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Background: Medication-related problems in older Blacks with diabetes mellitus (DM) are not well established. Objectives: To describe the frequency of medication-related problems in older Blacks with DM presenting to the emergency department (ED). Methods: The study was a cross-sectional analysis of baseline data from a randomized controlled trial evaluating Blacks aged ≥60 years of age presenting to the ED. Polypharmacy, potentially inappropriate medication (PIM) use, and anticholinergic score were evaluated. Results: Of 168 patients (median age = 68, range 60–92), most ( n = 164, 98%) were taking ≥5 medications, and 67 (39.9%) were taking a PIM. A majority ( n = 124, 74%) were taking a medication with an anticholinergic score ≥1. Number of medications was correlated with number of PIMs ( r = .22, p = .004) and anticholinergic score ( r = .50, p < .001). Conclusion: Polypharmacy and PIM use was common in older Blacks with DM.

The prevalence of dementia in Blacks/African Americans (AAs) is almost twice that of Whites. Inequities in access to health care, socioeconomic conditions, and diabetes contribute to this disparity. Poorly controlled diabetes, which is more prevalent in Blacks/AAs, causes microvascular disease and neurodegeneration and increases dementia risk. Improving glycemic control, therefore, may prevent cognitive decline. To address this issue, we developed Diabetes Regulation for Eyesight and Memory (DREAM), a community health worker (CHW)-led behavioral intervention to improve diabetes self-management and thereby prevent cognitive decline. DREAM consists of home-based diabetes education, goal setting, and telehealth visits with a diabetes nurse educator. Exploratory aims will investigate whether APOE genotype moderates and retinal biomarkers mediate treatment effects. This report describes the trial's rationale, methodology, and study procedures. (clinicaltrials.gov identifier NCT04259047).This randomized controlled trial will test the efficacy of DREAM to prevent decline in memory (primary outcome) in Blacks/AAs aged 65+ with poorly controlled diabetes and Mild Cognitive Impairment (MCI). Two hundred participants will be randomized to DREAM or an attention control condition, and will receive 11 in-home treatment sessions over two years. Outcome data are collected at 6, 12, 18, and 24 months. The primary outcome is verbal learning as measured by Hopkins Verbal Learning Test (HVLT) Total Recall scores. Participants will have retinal imaging at baseline, 12, and 24 months.This research aims to prevent cognitive decline in older Blacks/AAs with diabetes and MCI. If successful, this research will preserve health in an underserved population and reduce racial health disparities.

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

Objective: To determine the prevalence of depressive symptoms in an adult ophthalmic patient population and to delineate correlates. Design: Cross-sectional study. Participants: Adult patients (⩾18 years) were approached in general and sub-specialty cornea, retina, and glaucoma ophthalmic clinics. A total of 367 patients from the four clinics were enrolled. Methods: Depressive symptoms were assessed using the Patient Health Questionnaire-9. A cut-off score of ⩾10 was used to indicate clinically significant depressive symptoms. Patient Health Questionnaire-9 scores were used to evaluate bivariate relationships between depressive symptoms and distance visual acuity, ocular diagnosis, diabetes status, smoking status, demographic information, and medications. Results: The majority of patients were female (52.9%) and Caucasian (48.6%). The mean age was 52.0 years (standard deviation: 16.7). Clinically significant depressive symptoms were present in 19.9% of patients overall; this rate varied slightly by clinic. Patients with low vision and blindness (visual acuity worse than 20/60) were more likely to have depressive symptoms (odds ratio = 2.82; 95% confidence interval: 1.90–4.21). Smoking and diabetes were also associated with depressive symptoms (odds ratio = 3.11 (2.66–3.64) and 3.42 (1.90–6.16), respectively). Conclusion: In a sample of urban ophthalmic adult patients, depressive symptoms were highly associated with low vision, smoking, and diabetes. This information can be used to target interventions to those at greatest risk of depressive symptoms.

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.

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.

The prevalence of diabetes mellitus (DM) in black individuals (blacks) is twice that of white individuals (whites), and blacks are more likely to have worse glycemic control, less optimal medication regimens, and higher levels of mistrust in the medical system. These three factors account for higher rates of acute medical care use in blacks with DM. To address this disparity, we developed DM I-TEAM (Diabetes Interprofessional Team to Enhance Adherence to Medical Care), a home-based multidisciplinary behavioral intervention that integrates care from a community health worker (CHW), the participant's primary care physician (PCP), a DM nurse educator, and a clinical pharmacist. Treatment is delivered during 9 sessions over 1 year, and includes diabetes education and goal setting, telehealth visits with participants' PCP and a DM nurse educator, and comprehensive medication reviews by a pharmacist. We describe the rationale and methods for a randomized controlled trial to test the efficacy of DM I-TEAM to reduce emergency department (ED) visits and hospitalizations. We are enrolling 200 blacks with DM during an ED visit. Participants are randomized to DM I-TEAM or Usual Medical Care (UMC). Follow-up assessments are conducted at 6 and 12 months. The primary outcome is the number of ED visits and hospitalizations over 12 months, and is measured by participant self-report and medical record review. Secondary outcomes include hemoglobin A1c (HbA1c), number of potentially inappropriate medications (PIMs), and trust in health care.

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).

Although the importance of ophthalmologic screening in diabetic patients is widely recognized by clinicians, the cost-effectiveness of strategies aimed at improving eye care utilization in this population is not well established. A cost-effectiveness analysis was performed comparing behavior activation (BA) to supportive therapy (ST) in activating patients to receive a dilated fundus exam (DFE) and promoting healthy management of diabetes. Two hundred six subjects were randomized to receive either BA or ST between 2009 and 2013. Cost-effectiveness was calculated as incremental cost-effectiveness ratio (ICER) of BA versus ST. Total costs for BA and ST per participant were $259.02 and $216.12, respectively. At the 6-month follow-up, 87.91% of BA subjects received a DFE compared to 34.48% of ST subjects. The ICER for BA versus ST was $80.29/percent increase in DFE rate. In terms of improving DFE rates, BA was found to be more cost-effective than ST.

Vision loss due to age-related macular degeneration (AMD) is a major source of disability among older adults. Anti-vascular endothelial growth factor (VEGF) treatment has stabilized or improved vision in some patients with neovascular AMD. Despite this revolutionary treatment, many patients continue to experience substantial vision loss, either because they have atrophic disease (for which there is no treatment), or because they have achieved maximal benefit from anti-VEGF treatment (Rosenfeld et al., 2006; Sloan & Hanrahan, 2014). For these patients, low vision rehabilitation is an important option for learning to live more effectively with low vision. Although effects vary, research supports the efficacy of low vision rehabilitation to improve reading speed (Coco-Martin et al., 2013; Nguyen & Trauzettel-Klosinski, 2009), social engagement (Brunnstrom, Sorensen, Alsterstad, & Sjostrand, 2005; Scanlan & Cuddeford, 2004), psychological well-being (Horowitz, Brennan, Reinhardt, & MacMillan, 2006), and activities of daily living (Eklund & Dahlin Ivanoff, 2007; Markowitz, Kent, Schuchard, & Fletcher, 2008; McCabe, Nason, Demers Turco, Friedman, & Seddon, 2007; Stelmack, Moran, Dean, & Massof, 2007; Stelmack et al., 2008). Despite the potential benefit of low vision rehabilitation, little is known about the low vision service, device, and strategy use in AMD patients outside of low vision clinic samples. Such knowledge is important to determine unmet rehabilitation and training needs. In this paper, we describe the use of low vision resources and important vision-related goals that were reported by a sample of patients with AMD who were treated by an ophthalmology clinic. Methods SAMPLE The sample comprised all participants from the Low Vision Depression Prevention Trial (VITAL). VITAL was a randomized clinical trial to test the efficacy of a multicomponent intervention that combined low vision optometry and home-based occupational therapy to prevent depression in patients with AMD and comorbid subthreshold depressive symptoms. Details of the study are described in Rovner et al. (2014). All participants had two low vision optometry visits and were prescribed low vision devices. After the optometry visits, participants were randomized to behavioral activation (active treatment) or supportive therapy (control treatment). Behavioral activation was delivered by occupational therapists, and is a structured behavioral treatment that aims to increase adaptive behaviors and achieve valued goals. Supportive therapy was delivered by master's-level counselors, and is a nondirective, psychological treatment that provides emotional support and controls for attention. Both treatments were delivered in participants' homes over six sessions. We enrolled 188 consecutive participants with AMD (from July 2009 to February 2013) from ophthalmology clinics in Philadelphia, Pennsylvania. Eligibility criteria were: (1) age 65 years or older; (2) bilateral AMD; (3) best eye corrected visual acuity of 20/70 or worse; (4) five or more anti-VEGF injections if the better eye had neovascular disease (or no injections in the past 3 months); (5) moderate difficulty performing a valued activity; and (6) subthreshold depressive symptoms, defined as a Patient Health Questionnaire-9 (PHQ-9) score of 5 or more (Kroenke, Spitzer, & Williams, 2001), or depressed mood or anhedonia several days per week. We excluded patients with cognitive deficits (assessed by an abbreviated version of the Mini Mental State Exam) (Reischies & Geiselmann, 1997), impending antiVEGF treatment, current depressive disorder (Diagnostic and Statistical Manual of Mental Disorders [DSM]) (American Psychiatric Association, 1994), or other ophthalmologic disease. Monthly, we reviewed medical charts of consecutive patients to identify those who met eligibility criteria. Recruitment letters were mailed to patients, and were followed by telephone calls to screen for eligibility. …

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

To determine the rate of loss to follow-up (LTFU) and associated risk factors in patients with nonproliferative diabetic retinopathy (NPDR) who had diabetic macular edema (DME) and were receiving intravitreal anti-vascular endothelial growth factor (VEGF) injections.Retrospective cohort study.A total of 2595 NPDR patients with DME who received at least one anti-VEGF injection at a single large retina practice from January 1, 2012, to January 1, 2017.A retrospective review based on billing codes was performed. LTFU was defined as no subsequent office visits within 12 months after an intravitreal injection. Patient demographics and clinical features were evaluated, and logistic regression was used to identify independent predictors for LTFU.LTFU rates and potential risk factors.LTFU was found in 413 (25.3%) of 1632 patients. Examining LTFU by racial groups, 21.3% identified themselves as white, 29.1% as black, 30.6% as Asian, and 35.0% as Hispanic (P0.001). A difference in LTFU was also found based on average adjusted gross income (AGI) (P0.001) and NPDR stage (P = 0.04). In the multivariate model, factors associated with LTFU included Hispanic (odds ratio [OR] 1.66), American Indian, Pacific Islander, multiple races (OR 2.60), and unknown race (OR 1.59) compared with those who were white. Additional factors included those with an average AGI of $50000 to $75000 (OR 1.37) and$50000 (OR 1.88) compared with those with an average AGI$75000. Based on subgroup analysis of patients with available visual acuity data, a significant association was found between decreasing baseline vision and LTFU (P0.001).Approximately 1 in 4 patients with NPDR who had DME had no follow-up visit for at least 1 year after an anti-VEGF injection. Given the importance of ongoing therapy, these real-world findings may help identify at-risk groups for noncompliance with care.

Acknowledgements The study was funded by Pennsylvania Department of Health’s Commonwealth Universal Research Enhancement (CURE) Program (SAP#4100051727). Objective To describe the determinants of personal control over diabetes complications in older African Americans (N=123) with type 2 diabetes. Methods We administered structured instruments to assess perceptions of personal control, time orientation, religiosity, depression, and cognition in this cross-sectional study. Results More years of education (p ≤ .001), better Clock Drawing (p ≤ .001), higher levels of Religiosity (p ≤ .04), and lower Present Time Orientation (p ≤ .01 ) were independent predictors of higher levels of Personal Control. Discussion Risk perceptions of control over diabetes complications vary among older African Americans according to cultural constructs, executive function, and education. This finding highlights the cultural diversity in this population and the potential impact of culturally-determined views and cognitive function on health behaviors. Cognitive screening of older persons with diabetes and interventions that incorporate perceptions of time and religion to increase rates of eye examinations are needed.

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.

Objective Methods to evaluate adverse effects of medications are significantly underdeveloped compared to those for efficacy. In this pilot proof-of-concept study, we preliminarily compared a novel approach-the Symptom Assessment Tool (SAT)-to a systematic and detailed assessment by a physician for identifying symptoms that were potentially adverse effects (sensitivity) and excluding symptoms that were unlikely to be adverse effects (specificity). Methods A symptom inventory and rating of symptom severity were completed before starting a psychotropic medication (or increasing its dose), and again 2 weeks later. Each symptom was systematically assessed by the patient-rated SAT and by a physician and was classified as either a potential or unlikely adverse effect. The primary analysis compared the classification of symptoms by the SAT to that by the physician. Potential adverse effects were also subcategorized as possible or probable adverse effects. Results A sample of 193 symptoms from 15 adults was evaluated, only 37.3% of which were considered potential adverse effects by the physician. Sensitivity of the SAT compared to physician's assessment was 90.3% for potential adverse effects and 97.5% for the subgroup of probable adverse effects. The SAT correctly identified 63.6% of the symptoms as unlikely adverse effects (specificity), and its negative predictive value was 91.7%. Conclusions The SAT, appropriate for its intended use as a screening tool, had high sensitivity and moderate specificity and could present physicians with a limited number of potential adverse effects for further assessment and intervention. Further evaluation and refinement of this approach is warranted.

We examined the relationship of cognitive, medical, psychological, and behavioral factors with everyday functioning in a racially diverse older community population recruited from health service agencies. Everyday functioning was characterized as a latent variable composed of 15 instrumental activities of daily living (IADL). The mean (SD) age of the participants (N = 237) was 78.3 (8.1) years; 67% were women, 34% were African-American, 18 (7.6%) met criteria for a depressive disorder, and 61 (27.0%) met criteria for dementia. Worse verbal memory, older age, depression, and number of medical conditions were independently associated with worse IADL ability. The final model explained 60% of the variability. As the population ages and the prevalence of impaired cognition and disability rises, identifying cognitive and noncognitive determinants of disability becomes increasingly important. Interventions to optimize episodic memory, medical status, and treatment of depression may slow down the pathway to disability in older persons.

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.

This article describes a randomized clinical trial to test the impact of a home-based behavioral activation program to improve rates of dilated fundus examinations in older African–Americans with diabetes. This trial is enrolling subjects who have not met the recommendations for annual eye examinations. The intervention being testing is novel, culturally relevant and has the potential to reduce a significant health disparity regarding vision impairment. Subjects are randomized to behavioral activation or a placebo condition to control for the effects of attention. Both the active and control interventions are delivered in subjects’ homes by a community healthcare worker. The primary outcome is whether a subject had a dilated fundus examination by an ophthalmologist by 6 months.

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.

In the United States, 5.5 million people over the age of 40 meet criteria for visual impairment (VI). They often suffer significant psychosocial and health consequences, including reduced quality of life and depression, which can be persistent and difficult to treat. Additionally, VI may increase the risk of suicide. We report a case of a patient with age-related macular degeneration (ARMD) and suicidal ideation. While this link is reasonable, there are no prior cases of suicidality among patients with ARMD. Moreover, the literature is silent regarding proper approaches to diagnosing and managing suicidality among patients with VI, especially ARMD.

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.

Several studies indicate that vision loss, particularly age-related macular degeneration [AMD], is a risk factor for depression in the elderly and this has serious consequences for the quality of life among AMD patients. Rates of depression in this group parallel those of other debilitating diseases and depression magnifies the disability that is caused by vision loss. This article summarizes research on vision loss and depression, and describes psychological interventions designed to help older people cope with the emotional consequences of vision loss. Treatment strategies for dealing with depression in the context of vision loss are provided.

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.

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 AND PURPOSE No treatments have been identified to lower the risk of intracerebral hemorrhage due to cerebral amyloid angiopathy (CAA). A potential approach to prevention is the use of agents that interfere with the pathogenic cascade initiated by the beta-amyloid peptide (Abeta). Tramiprosate (3-amino-1-propanesulfonic acid) is a candidate molecule shown in preclinical studies to reduce CAA in a transgenic mouse model. METHODS We performed a 5-center phase 2 double-blinded trial to evaluate the safety, tolerability, and pharmacokinetics of tramiprosate in subjects with lobar intracerebral hemorrhage. Twenty-four subjects age > or =55 years with possible or probable CAA were randomized to receive 12 weeks of tramiprosate at 1 of 3 oral doses (50, 100, or 150 mg twice daily). Subjects were followed for clinical adverse effects, laboratory, vital sign, electrocardiogram, cognitive, or functional changes, appearance of new symptomatic or asymptomatic hemorrhages, and pharmacokinetic parameters. RESULTS Enrolled subjects were younger (mean age 70.8+/-5.4, range 61 to 78) and had more advanced baseline disease (measured by number of previous hemorrhages) than consecutive subjects in a CAA natural history cohort. No concerning safety issues were encountered with treatment. Nausea and vomiting were the most common adverse events and were more frequent at high doses. Nine subjects had new symptomatic or asymptomatic hemorrhages during treatment; all occurred in subjects with advanced baseline disease, with no apparent effect of drug dosing assignment. CONCLUSIONS These data suggest that tramiprosate can be given safely to subjects with suspected CAA and support future efficacy trials.

Late-life depression is very common and is associated with high rates of morbidity and mortality. While the field of geriatric psychiatry is focused on depression treatment, prevention is an enticing option. Prevention of late-life depression would decrease both emotional suffering and depression-associated morbidity and mortality and may decrease dependence on non-mental health professionals to detect depression and to initiate a treatment referral. This paper will review current thinking on prevention research with a particular focus on its application to late-life depression. To illustrate these issues, we discuss recent and ongoing clinical trials of interventions to prevent depression in two populations of older persons: those with age-related macular degeneration (AMD) and those with cerebrovascular disease.

Visual impairment (blindness or low vision) is a leading cause of disability among older adults and is most often due to age-related macular degeneration (AMD). The prevalence of AMD is rapidly increasing with the aging of the population; from 1991 to 1997, it increased from 5.0% to 27.1% in a cohort of Medicare beneficiaries (Crews, 1991; Lee, Feldman, Ostermann, Brown, & Sloan, 2003). It is predicted that 2.95 million people will have AMD by 2020 (Eye Diseases Prevalence Research Group, 2004). Compared to older people with typical vision, those with AMD report greater difficulty with a variety of daily activities (Williams, Brody, Thomas, Kaplan, & Brown, 1998). For example, in a community sample of 872 older people, those with AMD were 9.7 times more likely to have impairments in instrumental activities of daily living (such as taking medication and shopping) than were people with typical vision (Rovner & Ganguli, 1998). Unfortunately, there is no cure for AMD, nor can lost vision be restored. Although there are interventions to slow the progression of the condition, treatment is primarily rehabilitative. Services for people with low vision include low vision rehabilitation, occupational therapy, social support programs, and orientation and mobility training. Assistive devices include magnifiers, large-print materials (such as books, clocks, and calculators), audio materials (such as books and magazines), electronic reading devices, and speech-output systems. Despite the availability of these rehabilitative services and devices, they are underutilized. A series of focus groups that were conducted by the National Eye Institute (NEI) indicated that many older persons with low vision have little or no awareness of these services, and, as a consequence, few take advantage of them (National Eye Institute, 2001). Similar findings were reported in the Lighthouse National Survey on Vision Loss (Lighthouse International, 1995). Among adults with low vision, only 30% were using optical devices, 21% were using large-print reading materials, and 6% received rehabilitation. The most common reason for the lack of utilization of low vision devices and services was the participants’ unawareness of them. Ophthalmologists may not be informing and educating their patients about these resources. Some studies have reported that ophthalmologists refer only 28%–35% of appropriate patients to low vision rehabilitation services (Greenblat, 1988). Leinhaas and Massof (2001) found that only 15% of ophthalmologists and 21% of optometrists “always or often” prescribed low vision devices, and only 44% of ophthalmologists and 27% of optometrists “always or often” referred patients for low vision services. The goal of the current study was to obtain more detailed information on the use of low vision services and devices by older adults with AMD and to determine whether knowledge and use of such services are related to the severity of vision loss.

Objective The authors sought to determine whether depression influences the measurement of visual acuity (VA) in older persons. Methods This was a prospective study, in a geriatric psychiatry inpatient unit. Participants were 32 older patients with major depression. Authors measured VA before and after treatment of major depression, as measured by the Center for Epidemiologic Studies Depression Scale (CES–D). Results As depression resolved, there was no significant change in VA from admission to discharge. CES–D scores significantly declined from admission to discharge. VA was not correlated with depression severity (CES–D score) either at baseline or at discharge. Conclusion This study found no evidence that depression influenced VA testing in older adults. Additional studies in patients with major eye diseases are necessary to evaluate the generalizability of this finding.

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.

This study examined how depression impacts age-related macular degeneration (AMD) disability among 114 elderly AMD patients. Results indicated that 49 patients met DSM-IV criteria for syndromal depression, and that visual acuity was the only variable significantly associated with vision-specific function. For general function, health was significant, and the relationship between visual acuity and function was only significant for depressed patients. Given that AMD results in high rates of depression and that depression exacerbates physical disability in AMD, devising optimal ways to identify and treat depressed patients in ophthalmology clinics is clearly important.