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Background: The National Institute on Aging (NIA)/Alzheimer’s Association (AA) 2018 framework conceptualizes Alzheimer’s disease (AD) biologically. Evidence of brain amyloid by biomarkers defines AD pathologic change and the Alzheimer’s continuum. The presence of tau or neurodegeneration in the absence of amyloid defines non-AD pathologic change. Objective: To examine the relation of in vivo amyloid and neurodegeneration with verbal learning, one of the cognitive abilities affected early in AD, in late middle age. Methods: This was a cross-sectional study of amyloid and neurodegeneration biomarkers in a community-based cohort of 350 late-middle aged Hispanics without dementia (mean age: 64.15±3.34; 72.0%women). Amyloid (A) was measured as global standardized uptake value ratio (SUVR) with 18F-Florbetaben positron emission tomography (PET). Neurodegeneration (N) was ascertained as cortical thickness (CT) in AD signature areas using brain magnetic resonance imaging. We examined A/N continuously, categorically, by A/N profiles, and profile categories. The amyloid threshold for positivity was defined using the K means method. The CT threshold was defined as 2 standard deviations below the mean CT. Verbal learning was ascertained using total recall and delayed recall in the Buschke Selective Reminding test (SRT). Results: Higher cortical thickness was associated with higher performance in SRT delayed recall. Amyloid SUVR was not related to SRT performance. The low CT category was associated with lower performance in SRT delayed recall, while Amyloid categories were not related to any SRT score. The non-AD pathologic change group (A-N+) performed worse in SRT delayed recall compared to the Normal A/N profile group (A-N-). Conclusion: In late middle-aged Hispanics without dementia, non-AD pathologic change, but not the Alzheimer’s continuum, was related to verbal learning.

ObjectiveTo examine in vivo amyloid burden in relation to APOEε4 genotype in middle-aged Hispanics. We hypothesize higher amyloid levels among APOE ε4 carriers vs APOE ε4 noncarriers.MethodsThis is a cross-sectional study in a community-based sample of 249 middle-aged Hispanics in New York City who underwent a 3T brain MRI and PET with the amyloid radioligand 18F-florbetaben. APOE genotype was the primary exposure. The primary outcome was amyloid positivity. The secondary outcome was subthreshold amyloid levels examined as a continuous variable.ResultsAPOE ε4 carriers (n = 85) had a higher frequency (15.3%) of amyloid positivity compared to APOE ε4 noncarriers (n = 164, 1.8%). In the subthreshold group of amyloid-negative participants (n = 233), APOE ε4 carriers (n = 72) had a 0.02 (95% confidence interval [CI] 0.01–0.04) higher global brain amyloid standardized uptake value ratio (SUVR) compared to APOE ε4 noncarriers (n = 161). Compared to participants with the ε3/ε3 genotype, participants with ε4/ε4 had the highest frequency of amyloid positivity (28.6%), followed by those with ε3/ε4 (11%). Among amyloid-negative participants (n = 233), compared to participants with ε3/ε3 (n = 134), those with ε4/ε4 (n = 5) had a 0.12 (95% CI 0.07–0.17) higher global brain amyloid SUVR, and those with ε3/ε4 had a 0.02 higher SUVR (95% CI 0.003–0.04). Results were similar when a median split was used for elevated amyloid, when continuous amyloid SUVR was analyzed in all participants, and in nonparametric Mann-Whitney comparisons.ConclusionMiddle-aged Hispanic APOE ε4 carriers have higher in vivo brain amyloid burden compared with noncarriers, as reported in non-Hispanics.

Background Resident-to-resident elder mistreatment (R-REM) is defined as negative and aggressive physical, sexual, or verbal interactions between (long-term care) residents that in a community setting would likely be construed as unwelcome and have high potential to cause physical and/or psychological harm and distress. R-REM has been established as a serious problem that has a negative impact on the safety, physical well-being, and quality-of-life of residents living in nursing homes. Although there are no in-depth studies, there is evidence that it is prevalent in assisted living residences and associated with a variety of person, environmental, and facility characteristics. The authors conducted the first systematic, prospective study of resident-to-resident elder mistreatment in nursing homes and developed an intervention for direct care staff to enhance knowledge of R-REM and increase reporting and resident safety by reducing falls and associated injuries. The study aim was to examine the effects of this intervention in assisted living residences. The primary distal outcome is falls and injuries, and the key process outcomes are staff knowledge and reporting. Methods Twelve larger licensed assisted living residences with special care dementia units in two New York State regions will be enrolled on a rolling basis and randomized to intervention or usual care. Data derived from five sources, (1) resident interviews, (2) staff informants, (3) observational data, (4) chart, and (5) incident/accident report data, will be collected at baseline and 6 and 12 months with respect to 1050 residents (750 “downstate” and 300 “upstate”). The intervention is three training modules delivered on-site after baseline data collection for front line staff on all shifts in facilities randomized to the intervention. Modules relate to recognition, management, and reporting of resident-to-resident elder mistreatment. Discussion Given the movement toward alternative congregate living arrangements for older individuals with significant comorbidities, including cognitive impairment; it is critical to enhance resident safety measured by falls, accidents, and injuries and staff knowledge related to recognition, reporting, and treatment of resident-to-resident aggressive and related negative interactions in such settings. This project is important in developing approaches for ameliorating and preventing R-REM in assisted living residences and enhancing resident safety and quality of life. Trial registration ClinicalTrials.gov NCT03383289. Registered on 26 December 2017

Background/objectives The Hospital Elder Life Program (HELP) has been shown to prevent delirium in hospitalized older adults. The objective of this study was to test the efficacy of HELP adapted to long-term care (HELP-LTC). Design Cluster randomized controlled trial. Setting A 514-bed academic urban nursing home. Participants A total of 219 long-term nursing home residents who developed an acute illness or change in condition were randomly assigned to HELP-LTC (n = 105) or usual care (n = 114) by unit. Intervention HELP-LTC is a multicomponent intervention targeting delirium risk factors of cognitive impairment, immobility, dehydration, and malnutrition. Two certified nursing assistants (CNAs) delivered HELP-LTC components twice daily 7 days per week. In addition, recommendations were given to primary providers to reduce medications associated with delirium. Measurements Delirium (primary outcome) and delirium severity were ascertained each weekday by a research assistant blinded to group assignment, using the Confusion Assessment Method (CAM) and CAM severity score (CAM-S), respectively. Cognitive function was determined using the Cognitive Performance Scale (CPS). Hospitalization was ascertained by chart review. Results Participants were 81.7 years of age on average and 65.3% female. At baseline, usual care group participants had better cognitive function than intervention group participants (CPS = 1.33 vs 2.25; P = .004). Delirium symptoms declined over the course of the episode (mean CAM-S = 3.63 at start vs 3.27 at end). Overall, 33.8% of the total sample experienced incident delirium. After adjusting for baseline cognitive function, no significant differences were found in delirium or delirium severity between intervention and usual care groups. Hospitalization was not significantly different between groups. Conclusion An intervention targeting delirium risk in long-term nursing home residents did not prevent delirium or reduce delirium symptoms. Baseline differences in cognitive function between groups, greater than expected improvements in both groups, quality-enhancing practices such as consistent assignments delivered to both groups, and adaptations of the intervention may have biased results toward null. J Am Geriatr Soc 68:2329-2335, 2020.

Pilot studies test the feasibility of methods and procedures to be used in larger-scale studies. Although numerous articles describe guidelines for the conduct of pilot studies, few have included specific feasibility indicators or strategies for evaluating multiple aspects of feasibility. Additionally, using pilot studies to estimate effect sizes to plan sample sizes for subsequent randomized controlled trials has been challenged; however, there has been little consensus on alternative strategies. METHODS: In Section 1, specific indicators (recruitment, retention, intervention fidelity, acceptability, adherence, and engagement) are presented for feasibility assessment of data collection methods and intervention implementation. Section 1 also highlights the importance of examining feasibility when adapting an intervention tested in mainstream populations to a new more diverse group. In Section 2, statistical and design issues are presented, including sample sizes for pilot studies, estimates of minimally important differences, design effects, confidence intervals and non-parametric statistics. An in-depth treatment of the limits of effect size estimation as well as process variables is presented. Tables showing confidence intervals around parameters are provided. With small samples, effect size, completion and adherence rate estimates will have large confidence intervals. CONCLUSION: This commentary offers examples of indicators for evaluating feasibility, and of the limits of effect size estimation in pilot studies. As demonstrated, most pilot studies should not be used to estimate effect sizes, provide power calculations for statistical tests or perform exploratory analyses of efficacy. It is hoped that these guidelines will be useful to those planning pilot/feasibility studies before a larger-scale study.

Metabolic syndrome (MetS) is associated with dementia, but it is unclear whether MetS is related to Alzheimer's disease (AD). We investigated the association of MetS with brain amyloid, a key AD feature, and neurodegeneration. A community-based sample of 350 middle-aged Hispanics in New York City had cerebral amyloid β (Aβ) burden ascertained with 18F-Florbetaben positron emission tomography. Neurodegeneration was ascertained as cortical thickness in AD signature regions from 3T brain MRI. MetS and its components (glucose, blood pressure, triglycerides, high-density lipoprotein, adiposity) were defined using the National Institutes of Health criteria. Neither the presence of MetS nor the MetS score was associated with Aβ or neurodegeneration. Among the MetS components, elevated glucose was associated with lower Aβ burden, and this association was not explained by diabetes treatment. Glucose and triglycerides were related to smaller cortical thickness. Our findings suggest that MetS as an arbitrary measure of aggregate metabolic and vascular risk does not capture the risk of AD neuropathology in late middle age and that other approaches to measure the aggregate risk should be examined.

Background: Symptoms (e.g., pain, shortness of breath, and fatigue) at the end of life (EoL) are common. Although symptoms can contribute to poor quality of life at the EoL, much remains unknown regarding their prevalence and correlates in home hospice care. Objectives: To determine the prevalence and correlates of caregiver-reported symptoms in home hospice patients during the last week before discharge using the Edmonton Symptom Assessment Scale (ESAS). Design: This is a cross-sectional study measuring perceived patient symptoms using caregiver proxy data. Bivariate and multivariate analyses were conducted to examine patient and caregiver characteristics associated with ESAS scores. Setting/Subjects: Subjects were from an urban nonprofit home hospice organization. Measurements: Symptoms were measured using the ESAS. Results: The mean ESAS score was 51.2 (SD ±17.4). In bivariate analyses, higher perceived symptom score was associated with younger patient age (p

Importance Black individuals and Hispanic individuals are less likely to recognize stroke and call 911 (stroke preparedness), contributing to racial/ethnic disparities in intravenous tissue plasminogen activator use. Objective To evaluate the effect of culturally tailored 12-minute stroke films on stroke preparedness vs the usual care practice of distributing stroke education pamphlets. Design, Setting, and Participants Cluster randomized clinical trial between July 26, 2013, and August 16, 2018, with randomization of 13 black and Hispanic churches located in urban neighborhoods to intervention or usual care. In total, 883 congregants were approached, 503 expressed interest, 375 completed eligibility screening, and 312 were randomized. Sixty-three individuals were ineligible (younger than 34 years and/or did not have at least 1 traditional stroke risk factor). Interventions Two 12-minute stroke films on stroke preparedness for black and Hispanic audiences. Main Outcomes and Measures The primary outcome was the Stroke Action Test (STAT), assessed at baseline, 6 months, and 12 months. Results In total, 261 of 312 individuals completed the study (83.7% retention rate). Most participants were female (79.1%). The mean (SD) age of participants was 58.57 (11.66) years; 51.1% (n = 159) were non-Hispanic black, 48.9% (n = 152) were Hispanic, and 31.7% (n = 99) had low levels of education. There were no significant end-point differences for the STAT at follow-up periods. The mean (SD) baseline STAT scores were 59.05% (29.12%) correct for intervention and 58.35% (28.83%) correct for usual care. At 12 months, the mean (SD) STAT scores were 64.38% (26.39%) correct for intervention and 61.58% (28.01%) correct for usual care. Adjusted by education, a post hoc subgroup analysis revealed a mean (SE) intervention effect of 1.03% (0.44%) (P = .02) increase per month in the low-education subgroup (about a 10% increase in 12 months). In the high-education subgroup, the mean (SE) intervention effect was −0.05% (0.30%) (P = .86). Regarding percentage correct, the low-education intervention subgroup improved from 52.4% (7 of 21) to 66.7% (14 of 21) compared with the other subgroups. Conclusions and Relevance No difference was observed in stroke preparedness at 12 months in response to culturally tailored 12-minute stroke films or conventional stroke education pamphlets. Additional studies are required to confirm findings from a post hoc subgroup analysis that suggested a significant education effect. Trial Registration ClinicalTrials.gov identifier:NCT01909271.

BACKGROUND Uncontrolled hypertension (HTN) is a leading modifiable stroke risk factor contributing to global stroke disparities. This study is unique in testing a transitional care model aimed at controlling HTN in black and Hispanic poststroke, home health patients, an understudied group. METHODS A 3-arm randomized controlled trial design compared (i) usual home care (UHC), with (ii) UHC plus a 30-day nurse practitioner transitional care program, or (iii) UHC plus nurse practitioner plus a 60-day health coach program. The trial enrolled 495 black and Hispanic, English- and Spanish- speaking adults with uncontrolled systolic blood pressure (SBP ≥ 140 mm Hg) who had experienced a first-time or recurrent stroke or transient ischemic attack. The primary outcome was change in SBP from baseline to 3 and 12 months. RESULTS Mean participant age was 67; 57.0% were female; 69.7% were black, non-Hispanic; and 30.3% were Hispanic. Three-month follow-up retention was 87%; 12-month retention was 81%. SBP declined 9–10 mm Hg from baseline to 12 months across all groups; the greatest decrease occurred between baseline and 3 months. The interventions demonstrated no relative advantage compared to UHC. CONCLUSION The significant across-the-board SBP decreases suggest that UHC nurse/patient/physician interactions were the central component of SBP reduction and that additional efforts to lower recurrent stroke risk should test incremental improvements in usual care, not resource-intensive transitional care interventions. They also suggest the potential value of pragmatic home care programs as part of a broader strategy to overcome HTN treatment barriers and improve secondary stroke prevention globally. CLINICAL TRIALS REGISTRATION Trial Number NCT01918891.

Introduction: Delayed hospital arrival (DHA) after onset of stroke symptoms often precludes minority stroke victims from life-saving interventions. We sought to identify predictors of DHA in a cohort of Black and Hispanic stroke survivors. Methods: We analyzed data from a clinical trial comprising Blacks and Hispanics with recent stroke recruited from New York City stroke centers. Variables associated with pre-hospital behaviors were abstracted from medical records. DHA was defined as arrival to ER >4.5 hours after symptom onset. A GEE model assuming a binomial distribution with a logit link was used in all multivariate analyses adjusting for demographic variables, recurrent stroke, stroke severity, stroke symptomatology, stroke type, being alone at symptom onset, and mode of transportation. Results: Data was available for 209 Hispanics and 202 Blacks. The sample was 44% female with average age 61.9±11.0 years. Annual income was reported to be Conclusions: The frequency of DHA is high and is associated with a failure to activate EMS. The failure to activate EMS may be related to the experience of non-motor symptoms and is associated with being alone during symptom onset. Stroke education efforts should emphasize development of an action plan for alerting EMS that can be implemented when alone and emphasize that stroke symptoms are often non-motor in nature.

Objective: To (1) develop a patient-reported, multidomain functional assessment tool focused on medically ill patients in acute care settings; (2) characterize the measure's psychometric performance; and (3) establish clinically actionable score strata that link to easily implemented mobility preservation plans. Design: This article describes the approach that our team pursued to develop and characterize this tool, the Functional Assessment in Acute Care Multidimensional Computer Adaptive Test (FAMCAT). Development involved a multistep process that included (1) expanding and refining existing item banks to optimize their salience for hospitalized patients; (2) administering candidate items to a calibration cohort; (3) estimating multidimensional item response theory models; (4) calibrating the item banks; (5) evaluating potential multidimensional computerized adaptive testing (MCAT) enhancements; (6) parameterizing the MCAT; (7) administering it to patients in a validation cohort; and (8) estimating its predictive and psychometric characteristics. Setting: A large (2000-bed) Midwestern Medical Center. Participants: The overall sample included 4495 adults (2341 in a calibration cohort, 2154 in a validation cohort) who were admitted either to medical services with at least 1 chronic condition or to surgical/medical services if they required readmission after a hospitalization for surgery (N=4495). Intervention: Not applicable. Main Outcome Measures: Not applicable. Results: The FAMCAT is an instrument designed to permit the efficient, precise, low-burden, multidomain functional assessment of hospitalized patients. We tried to optimize the FAMCAT's efficiency and precision, as well as its ability to perform multiple assessments during a hospital stay, by applying cutting edge methods such as the adaptive measure of change (AMC), differential item functioning computerized adaptive testing, and integration of collateral test-taking information, particularly item response times. Evaluation of these candidate methods suggested that all may enhance MCAT performance, but none were integrated into initial MCAT parameterization. Conclusions: The FAMCAT has the potential to address a longstanding need for structured, frequent, and accurate functional assessment among patients hospitalized with medical diagnoses and complications of surgery.

An increasing proportion of hemodialysis patients are ineligible for transplant. Often these patients are elderly, with multiple comorbidities and decreased functional status. Such patients may benefit from modified treatment goals to reduce symptom burden.To demonstrate the feasibility of a trial of reduced-intensity treatment in nontransplantable patients with end-stage renal disease (ESRD).A 6-week study randomized patients to a reduced-intensity intervention versus usual care. Intervention subjects were treated with liberalized goals for serum phosphorus and parathyroid hormone (PTH) as well as predialysis blood pressure in comparison with usual care subjects. Outcomes included assessed feasibility of recruitment, randomization, and data collection.Sixteen transplant-ineligible hemodialysis patients were recruited from two urban units.Blood pressure was recorded weekly, while serum PTH and phosphorus were assessed every 10 days. A quality-of-life measure was administered before and after the trial.Of 300 patients, 51 were eligible and 16 consented. All were randomized and completed the trial. Patients in the intervention group received significantly lower doses of phosphorus binders and vitamin D analogues, and were less likely to have their dry weight reduced. All patient surveys were completed.High-risk hemodialysis patients may benefit from liberalized treatment guidelines but larger studies are necessary.

Low levels of symptom recognition by staff have been "gateway" barriers to the management of depression in long-term care. The study aims were to refine a depression training program for front-line staff in long-term care and provide evaluative knowledge outcome data. Three primary training modules provide an overview of depression symptoms; a review of causes and situational and environmental contributing factors; and communication strategies, medications, and clinical treatment strategies. McNemar's chi-square tests and paired t-tests were used to examine change in knowledge. Data were analyzed for up to 143 staff members, the majority from nursing. Significant changes (p

Significant racial and ethnic disparities in stroke risk factors, occurrence and outcomes persist in the United States. This article examines socio-economic and health disparities in a diverse, hypertensive sample of 495 post-stroke Black, non-Hispanic and Hispanic home health patients at risk of a recurrent stroke due to elevated systolic blood pressure (SBP), defined as SBP ≥ 140 mmHg. The article, which analyzes cross-sectional data, focuses on correlates of patients’ SBP – the leading modifiable cause of stroke – and physical function – a key stroke sequela and indicator of post-stroke quality of life. Of the 495 participants, 69.7% were Black, non-Hispanic, and 30.3% Hispanic. Black participants had significantly higher mean SBP than Hispanics. After controlling for multiple potential confounders/predictors, being Black was associated with a 3.55 mmHg elevation in SBP relative to being Hispanic. There were no significant Black/Hispanic differences in physical function measures. Seven independent variables significantly predicted better physical function: being male, younger, having fewer comorbidities, lower BMI, fewer depressive symptoms, higher health literacy and current alcohol drinking (vs abstinence). Our data provide a unique comparison of homebound Black and Hispanic stroke survivors at heightened risk of recurrent stroke absent targeted intervention. The finding of a significant Black/Hispanic disparity in SBP is striking in this narrowly defined home health care population all of whom are at risk for recurrent stroke. Priority should be given to culturally tailored interventions designed to link vulnerable home care patients to continuous, responsive hypertension care.

Resident-to-resident elder mistreatment (R-REM) occurs frequently in long-term services and support settings. The purpose of the current study was to evaluate the effect of a R-REM training program for nursing and other front-line staff on resident falls and injuries in a cluster randomized trial of units within four nursing homes. Interview and observational data from a sample of 1,201 residents ( n = 600 and n = 601 in the usual care and intervention groups, respectively) and staff were collected at baseline and 6 and 12 months. A generalized linear model was used to model the falls/injuries outcome. The net reduction in falls and injuries was 5%, translating to 10 saved events per year in an averagesized facility. Although the result did not reach statistical significance due to low power, the findings of fall prevention associated with implementing the intervention in long-term care facilities is clinically important. [ Journal of Gerontological Nursing, 44 (6), 15–23.]

Introduction. We describe the design and implementation of a psychiatric collaborative care model in a university-based geriatric primary care practice. Initial results of screening for anxiety and depression are reported. Methods and Materials. Screens for anxiety and depression were administered to practice patients. A mental health team, consisting of a psychiatrist, mental health nurse practitioner, and social worker, identified patients who on review of screening and chart data warranted evaluation or treatment. Referrals for mental health interventions were directed to members of the mental health team, primary care physicians at the practice, or community providers. Results. Subjects (N=1505) comprised 38.2% of the 3940 unique patients seen at the practice during the 4-year study period. 37.1% (N=555) screened positive for depression, 26.9% (N=405) for anxiety, and 322 (21.4%) screened positive for both. Any positive score was associated with age (P<0.033), female gender (P<0.006), and a nonsignificant trend toward living alone (P<0.095). 8.87% had suicidal thoughts. Conclusions. Screening captured the most affectively symptomatic patients, including those with suicidal ideation, for intervention. The partnering of mental health professionals and primary care physicians offers a workable model for addressing the scarcity of expertise in geriatric psychiatry.

Background and Purpose— Deficiencies in stroke preparedness cause major delays to stroke thrombolysis, particularly among economically disadvantaged minorities. We evaluated the effectiveness of a stroke preparedness intervention delivered to preadolescent urban public school children on the stroke knowledge/preparedness of their parents. Methods— We recruited 3070 fourth through sixth graders and 1144 parents from 22 schools into a cluster randomized trial with schools randomized to the HHS (Hip-Hop Stroke) intervention or attentional control (nutrition classes). HHS is a 3-hour culturally tailored, theory-based, multimedia stroke literacy intervention targeting school children, which systematically empowers children to share stroke information with parents. Our main outcome measures were stroke knowledge/preparedness of children and parents using validated surrogates. Results— Among children, it was estimated that 1% (95% confidence interval [CI], 0%–1%) of controls and 2% (95% CI, 1%–4%; P =0.09) of the intervention group demonstrated optimal stroke preparedness (perfect scores on the knowledge/preparedness test) at baseline, increasing to 57% (95% CI, 44%–69%) immediately after the program in the intervention group compared with 1% (95% CI, 0%–1%; P P P =0.0062), with no significant changes (3% identification) among controls. Four children, all in the intervention group, called 911 for real-life stroke symptoms, in 1 case overruling a parent’s wait-and-see approach. Conclusions— HHS is an effective, intergenerational model for increasing stroke preparedness among economically disadvantaged minorities. Clinical Trial Registration— URL: https://clinicaltrials.gov . Unique identifier: NCT01497886.

Purpose This was a Phase II pilot study of a problem-solving treatment (PST) to address subsyndromal depression in residents of long-term care facilities. Our goal was to demonstrate PST implementation feasibility and to identify PST’s potential for reducing depressive symptoms in this geriatric health care setting. Methods Eligible participants were randomized to receive a PST treatment (six 1-hour sessions) or a social contact comparison (6 “friendly” visits) after an initial baseline assessment. Follow-up assessments occurred 7 weeks later (after treatment) and 2 months posttreatment. The basic analytic approach was based on an intention-to-treat analysis. Findings We enrolled 21 elderly subjects in the PST group and 16 elderly subjects in the social contact comparison group. The PST group experienced a decline in depression scores compared with the social contact group. Although not statistically significant (likely due to the small sample size), PST was associated with decreased depressive symptom scores for those who were able to complete the intervention. Implementation proved to be difficult in terms of study recruitment and intervention acceptance and adherence. Implications These study findings point to the potential benefits of an integrated mental health component in long-term care, involving rehabilitation professionals who are already working with the older adults in both postacute/short-stay and long-stay settings.

The Family Satisfaction with End-of-Life Care (FAMCARE) has been used widely among caregivers to individuals with cancer. The aim of this study was to evaluate the psychometric properties of this measure using item response theory (IRT). The analytic sample was comprised of caregivers to 1,983 patients with advanced cancer. Among the patients, 56 % were females, with mean age 59.9 years (s.d. = 11.8), 20 % were non-Hispanic Black. The majority were family members either living with (44 %) or not living with (35 %) the patient. Factor analyses and IRT were used to examine the dimensionality, information, and reliability of the FAMCARE. Although a bi-factor model fit the data slightly better than did a unidimensional model, the loadings on the group factors were very low. Thus, a unidimensional model appears to provide adequate representation for the item set. The reliability estimates, calculated along the satisfaction (theta) continuum, were adequate (>0.80) for all levels of theta for which subjects had scores. Examination of the category response functions from IRT showed overlap in the lower categories with little unique information provided; moreover, the categories were not observed to be interval. Based on these analyses, a three-response category format was recommended: very satisfied, satisfied, and not satisfied. Most information was provided in the range indicative of either dissatisfaction or high satisfaction. These analyses support the use of fewer response categories and provide item parameters that form a basis for developing shorter-form scales. Such a revision has the potential to reduce respondent burden.

The disproportionately high prevalence of hypertension and its associated mortality and morbidity in minority older adults is a major public health concern in the United States. Despite compelling evidence supporting the beneficial effects of therapeutic lifestyle changes on blood pressure reduction, these approaches remain largely untested among minority elders in community-based settings. The Counseling Older Adults to Control Hypertension trial is a two-arm randomized controlled trial of 250 African-American and Latino seniors, 60 years and older with uncontrolled hypertension, who attend senior centers. The goal of the trial is to evaluate the effect of a therapeutic lifestyle intervention delivered via group classes and individual motivational interviewing sessions versus health education, on blood pressure reduction. The primary outcome is change in systolic and diastolic blood pressure from baseline to 12 months. The secondary outcomes are blood pressure control at 12 months; changes in levels of physical activity; body mass index; and number of daily servings of fruits and vegetables from baseline to 12 months. The intervention group will receive 12 weekly group classes followed by individual motivational interviewing sessions. The health education group will receive an individual counseling session on healthy lifestyle changes and standard hypertension education materials. Findings from this study will provide needed information on the effectiveness of lifestyle interventions delivered in senior centers. Such information is crucial in order to develop implementation strategies for translation of evidence-based lifestyle interventions to senior centers, where many minority elders spend their time, making the centers a salient point of dissemination.

Adherence to diabetes self care is poor for Hispanic American and African-American patients. This study examined the change in adherence over time and in response to a telemedicine intervention for elderly diabetes patients in these groups compared to white diabetes patients. We also examined whether adherence mediated the effect of the intervention on glycemic control (A1c).The Informatics for Diabetes Education and Telemedicine project randomized medically underserved Medicare patients (n=1665) to telemedicine case management (televideo educator visits, individualized goal-setting/problem solving) or usual care. Hispanic and African-American educators delivered the intervention in Spanish if needed.Annual assessment included A1c and self-reported adherence (Summary of Diabetes Self-Care Activities scale). A simple model (only time and group terms) and a model with covariates (e.g., age) were examined for baseline and 5 years of follow-up. SAS PROC Mixed was used with non-linear terms to examine mediating effects of adherence on A1c, by performing tests of the mediating path coefficients.Over time, self-reported adherence improved for the treatment group compared to usual care (p0.001). There was no significant interaction with racial/ethnic group membership, i.e., all groups improved. However, minority subjects were consistently less adherent than whites. Also, greater comorbidity and diabetes symptoms predicted poorer adherence, greater duration of diabetes and more years of education predicted better adherence. Adherence was a significant mediator of A1c (p0.001).A unique, tailored telemedicine intervention was effective in achieving improved adherence to diabetes self care. However, African-American and Hispanic American participants were less adherent than white participants at all time points despite an individualized and accessible intervention. The finding that adherence did mediate glycemic control suggests that unique interventions for minority groups may be needed to overcome this disparity.

The goal of this review is to discuss the state-of-the-science in elder abuse prevention. Findings from evidence-based programs to reduce elder abuse are discussed, drawing from findings and insights from evidence-based programs for child maltreatment and domestic/ intimate partner violence. A conceptual measurement model for the study of elder abuse is presented, and linked to possible measures of risk factors and outcomes. Advances in neuroscience in child maltreatment and novel measurement strategies for outcome assessment are presented.

Stroke is a leading cause of disability worldwide. It leads to a sudden and overwhelming disruption in one’s physical body, and alters the stroke survivors’ sense of self. Long-term recovery requires that bodily perception, social participation and sense of self are restored; this is challenging to achieve, particularly with a single intervention. However, rhythmic synchronization of movement to external stimuli facilitates sensorimotor coupling for movement recovery, enhances emotional engagement and has positive effects on interpersonal relationships. In this proof-of-concept study, we designed a group music-making intervention, Music Upper Limb Therapy-Integrated (MULT-I), to address the physical, psychological and social domains of rehabilitation simultaneously, and investigated its effects on long-term post-stroke upper limb recovery. The study used a mixed-method pre-post design with 1-year follow up. Thirteen subjects completed the 45-min intervention twice a week for 6 weeks. The primary outcome was reduced upper limb motor impairment on the Fugl-Meyer Scale (FMS). Secondary outcomes included sensory impairment (two-point discrimination test), activity limitation (Modified Rankin Scale, MRS), well-being (WHO well-being index), and participation (Stroke Impact Scale, SIS). Repeated measures analysis of variance (ANOVA) was used to test for differences between pre- and post-intervention, and 1-year follow up scores. Significant improvement was found in upper limb motor impairment, sensory impairment, activity limitation and well-being immediately post-intervention that persisted at 1 year. Activities of daily living and social participation improved only from post-intervention to 1-year follow up. The improvement in upper limb motor impairment was more pronounced in a subset of lower functioning individuals as determined by their pre-intervention wrist range of motion. Qualitatively, subjects reported new feelings of ownership of their impaired limb, more spontaneous movement, and enhanced emotional engagement. The results suggest that the MULT-I intervention may help stroke survivors re-create their sense of self by integrating sensorimotor, emotional and interoceptive information and facilitate long-term recovery across multiple domains of disability, even in the chronic stage post-stroke. Randomized controlled trials are warranted to confirm the efficacy of this approach. Clinical Trial Registration: National Institutes of Health, clinicaltrials.gov, NCT01586221.

OBJECTIVE To assess the association between serum adiponectin level and all-cause mortality in people with type 2 diabetes. Because of the insulin-sensitizing, anti-inflammatory, and antiatherogenic effects of adiponectin, we hypothesized that higher adiponectin level would be associated with lower all-cause mortality. RESEARCH DESIGN AND METHODS A total of 609 men and women aged 72 ± 6.3 years with type 2 diabetes and information on total and high molecular weight adiponectin were followed for a median of 5 years. The longitudinal association between adiponectin and all-cause mortality was analyzed with Cox proportional hazards models with time from adiponectin measurement to death as the time-to-event variable. Analyses were adjusted for demographic variables and significant diabetes parameters, significant cardiovascular parameters, and significant diabetes medications. RESULTS Total and high molecular weight adiponectin were highly correlated. The highest adiponectin quartile was strongly associated with higher all-cause mortality compared with the lowest quartile (hazard ratio = 4.0 [95% CI: 1.7–9.2]) in the fully adjusted model. These results did not change in analyses stratified by sex and thiazolidinedione use, after exclusion of people who died within one year of adiponectin measurement, or when change in weight before adiponectin measurement was considered. CONCLUSIONS Contrary to our hypothesis, higher adiponectin level was related to higher all-cause mortality. This association was not explained by confounding by other characteristics, including medications or preceding weight loss.

A randomized controlled trial examined whether the diagnostic process for Alzheimer’s disease and other dementias may be influenced by knowledge of the patient’s education and/or self-reported race. Four conditions were implemented: diagnostic team knows (a) race and education, (b) education only, (c) race only, or (d) neither. Diagnosis and clinical staging was established at baseline, at Wave 2, and for a random sample of Wave 3 respondents by a consensus panel. At study end, a longitudinal, “gold standard” diagnosis was made for patients with follow-up data (71%). Group differences in Diagnostic and Statistical Manual of Mental Disorders (4th ed.; American Psychiatric Association, 1994) diagnosis were estimated using logistic regression and generalized estimating equations. Sensitivity and specificity were examined for baseline diagnosis in relation to the gold standard, longitudinal diagnosis. Despite equivalent status on all measured variables across waves, members of the “knows race only” group were less likely than those of other groups to receive a diagnosis of dementia. At final diagnosis, 19% of the “knows race only” group was diagnosed with dementia versus 38% to 40% in the other 3 conditions (p = .038). Examination of sensitivities and specificities of baseline diagnosis in relation to the gold standard diagnosis showed a nonsignificant trend for lower sensitivities in the knowing race conditions (0.3846), as contrasted with knowing education only (0.480) or neither (0.600). The finding that knowledge of race may influence the diagnostic process in some unknown way is timely, given the recent State-of-the-Science conference on Alzheimer’s disease prevention, the authors of which called for information about and standardization of the diagnostic process.

doi:10.1111/j.1741-2358.2009.00335.x Correlates of dental visits among community-residing Latino elders: a public health alert Objectives: To examine oral service utilisation in a probability sample of community-residing Latino elders. Background: Older Latinos are at a potential increased risk of oral diseases, given their higher prevalence of co-morbidities and lower rate of dental service utilisation. Methods: A prevalence survey was conducted among a random sample of Latino (largely Puerto Rican) elders (n = 205; mean age = 75.8; SD ± 5.3) in New York City during 2001–2002. A systematic random sample was drawn from the Centers for Medicare and Medicaid Services Beneficiary tape files. Current use of oral health services and self-reported health conditions was obtained. Functional and cognitive impairment were assessed. Results: Less than half of the sample reported a dental visit in the previous year. The average time since the last dental visit was 54 months (SD ± 84.5). Last year dental visit compliers were more likely to be unmarried, living alone, with higher levels of education, fewer health conditions and less impairment with activities of daily living. In multivariate analyses, problem-oriented behaviour, Medicaid beneficiary, education, living alone, chronic health conditions and mobility impairment explained 14% of the ‘time since last dental visit’ variance. Conclusions: Given that socio-demographic and level of functioning determinants appear to influence the frequency of dental visits, a multilevel approach to oral health promotion is imperative.

Caring for persons with diabetes is expensive, and this burden is increasing. Little is known about service use, behaviors, and self-care of older individuals with diabetes who live in underserved communities. Information about self-care, informal care, and service utilization in urban (largely Latino, n = 695) and rural (mostly white, n = 819) Medicare beneficiaries with diabetes living in federally designated medically underserved areas was collected using computer-aided telephone interviews as part of the baseline assessment in the Informatics and Diabetes Education and Telemedicine (IDEATel) Project. Where items were comparable, service use was compared with that of a nationally representative group of Medicare beneficiaries with diabetes, using data from the Medical Expenditure Panel Survey. Compared to nationally representative groups, the underserved groups reported worse general health but similar health care service use, with the exception of home care. However, compared to the underserved rural group, the underserved, largely minority urban group, reported worse general health (P

Objective To determine whether a diabetes case management telemedicine intervention reduced healthcare expenditures, as measured by Medicare claims, and to assess the costs of developing and implementing the telemedicine intervention. Design We studied 1665 participants in the Informatics for Diabetes Education and Telemedicine (IDEATel), a randomized controlled trial comparing telemedicine case management of diabetes to usual care. Participants were aged 55 years or older, and resided in federally designated medically underserved areas of New York State. Measurements We analyzed Medicare claims payments for each participant for up to 60 study months from date of randomization, until their death, or until December 31, 2006 (whichever happened first). We also analyzed study expenditures for the telemedicine intervention over six budget years (February 28, 2000- February 27, 2006). Results Mean annual Medicare payments (SE) were similar in the usual care and telemedicine groups, $9040 ($386) and $9669 ($443) per participant, respectively (p>0.05). Sensitivity analyses, including stratification by censored status, adjustment by enrollment site, and semi-parametric weighting by probability of dropping-out, rendered similar results. Over six budget years 28 821 participant/months of telemedicine intervention were delivered, at an estimated cost of $622 per participant/month. Conclusion Telemedicine case management was not associated with a reduction in Medicare claims in this medically underserved population. The cost of implementing the telemedicine intervention was high, largely representing special purpose hardware and software costs required at the time. Lower implementation costs will need to be achieved using lower cost technology in order for telemedicine case management to be more widely used.

Objective We present results of a feasibility test of a sequential treatment strategy using continuation phase cognitive-behavioral therapy (CBT) to prevent relapse in youths with major depressive disorder (MDD) who have responded to acute phase pharmacotherapy. Method: Forty-six youths (ages 11-18 years) who had responded to 12 weeks of treatment with fluoxetine were randomized to receive either 6 months of continued antidepressant medication management (MM) or antidepressant MM plus relapse prevention CBT (MM+CBT). Primary outcome was time to relapse, defined as a Childhood Depression Rating Scale-Revised score of 40 or higher and 2 weeks of symptom worsening or clinical deterioration warranting alteration of treatment to prevent full relapse. Results Cox proportional hazards regression, adjusting for depression severity at randomization and for the hazard of relapsing by age across the trial, revealed that participants in the MM treatment group had a significantly greater risk for relapse than those in the MM+CBT treatment group (hazard ratio=8.80; 95% confidence interval 1.01-76.89; X 2 = 3.86, p = .049) during 6 months of continuation treatment. In addition, patient satisfaction was significantly higher in the MM+CBT group. No differences were found between the two treatment groups on attrition rate, serious adverse events, and overall global functioning. Conclusions These preliminary results suggest that continuation phase CBT reduces the risk for relapse by eightfold compared with pharmacotherapy responders who received antidepressant medication alone during the 6-month continuation phase. J. Am. Acad. Child Adolesc. Psychiatry, 2008;47(12): 1395–1404.

Background: with increasing prevalence of diabetes in older people, it is important to understand factors that affect their outcomes.TheInformaticsforDiabetesEducationandTelemedicine(IDEATel)projectisademonstrationprojecttoevaluate the feasibility and effectiveness of telemedicine with diverse, medically underserved, older diabetes patients. Subjects were randomised to telemedicine case management or usual care. This intervention has been shown to result in improved medical outcomes and self-efficacy. Self-efficacy refers to one’s belief that (s)he can successfully engage in a behaviour. Self-efficacy has been shown to relate to behaviour change and glycaemic control in middle-aged individuals, but not studied in older individuals. Objectives: to assess whether (a) diabetes self-efficacy relates to the primary medical outcome of glycaemic control, and to secondary outcomes (blood pressure and cholesterol), and (b) whether, after an intervention, change in diabetes self-efficacy relates to change in these medical outcomes in a group of older, ethnically diverse individuals. Methods: three waves of longitudinal data from participants in IDEATel were analysed. Results: diabetes self-efficacy at baseline correlated with glycaemic control, blood pressure and cholesterol. An increase in diabetes self-efficacy over time was related to an improvement in glycaemic control (P < 0.0001), but not in blood pressure and lipid levels. The intervention was significantly related to improved self-efficacy over time (P < 0.0001), and both directly (P =0.022)andindirectlythroughself-efficacy(P

OBJECTIVES: To determine whether the Alzheimer's Disease Screen for Primary Care (ADS-PC) is more sensitive to early dementia than the Mini-Mental State Examination (MMSE) and whether it has as high a misclassification rate in minority patients and patients with limited education. DESIGN: Cross-sectional validation study. SETTING: Urban geriatric primary care practice. PARTICIPANTS: Three hundred sixteen African-American and Caucasian patients, including 55 patients with early dementia (Clinical Demential Rating of 0.5). MEASUREMENTS: The ADS-PC is a two-stage strategy for identifying early dementia that consists of a brief high-sensitivity dementia screen, applied to all patients aged 65 and older, and a second stage to identify memory impairment, applied to patients who fail the first stage. Differences in the sensitivities or specificities of the ADS-PC and the MMSE were evaluated using the McNemar test. RESULTS: Receiver operating characteristic curves were used to examine differences in the operating characteristics of the ADS-PC across a range of cutscores. When the specificities of both tests were equated (0.90), the sensitivities were significantly different (ADS-PC, 0.75; MMSE, 0.56). The MMSE failed to identify five times as many cases of dementia as the ADS-PC. When the sensitivities were equated, the specificities differed significantly (ADS-PC, 0.95; MMSE, 0.73). The MMSE misclassified five times as many noncases as the ADS-PC. This pattern of significantly higher sensitivity and specificity for the ADS-PC than for the MMSE was repeated in the results according to race and for individuals with high school or more education but not in individuals with less education. CONCLUSION: The ADS-PC outperformed the MMSE in identifying early dementia in a racially and educationally diverse primary care cohort.

Ambulatory 24‐hour pulse pressure predicts progression of albuminuria in persons with diabetes mellitus. The authors assessed whether nocturnal blood pressure (BP) patterns added predictive information and examined the multivariate‐adjusted association of nocturnal BP patterns with progression of urine albumin excretion during follow‐up in a multiethnic cohort of older people (n=957) with type 2 diabetes mellitus who were free of macroalbuminuria. Albuminuria was assessed by spot urine measurement of albumin‐to‐creatinine ratio at baseline and annually for 3 years. Participants were categorized according to their sleep/wake systolic BP ratio as dippers (ratio ≤0.9; n=295), nondippers (flat nocturnal pattern, ratio >0.9 to 1; n=475), and nocturnal BP risers (ratio >1; n=187). The proportion exhibiting progression of albuminuria in dippers, nondippers, and risers was 17.6%, 22.9%, and 27.3%, respectively (P for linear trend = .01). A nocturnal BP rise was independently associated with progression of albuminuria (hazard ratio, 1.68; 95% confidence interval [CI], 1.09–2.60; P=.02), whereas office pulse pressure was not. When ambulatory 24‐hour pulse pressure was added to the model, the nocturnal BP rise remained an independent predictor of progression of albuminuria (hazard ratio, 1.58; 95% CI, 1.02–2.45; P=.04). Nocturnal nondipping (without BP increase) was not an independent predictor. In conclusion, nocturnal BP rise on ambulatory monitoring is superior to office BP to predict worsening of albuminuria in elderly individuals with type 2 diabetes and adds to the information provided by 24‐hour pulse pressure.

The authors compared fluoxetine and placebo in continuation treatment to prevent relapse of major depressive disorder in children and adolescents.After a detailed evaluation, children and adolescents 7-18 years of age with major depressive disorder were treated openly with fluoxetine. Those who had an adequate response after 12 weeks, as indicated by a Clinical Global Impression improvement score of 1 or 2 and a decrease of at least 50% in Children's Depression Rating Scale-Revised score, were randomly assigned to receive fluoxetine or placebo for an additional 6 months. The primary outcome measures were relapse and time to relapse. Relapse was defined as either a score of 40 or higher on the Children's Depression Rating Scale with a history of 2 weeks of clinical deterioration, or clinical deterioration as judged by the clinician. Additional analyses were conducted with relapse defined only as a score of 40 or higher on the Children's Depression Rating Scale.Of 168 participants enrolled in acute fluoxetine treatment, 102 were randomly assigned to continuation treatment with fluoxetine (N=50) or placebo (N=52). Of these, 21 participants (42.0%) in the fluoxetine group relapsed, compared with 36 (69.2%) in the placebo group, a significant difference. Similarly, under the stricter definition of relapse, fewer participants in the fluoxetine group relapsed (N=11; 22.0%) than in the placebo group (N=25; 48.1%). Time to relapse was significantly shorter in the placebo group.Continuation treatment with fluoxetine was superior to placebo in preventing relapse and in increasing time to relapse in children and adolescents with major depression.

This project assessed the extent to which modern technology (Vigil) can augment or substitute for direct staff intervention in nonacute late-evening and nighttime situations in a nursing home setting. Vigil was implemented for dementia residents of a special care unit (SCU) in a large nursing home. An SCU matched in terms of unit-wide case mix and cognition was used for comparison. Results showed that there was no significant reduction in falls and injuries, but there was a significant improvement in affective disorder in the intervention group as contrasted with the comparison group. There was no significant increase in staff-perceived burden, despite the significant increase in the amount of direct care time logged. Additional time spent in staff care was significantly related to decreased affective disorder. The findings related to Vigil are generally mixed. The question remains as to whether the improvement in affect was due to Vigil or vigilance.

Ambulatory 24-h pulse pressure predicts progression of albuminuria in people with diabetes mellitus. It is not known whether the ambulatory arterial stiffness index (AASI) may add to that prediction.We compared the multivariate-adjusted association of AASI and 24-h pulse pressure with progression of urine albumin excretion during follow-up in a multiethnic cohort of older people with type-2 diabetes mellitus. The baseline evaluation included office and 24-h ambulatory blood pressure (BP) measurements, and a spot urine measurement of albumin-to-creatinine ratio (ACR). The ACR measurements were repeated annually during 3 years.The AASI wasor=0.55 units in 47% of those exhibiting progression of albuminuria, and in 37% of those without progression (P = .004), whereas 24-h pulse pressure wasor=65 mm Hg in 50% and 38% of those with and without progression, respectively (P = .001). In repeated measures mixed linear model (n = 1043), after adjustment for several covariates including office pulse pressure, AASI in the fourth quartile was independently associated with higher follow-up ACR (P = .024). However, that association did not persist after adjusting for 24-h pulse pressure, which was an independent predictor (P.001). Cox proportional hazards models examined progression of albuminuria in 957 participants without macroalbuminuria at baseline. The hazard ratio (95% CI) for AASIor=0.55 units was 1.37 (1.02-1.83) after multivariable adjustment, including office pulse pressure. But AASI was not an independent predictor after adjustment for ambulatory pulse pressure, which was again an independent predictor (P = .033).Ambulatory 24-h pulse pressure outperformed AASI in predicting progression of albuminuria in elderly people with type 2 diabetes.

BACKGROUND Although the efficacy of therapeutic lifestyle change (TLC) interventions are well proven, their relative effectiveness vs. single-session lifestyle counseling (SSC) on blood pressure (BP) reduction in primary care practices remains largely untested in hypertensive Blacks. The aim of this trial was to evaluate the comparative effectiveness of a comprehensive practice-based TLC intervention (motivational interviewing (MINT)-TLC) vs. SSC on BP reduction among 194 Blacks with uncontrolled hypertension. METHODS The MINT-TLC arm included 10 weekly group classes on TLC, followed by 3 individual MINT sessions. The SSC group received 1 individual counseling session on lifestyle modification plus print versions of the intervention material. The primary outcome was within-patient change in systolic BP (SBP) and diastolic BP (DBP) from baseline to 6 months. The secondary outcome was BP control at 6 months. RESULTS Mean age of the total sample was 57 (10.2) years; 50% were women, and the mean baseline BP was 147.4/89.3mm Hg. Eighty-four percent of SSC and 77% of MINT-TLC patients completed the final 6-month assessments. BP declined significantly (P < 0.001) in both groups at 6 months with a net-adjusted systolic BP reduction of 12.9 mm Hg for the SSC group vs. 9.5mm Hg for the MINT-TLC group (P = 0.18); and diastolic BP reduction of 7.6 and 7.2mm Hg for the SSC and MINT-TLC group, respectively (P = 0.79). The between-group difference in proportion of patients with adequate BP control at 6 months was nonsignificant (P = 0.82). CONCLUSION A significant group difference in BP between the intervention groups was not observed among a sample of hypertensive Blacks. Implementation of the pragmatic single-session intervention and its effects on utilization of healthcare services should be further evaluated. CLINICAL TRIAL REGISTRATION Trial Number NCT01070056 at http://clinicaltrials.gov/ct2/show/NCT01070056?term=TLC+clinic&rank=1.

We sought to examine the relationship between functional outcome and process of care for patients with hip fracture.We undertook a prospective cohort study in 4 hospitals of 554 patients treated with surgery for hip fracture.Information on patient characteristics and processes of hospital care collected from the medical record, interviews, and bedside observations. Follow-up information obtained at 6 months on function (using the Functional Independence Measure [FIM]), survival, and readmission.Individual processes of care were generally not associated with adjusted outcomes. A scale of 9 processes related to mobilization was associated with improved adjusted locomotion (P = 0.006), self care (P = 0.022), and transferring (P = 0.007) at 2 months, but the benefits were smaller and not significant by 6 months. These processes were not associated with mortality. The predicted value for the FIM locomotion measure (range, 2-14) at 2 months was 5.9 (95% confidence interval 5.4-6.4) for patients at the 10th percentile of performance on these processes compared with 7.1 (95% confidence interval 6.6, 7.6) at the 90th percentile. Patients who experienced no hospital complications and no readmissions retained the benefits in locomotion at 6 months. Anticoagulation processes were associated with improved transferring at 2 months (P = 0.046) but anticoagulation and other processes of care were not otherwise associated with improved function.Our findings indicate the need to attend to all steps in the care of patients with hip fracture. Additionally, functional outcomes were more sensitive markers of improved process of care, compared with 6-month mortality, in the case of hip fracture.

We studied whether ambulatory blood pressure monitoring added to office blood pressure in predicting progression of urine albumin excretion over 2 years of follow-up in a multiethnic cohort of older people with type-2 diabetes mellitus. Participants in the Informatics for Diabetes Education and Telemedicine study underwent a baseline evaluation that included office and 24-hour ambulatory blood pressure measurement and a spot urine measurement of albumin-to-creatinine ratio (ACR). Measurements of albumin-to-creatinine ratio were repeated 1 and 2 years later. In bivariate analyses, ambulatory 24-hour pulse pressure was the blood pressure variable most strongly associated with follow-up ACR. Repeated-measures mixed linear models (n=1040) were built adjusting for baseline ACR ratio, clustered randomization, time to follow-up, and multiple covariates. When both were entered into the model, ambulatory 24-hour pulse pressure and office pulse pressure were independently associated with follow-up ACR (β [SE]=0.010 [0.002], P P =0.002, respectively). Cox proportional hazards models examined associations with progression of albuminuria in 954 participants without macroalbuminuria at baseline, adjusting for all of the covariates independently associated with follow-up ACR in mixed linear models. Ambulatory 24-hour pulse pressure, but not office pulse pressure, was independently associated with progression of albuminuria ( P =0.015 and 0.052, respectively). The adjusted hazards ratio (95% CI) per each 10-mm Hg increment in ambulatory pulse pressure was 1.23 (1.04 to 1.42). In conclusion, ambulatory pulse pressure may provide additional information to predict progression of albuminuria in elderly diabetic subjects above and beyond office blood pressure.

Background: Telemedicine is a promising but largely unproven technology for providing case management services to patients with chronic conditions who experience barriers to access to care or a high burden of illness. Methods: The authors conducted a randomized, controlled trial comparing telemedicine case management to usual care, with blinding of those obtaining outcome data, in 1,665 Medicare recipients with diabetes, aged 55 years or greater, and living in federally designated medically underserved areas of New York State. The primary endpoints were HgbA1c, blood pressure, and low-density lipoprotein (LDL) cholesterol levels. Results: In the intervention group ( n = 844), mean HgbA1c improved over one year from 7.35% to 6.97% and from 8.35% to 7.42% in the subgroup with baseline HgbA1c ≥7% ( n = 353). In the usual care group ( n = 821) mean HgbA1c improved over one year from 7.42% to 7.17%. Adjusted net reductions (one-year minus baseline mean values in each group, compared between groups) favoring the intervention were as follows: HgbA1c, 0.18% (p = 0.006), systolic and diastolic blood pressure, 3.4 (p = 0.001) and 1.9 mm Hg (p < 0.001), and LDL cholesterol, 9.5 mg/dL (p < 0.001). In the subgroup with baseline HgbA1c ≥7%, net adjusted reduction in HgbA1c favoring the intervention group was 0.32% (p = 0.002). Mean LDL cholesterol level in the intervention group at one year was 95.7 mg/dL. The intervention effects were similar in magnitude in the subgroups living in New York City and upstate New York. Conclusion: Telemedicine case management improved glycemic control, blood pressure levels, and total and LDL cholesterol levels at one year of follow-up.

This study sought to compare the differences in attributes between older SCU residents and non-SCU residents with dementing illnesses. It used the Institutional Comprehensive Assessment and Referral Evaluation (INCARE) screening measure as a basis for analyses. A probability sample, consisting of 181 black elders residing in nursing homes in New York State, had been drawn earlier as part of the ten collaborative studies of dementia special care sponsored by the National Institute on Aging. Findings indicate that black elders in SCUs are different from the typical dementia special care residents as discussed in the literature. Implications are discussed in terms of social work practice.

The aims of the study were to: (a) assess the degree to which primary care physicians recognize psychiatric distress among an ethnically diverse primary care sample composed primarily of Asians and Hispanics; and (b) to investigate the relationship between patient and physician sociodemographic factors and overall diagnostic recognition of psychiatric distress. The study sample is comprised of 252 consecutively-selected patients and eleven primary care general internists from general medicine clinics in a large public ambulatory medical center. The measures used were the Center for Epidemiologic Studies-Depression (CES-D) scale, a demographic questionnaire, and an acculturation scale; these measures were completed during interviews conducted by trained bilingual research assistants. Physicians completed a mental health treatment summary immediately after the patient's visit. Hierarchical logistic regression analyses were performed in order to examine: (1) the degree to which providers identified psychiatric distress and (2) overall diagnostic recognition among this sample in relation to demographic characteristics and degree of acculturation. As measured by the CES-D, almost one half (47.3%) of the Latino and 41.6% of the Asian patients had depressive symptoms indicative of psychiatric distress. In contrast, physicians identified 43.8% of Latino patients and only 23.6% of Asian patients as being psychiatrically distressed (p < .01). Physicians were more likely to classify Latinos and those with higher acculturation status as distressed (p < .01 and p < .05, respectively). Higher patient acculturation status was the only factor significantly associated with overall diagnostic recognition (p < .05), as measured by physician agreement with the CES-D. Being Asian and/or having low acculturation levels may put the patient at risk for non-detection of psychiatric distress. The high prevalence of distress lends support to initiating improved methods for screening and detection of depression among low income and racially diverse primary care patients.

Background: Dementia prevalence and related caregiving burden are increasing, particularly among Hispanics. We studied the characteristics and mental health of Hispanic caregivers in New York City. Methods: We recruited 139 Hispanic family caregivers. We collected data on sociodemographic characteristics and predictors of caregiver burden, measured with the Zarit Caregiver Burden Scale, and depressive symptoms, measured with the Geriatric Depression Scale. Results: The mean age was 59.3 ± 10.4 years. The majority of caregivers were daughters and earned less than US$30 000 a year. In multivariate analyses with linear regression, lower satisfaction with social networks was associated with higher caregiver burden and a greater number of depressive symptoms. Higher dementia severity was associated with higher caregiver burden, while higher caregiver comorbidities were associated with higher depressive symptoms. Conclusions: Caregiver comorbidities and satisfaction with social support may be targets for intervention that could improve caregiver burden and depressive symptoms among Hispanic caregivers.

Objective The authors examined the multivariate relationships between depression recognition by staff members and characteristics of nursing home residents. Methods Analyses used a simple random sample of 270 residents, drawn from six randomly selected nursing homes, who were evaluated by psychiatrists for depression and depressive symptomatology. Results African Americans were generally seen by psychiatrists as having less depressive symptomatology than residents from other ethnic groups. The data suggest that nurse aides, perhaps because they see residents more often or because they are less influenced by demographic characteristics, may be the most valid source of information about residents' depression. In contrast, after partialing out the degree of depression severity, nurses tended to overrecognize depression among African-American residents. Social workers underrecognized depression among residents with cognitive impairment and/or Parkinson disease and among women, and overrecognized depression among African Americans. Conclusion The results underline the need for more training in depression recognition, particularly in distinguishing social from clinical phenomena and in distinguishing symptoms of dementia from those of depression. Equally important is further investigation of the potential biases associated with diagnosis and recognition of depression among African Americans.

Background Stroke is a leading cause of adult disability and mortality. Intravenous thrombolysis can minimize disability when patients present to the emergency department for treatment within the 3 − 4½ h of symptom onset. Blacks and Hispanics are more likely to die and suffer disability from stroke than whites, due in part to delayed hospital arrival and ineligibility for intravenous thrombolysis for acute stroke. Low stroke literacy (poor knowledge of stroke symptoms and when to call 911) among Blacks and Hispanics compared to whites may contribute to disparities in acute stroke treatment and outcomes. Improving stroke literacy may be a critical step along the pathway to reducing stroke disparities. The aim of the current study is to test a novel intervention to increase stroke literacy in minority populations in New York City. Design and Methods In a two-arm cluster randomized trial, we will evaluate the effectiveness of two culturally tailored stroke education films – one in English and one in Spanish – on changing behavioral intent to call 911 for suspected stroke, compared to usual care. These films will target knowledge of stroke symptoms, the range of severity of symptoms and the therapeutic benefit of calling 911, as well as address barriers to timely presentation to the hospital. Given the success of previous church-based programs targeting behavior change in minority populations, this trial will be conducted with 250 congregants across 14 churches (125 intervention; 125 control). Our proposed outcomes are (1) recognition of stroke symptoms and (2) behavioral intent to call 911 for suspected stroke, measured using the Stroke Action Test at the 6-month and 1-year follow-up. Discussion This is the first randomized trial of a church-placed narrative intervention to improve stroke outcomes in urban Black and Hispanic populations. A film intervention has the potential to make a significant public health impact, as film is a highly scalable and disseminable medium. Since there is at least one church in almost every neighborhood in the USA, churches have the ability and reach to play an important role in the dissemination and translation of stroke prevention programs in minority communities. Trial registration NCT01909271; July 22, 2013

Objectives: To determine whether older adults with type 2 diabetes mellitus and cognitive dysfunction have poorer metabolic control of glycosylated hemoglobin, systolic blood pressure, and low-density lipoprotein cholesterol than those without cognitive dysfunction. Design: Prospective cohort study. Setting: A minority cohort in New York City previously recruited for a trial of telemedicine. Participants: Persons aged 73.0 ± 3.0 (N = 613; 69.5% female; 82.5% Hispanic, 15.5% non-Hispanic black). Measurements: Participants were classified with executive or memory dysfunction based on standardized score cutoffs (

Little is known about diabetes and depression in disadvantaged urban Hispanic subgroups, particularly those of Caribbean origin. Using data from 360 urban Hispanics of Caribbean origin with poorly controlled diabetes, our objectives were to examine the prevalence and correlates of depressive symptoms and depression using the Euro-D, and the association of depressive symptoms and depression with diabetes self-management and clinical parameters of diabetes control, employing multivariate analyses. The prevalence of depression was 52.8%. Higher levels of depressive symptoms were related to female gender (p < .0001), antidepressant use (p < .0001), stressful life events (p < .0001), SSI (p = .0011), lower education (p < .0001), lower statin use (p = .0014), and less walking (p = .0152). Depression (Euro-D > 3), was associated significantly with female gender (OR = 2.30, 95%CI = 1.38– 3.82), SSI (OR = 2.44, 95%CI = 1.45– 4.12), antidepressant use (OR = 2.94, 95%CI = 1.54– 5.64), and stressful life events (OR = 1.93, 95%CI = 1.52– 2.44). Depressive symptoms and depression were related to markers of adversity and two indicators of diabetes self-management, but not clinical parameters of diabetes control.

OBJECTIVE The Northern Manhattan Diabetes Community Outreach Project evaluated whether a community health worker (CHW) intervention improved clinically relevant markers of diabetes care in adult Hispanics. RESEARCH DESIGN AND METHODS Participants were adult Hispanics, ages 35–70 years, with recent hemoglobin A1c (A1C) ≥8% (≥64 mmol/mol), from a university-affiliated network of primary care practices in northern Manhattan (New York City, NY). They were randomized to a 12-month CHW intervention (n = 181), or enhanced usual care (educational materials mailed at 4-month intervals, preceded by phone calls, n = 179). The primary outcome was A1C at 12 months; the secondary outcomes were systolic blood pressure (SBP), diastolic blood pressure, and LDL-cholesterol levels. RESULTS There was a nonsignificant trend toward improvement in A1C levels in the intervention group (from unadjusted mean A1C of 8.77 to 8.40%), as compared with usual care (from 8.58 to 8.53%) (P = 0.131). There was also a nonsignificant trend toward an increase in SBP and LDL cholesterol in the intervention arm. Intervention fidelity, measured as the number of contacts in the intervention arm (visits, phone contacts, group support, and nutritional education), showed a borderline association with greater A1C reduction (P = 0.054). When assessed separately, phone contacts were associated with greater A1C reduction (P = 0.04). CONCLUSIONS The trend toward A1C reduction with the CHW intervention failed to achieve statistical significance. Greater intervention fidelity may achieve better glycemic control, and more accessible treatment models, such as phone-based interventions, may be more efficacious in socioeconomically disadvantaged populations.

Item response theory was used to examine the psychometric properties of a cognitive screening measure used in several epidemiological surveys among Latino, African American, and White non-Latino elderly. Estimates of precision (reliability) examined across several values of Θ (the estimate of degree of cognitive impairment) were good (.70s to .90s) in the range representing most respondents. Overall reliability, although adequate, was lower among the White non-Latino and high-education subgroups relative to other racial/ethnic and education subgroups. Differential item functioning (DIF) was examined using several area- and model-based tests. Tests of the magnitude of DIF showed the measure to be relatively free of DIF for the racial/ethnic subgroup and education subgroups examined. However, one item related to remembering the telephone number was more difficult for Latinos than for other racial/ethnic subgroups. Several other items evidenced mild DIF, and one (difficulty remembering words or names) was a poorly discriminating item. The subjective memory items, intended to provide additional information at the earlier, “borderzone” stages of cognitive impairment, did provide more information at the mild to moderate levels of impairment, although maximum information was not provided at these borderzone ranges.