David J. Hyman

The high prevalence of depression and dementia in elder abuse or neglect.

BACKGROUND: The risk factors for mistreatment of older people include age, race, low income, functional or cognitive impairment, a history of violence, and recent stressful events. There is little information in the literature concerning the clinical profile of mistreated older people.

Quantifying the Problem of Abuse and Neglect in Adults—Analysis of a Statewide Database

BACKGROUND: Mistreatment of adults, including abuse, neglect, and exploitation, affects more than 1.8 million older Americans. Presently, there is a lack of precise estimates of the magnitude of the problem and the variability in risk for different types of mistreatment depending on such factors as age and gender.

Entertainment Education for Prostate Cancer Screening: A Randomized Trial among Primary Care Patients with Low Health Literacy

OBJECTIVE To evaluate an entertainment-based patient decision aid for prostate cancer screening among patients with low or high health literacy. METHODS Male primary care patients from two clinical sites, one characterized as serving patients with low health literacy (n=149) and the second as serving patients with high health literacy (n=301), were randomized to receive an entertainment-based decision aid for prostate cancer screening or an audiobooklet-control aid with the same learner content but without the entertainment features. Postintervention and 2-week follow-up assessments were conducted. RESULTS Patients at the low-literacy site were more engaged with the entertainment-based aid than patients at the high-literacy site. Overall, knowledge improved for all patients. Among patients at the low-literacy site, the entertainment-based aid was associated with lower decisional conflict and greater self-advocacy (i.e., mastering and obtaining information about screening) when compared to patients given the audiobooklet. No differences between the aids were observed for patients at the high-literacy site. CONCLUSION Entertainment education may be an effective strategy for promoting informed decision making about prostate cancer screening among patients with lower health literacy. PRACTICE IMPLICATIONS As barriers to implementing computer-based patient decision support programs decrease, alternative models for delivering these programs should be explored.

Cardiovascular Risk Factors and Cognitive Function in Adults 30–59 Years of Age (NHANES III)

In the Third National Health and Nutrition Examination Survey (NHANES III), three measures of cognitive function [Simple Reaction Time Test (SRTT), Symbol Digit Substitution Test (SDST), and Serial Digit Learning Test (SDLT)] were administered to a half-sample of 3,385 adult men and nonpregnant women 30–59 years of age with no history of stroke. We used multiple linear regression analysis to determine whether there was an independent association between performance on each cognitive function measure and defined hypertension (HTN) alone, type 2 diabetes mellitus (DM) alone, and coexistent HTN and DM after adjustment for demographic and socioeconomic variables and selected health behaviors. After adjustment for the sociodemographic variables, the combination of HTN + DM, but not HTN alone or DM alone, was significantly associated with worse performance on the SRTT (p = 0.031) and the SDST (p = 0.011). A similar pattern was observed for SDLT performance, but the relationship did not reach statistical significance (p = 0.101). We conclude that HTN in combination with DM is associated with detectable cognitive decrements in persons under age 60.

Hurricane katrina : Medical response at the houston astrodome/reliant center complex

On September 1, 2005, with only 12 hours notice, various collaborators established a medical facility—the Katrina Clinic—at the Astrodome/Reliant Center Complex in Houston. By the time the facility closed roughly two weeks later, the Katrina Clinic medical staff had seen over 11,000 of the estimated 27,000 Hurricane Katrina evacuees who sought shelter in the Complex. Herein, we describe the scope of this medical response, citing our major challenges, successes, and recommendations for conducting similar efforts in the future.

How Geriatricians Identify Elder Abuse and Neglect

Background: Up to 2 million elderly persons are abused or neglected in the United States each year. Although elderly patients see their physicians an average of five times per year, physicians make only a small percentage of reports to Adult Protective Services (APS) agencies. The purpose of this study was to learn how practicing geriatricians define, diagnose, and address abuse and neglect to provide some guidance to the busy general internist regarding this complex issue. Methods: Ten local geriatricians were interviewed with a standardized set of open‐ended questions. A team analyzed the verbatim transcriptions using both quantitative and qualitative methods. Results: The average number of cases diagnosed per year was 8.7 (range, 2–20). The geriatricians were fairly consistent in their definitions of elder abuse and neglect and how they diagnosed it through the history and physical exam. The most common findings in the history were rapport between the patient and caregiver, medical noncompliance, activities of daily living and instrumental activities of daily living assessments, and loss of social activities. The most common findings on the physical exam were bruising/trauma, general appearance/hygiene, malnutrition, and dehydration. Conclusions: The geriatricians emphasized keeping the diagnosis of abuse and neglect in mind for every patient. A variety of interventions were employed by physicians and ranged from automatically calling APS on each case to addressing cases through work with an interdisciplinary geriatrics team.

Dietary intervention for cholesterol reduction in public clinic patients

OBJECTIVES To test the feasibility and effectiveness of a diet intervention (consisting of interactive mailings, computer-generated phone calls, and classes) in hypercholesterolemic low-income public clinic patients. METHODS Clinic patients with serum cholesterol > 200 mg/dl, referred by their primary care physician were randomized to a 6-month special intervention (SI) or usual care (UC). The intervention included mailings, computer phone calls, and four 1-hour classes. Serum total cholesterol (TC) was measured before and after intervention, and participation was monitored. RESULTS One hundred sixty-five of the 212 patients referred (77.8%) agreed to participate. A medical records review revealed 123 (74.5%) met eligibility criteria. Eligible subjects had a mean age of 56.7 years, 80.0% were African American, 74.8% were female, 33.6% were married, and 89.4% had a high school or lower education. Subjects were randomized with 80.5% (99) completing follow-up cholesterol measures. SI subjects were encouraged to use all three components, with 84.6% (55 of 65) actively participating in at least one component. Seventy-two percent (47 of 65) returned at least one mailing, 49.1% (28 of 57) of those with touch-tone phones accessed the computer system, and 43.1% (28 of 65) attended classes. The TC in SI decreased from 273.2 mg/dl to 265.0 mg/dl (P = 0.05) and in UC 272.4 mg/dl to 267.6 mg/dl (P = 0.32). The net reduction in SI compared with UC was 3.4 mg/dl (P = 0.58). CONCLUSIONS (1) Low-income public clinic patients will participate in diet interventions, (2) computer-generated interactive phone calls are feasible in this population, and (3) clinically meaningful decreases in serum cholesterol are difficult to achieve with interventions of practical intensity.

Hypertension awareness and control in an inner-city African–American sample

African–Americans in the US are at high risk for hypertension-related morbidity and mortality. The majority of African–Americans live in central city areas, and lower socioeconomic status and health care utilization patterns have been hypothesized to contribute to higher blood pressure (BP) levels and poorer control of treated hypertension in this group. In order to plan an intervention to improve hypertension care for inner city African–Americans in Houston, Texas, we conducted a baseline survey of residents in 12 low-income ZIP code areas with a >70% African–American population to determine the level of hypertension awareness, treatment and control, and associated sociodemographic, health care utilization, and medication compliance variables. Subjects were recruited to attend a BP measurement and assessment of knowledge, attitudes and behaviors through random digit phone dialing in the target ZIP code areas. Of the 962 subjects examined, 433 (45%) were hypertensive (systolic BP ⩾140 mm Hg or diastolic pressure ⩾90 mm Hg or taking antihypertensive medication). Among all hypertensives, 73% were aware, 64% were on treatment, and 28% were controlled to 140/90 mm Hg. Of hypertensives on treatment, 43% were controlled to 140/90 mm Hg, but 72% were controlled using the criterion of 160/95 mm Hg, and 75% were controlled using a diastolic pressure <90 mm hg only. these results are similar to those reported for african–americans in the most recent us national health survey. males were less likely to be aware, receiving treatment and controlled than were females. although lack of awareness was associated with less frequent bp measurement, 77% of those unaware reported a measurement within the past 2 years. the majority of aware hypertensives reported frequent physician contact and high compliance with medication. we conclude that intervention to improve hypertension control in this population should focus on ensuring that health providers diagnose bp and establish treatment goals based on the current standard of 140/90 mm hg.

Genetic bottlenecks, perceived racism, and hypertension risk among African Americans and first-generation African immigrants

The complexity of factors influencing the development of hypertension (HTN) in African Americans has given rise to theories suggesting that genetic changes occurred due to selection pressures/genetic bottleneck effects (ie, constriction of existing genetic variability) over the course of the slave trade. Ninety-nine US-born and 86 African-born health professionals were compared in a cross-sectional survey examining genetic and psychosocial predictors of HTN. We examined the distributions of three genetic loci (G-protein, AGT-235, and ACE I/D) that have been associated with increased HTN risk. There were no significant differences between US-born African Americans and African-born immigrants in the studied genetic loci or biological variables (eg, plasma renin and angiotensin converting enzyme activity), except that the AGT-235 homozygous T genotype was somewhat more frequent among African-born participants than US-born African Americans. Only age, body mass index, and birthplace consistently demonstrated associations with HTN status. Thus, there was no evidence of a genetic bottleneck in the loci studied, ie, that US-born African Americans have different genotype distributions that increase their risk for HTN. In fact, some of the genotypic distributions evidenced lower frequencies of HTN-related alleles among US-born African Americans, providing evidence of European admixture. The consistent finding that birthplace (ie, US vs Africa) was associated with HTN, even though it was not always significant, suggests potential and unmeasured cultural, lifestyle, and environmental differences between African immigrants and US-born African Americans that are protective against HTN.

Self-efficacy and barriers to multiple behavior change in low-income African Americans with hypertension

Behavioral risk factors are among the preventable causes of health disparities, yet long-term change remains elusive. Many interventions are designed to increase self-efficacy, but little is known about the effect on long-term behavior change in older, low-income African Americans, especially when facing more problematic barriers. A cohort of 185 low-income African–Americans with hypertension reported barriers they encountered while undergoing a multiple behavior change trial from 2002 to 2006. The purpose of the present study was to explore the relationships between self-efficacy, barriers, and multiple behavior change over time. Higher self-efficacy seemed to be partially helpful for smoking reduction and increasing physical activity, but not for following a low-sodium diet. Addiction was indirectly associated with less reduction in smoking through lower self-efficacy. Otherwise, different barriers were associated with behavior change than were associated with self-efficacy: being “too busy” directly interfered with physical activity and “traditions” with low-sodium diet; however, they were neither the most frequently reported barriers, nor associated with lower self-efficacy. This suggests that an emphasis on self-efficacy alone may be insufficient for overcoming the most salient barriers encountered by older African Americans. Additionally, the most common perceived barriers may not necessarily be relevant to long-term behavioral outcomes.