratio, 0.48; 95% confidence interval, 0.25-0.96; P = .04). This effect mediated the relationship between treatment group and depression. By 6 months, most earlier observed benefits had diminished, though problem-solving treatment subjects were less likely to suffer persistent depression (χ 2 1,3 = 8.46; P = .04). Conclusions Problem-solving treatment prevented depressive disorders and loss of valued activities in patients with age-related macular degeneration as a short-term treatment, but these benefits were not maintained over time. Booster or rescue treatments may be necessary to sustain problem-solving treatment's preventative effect. This study adds important new information to the emerging field of enhanced-care models to prevent or treat depression in older persons. Trial Registration clinicaltrials.gov Identifier:http://clinicaltrials.gov/show/NCT00042211>NCT00042211

Objectives To report the prevalence rate of depression in older patients with recent vision loss due to age-related macular degeneration (AMD) and to describe the effect of depression on self-reported vision function during 6 months. Methods Prospective cohort study of 51 older patients with recent-onset bilateral AMD attending the Retina Clinic of Wills Eye Hospital, Philadelphia, Pa. Main outcome measures included the Center for Epidemiological Studies Depression Scale, visual acuity, Functional Vision Screening Questionnaire, Chronic Disease Score, and Community Disability Scale. Results Seventeen patients (33%) were depressed at baseline and had worse visual acuity ( P = .04) and greater levels of vision-specific( P = .03) and general ( P = .002) physical disability than nondepressed patients. The correlations of Center for Epidemiological Studies Depression Scale score with visual acuity and visual-specific disability, however, were not significant after controlling for general physical disability. An increase in depressive symptoms over time predicted decline in self-reported vision function independent of changes in visual acuity or medical status ( P Conclusions The prevalence and disabling effects of depression in older patients with AMD are substantial. Recognizing that depression is a treatable disorder that exacerbates the effects of AMD will lead to improved outcomes. Innovative interventions to prevent or treat depression in specialty eye clinics are possible.

Giving medications in nursing homes is time consuming and expensive. The orders for medications in a community nursing home were examined to determine if nursing time could be saved by consolidating the administration of medications. Nineteen percent of the medication administration visits could be eliminated by this method according to the independent judgments of two physicians. This could save up to $19,000 in nursing time per year, and the time could be redirected to other nursing activities that could improve the quality of care in nursing homes.

Background Healthcare systems increasingly engage interprofessional healthcare team members such as case managers, social workers, and community health workers to work directly with patients and improve population health. This study elicited perspectives of interprofessional healthcare team members regarding patient barriers to health and suggestions to address these barriers. Methods This is a qualitative study employing focus groups and semi-structured interviews with 39 interprofessional healthcare team members in Philadelphia to elicit perceptions of patients’ needs and experiences with the health system, and suggestions for positioning health care systems to better serve patients. Themes were identified using a content analysis approach. Results Three focus groups and 21 interviews were conducted with 26 hospital-based and 13 ambulatory-based participants. Three domains emerged to characterize barriers to care: social determinants, health system factors, and patient trust in the health system. Social determinants included insurance and financial shortcomings, mental health and substance abuse issues, housing and transportation-related limitations, and unpredictability associated with living in poverty. Suggestions for addressing these barriers included increased financial assistance from the health system, and building a workforce to address these determinants directly. Health care system factors included poor care coordination, inadequate communication of hospital discharge instructions, and difficulty navigating complex systems. Suggestions for addressing these barriers included enhanced communication between care sites, patient-centered scheduling, and improved patient education especially in discharge planning. Finally, factors related to patient trust of the health system emerged. Participants reported that patients are often intimidated by the health system, mistrusting of physicians, and fearful of receiving a serious diagnosis or prognosis. A suggestion for mitigating these issues was increased visibility of the health system within communities to foster trust and help providers gain a better understanding of unique community needs. Conclusion This work explored interprofessional healthcare team members’ perceptions of patient barriers to healthcare engagement. Participants identified barriers related to social determinants of health, complex system organization, and patient mistrust of the health system. Participants offered concrete suggestions to address these barriers, with suggestions supporting current healthcare reform efforts that aim at addressing social determinants and improving health system coordination and adding new insight into how systems might work to improve patient and community trust. Electronic supplementary material The online version of this article (doi:10.1186/s12913-016-1751-5) contains supplementary material, which is available to authorized users.