Katharina V. Echt

Factors Associated with Medication Refill Adherence in Cardiovascular-related Diseases: A Focus on Health Literacy

BACKGROUND: The factors influencing medication adherence have not been fully elucidated. Inadequate health literacy skills may impair comprehension of medical care instructions, and thereby reduce medication adherence.OBJECTIVES: To examine the relationship between health literacy and medication refill adherence among Medicare managed care enrollees with cardiovascular-related conditions.RESEARCH DESIGN: Prospective cohort study.SUBJECTS: New Medicare enrollees from 4 managed care plans who completed an in-person survey and were identified through administrative data as having coronary heart disease, hypertension, diabetes mellitus, and/or hyperlipidemia (n=1,549).MEASURES: Health literacy was determined using the short form of the Test of Functional Health Literacy in Adults (S-TOFHLA). Prospective administrative data were used to calculate the cumulative medication gap (CMG), a valid measure of medication refill adherence, over a 1-year period. Low adherence was defined as CMG ≥ 20%.RESULTS: Overall, 40% of the enrollees had low refill adherence. Bivariate analyses indicated that health literacy, race/ethnicity, education, and regimen complexity were each related to medication refill adherence (P<.05). In unadjusted analysis, those with inadequate health literacy skills had increased odds (odds ratio [OR]=1.37, 95% confidence interval [CI]: 1.08 to 1.74) of low refill adherence compared with those with adequate health literacy skills. However, the OR for inadequate health literacy and low refill adherence was not statistically significant in multivariate analyses (OR=1.23, 95% CI: 0.92 to 1.64).CONCLUSIONS: The present study suggests, but did not conclusively demonstrate, that low health literacy predicts poor refill adherence. Given the prevalence of both conditions, future research should continue to examine this important potential association.

Cognitive and Motor Mechanisms Underlying Older Adults' Ability to Divide Attention While Walking

Background An impaired ability to allocate attention to gait during dual-task situations is a powerful predictor of falls. Objective The primary purpose of this study was to examine the relative contributions of participant characteristics and motor and cognitive factors to the ability to walk while performing cognitive tasks. The impact of cognitive task complexity on walking also was examined. Design A cross-sectional, exploratory study design was used. Methods Seventy-seven community-dwelling older adults with a mean (SD) age of 75.5 (5.8) years completed comprehensive testing. Participant characteristics were assessed via questionnaires. The motor test battery included measures of strength (force-generating capacity), gait speed, and static and dynamic balance. The cognitive abilities test battery assessed psychomotor and perceptual speed, recall and working memory, verbal and spatial ability, and attention (sustained, selective, and divided). Time to walk while performing 4 cognitive tasks was measured. In addition, dual-task costs (DTCs) were calculated. Multiple hierarchical regressions explored walking under dual-task conditions. Results The ability to walk and perform a simple cognitive task was explained by participant characteristics and motor factors alone, whereas walking and performing a complex cognitive task was explained by cognitive factors in addition to participant and motor factors. Regardless of the cognitive task, participants walked slower under dual-task conditions than under single-task conditions. Increased cognitive task complexity resulted in greater slowing of gait: gait DTCs were least for the simplest conditions and greatest for the complex conditions. Limitations Walking performance was characterized by a single parameter (time), whereas other spatiotemporal parameters have been related to dual-task performance. However, this type of measurement (timed performance) will be easy to implement in the clinic. Conclusions Two factors—participant characteristics and motor abilities—explained the majority of variance of walking under dual-task conditions; however, cognitive abilities also contributed significantly to the regression models. Rehabilitation focused on improving underlying balance and gait deficits, as well as specific cognitive impairments, may significantly improve walking under dual-task conditions.

An Overview of Dual Sensory Impairment in Older Adults: Perspectives for Rehabilitation:

Dual sensory impairment (DSI) refers to the presence of both hearing loss and vision loss. The occurrence of DSI is particularly prevalent among the aging population, with studies showing between 9% and 21% of adults older than 70 years having some degree of DSI. Despite this, there is little direction regarding recommended clinical practice and rehabilitation of individuals with DSI. It is assumed that the problems encountered by individuals with DSI are considerably greater than the effects of vision impairment or hearing impairment alone, because when these two sensory impairments are combined, the individual is seriously deprived of compensatory strategies that make use of the nonimpaired sense. In this article, the literature available regarding DSI is summarized, and research needs regarding rehabilitation strategies are outlined and discussed. Simple suggestions for addressing DSI are provided that use available tools and technology.

Dancing for Balance: Feasibility and Efficacy in Oldest-Old Adults With Visual Impairment

Background:Fall risk increases with age and visual impairment, yet the oldest-old adults (>85 years) are rarely studied. Partnered dance improves mobility, balance, and quality of life in older individuals with movement impairment. Objective:The aim of the study was to determine the feasibility and participant satisfaction of an adapted tango program amongst these oldest-old adults with visual impairment. Exploratory analyses were conducted to determine efficacy of the program in improving balance and gait. Methods:In a repeated-measures, one-group experimental design, 13 older adults (7 women; age: M = 86.9 years, SD = 5.9 years, range = 77–95 years) with visual impairment (best eye acuity: M = 0.63, SD = 0.6 logMAR) participated in an adapted tango program of twenty 1.5-hour lessons, within 11 weeks. Feasibility included evaluation of facility access, safety, volunteer assistant retention, and participant retention and satisfaction. Participants were evaluated for balance, lower body strength, and quality of life in two baseline observations, immediately after the program and 1 month later. Results:Twelve participants completed the program. The facility was adequate, no injuries were sustained, and participants and volunteers were retained throughout. Participants reported enjoyment and improvements in physical well-being. Exploratory measures of dynamic postural control (p < .001), lower body strength (p = .056), and general vision-related quality of life (p = .032) scores showed improvements following training. Discussion:These older individuals with visual impairment benefitted from 30 hours of tango instruction adapted for their capabilities.

Severe lack of comprehension of common prostate health terms among low-income inner-city men.

Patients diagnosed with prostate cancer are often counseled about treatment options with the use of terms that are part of the “core vocabulary” of prostate cancer. It is hypothesized that predominantly lower literacy patients would demonstrate a severe lack of comprehension of prostate cancer terms, thus validating the findings of a previous single‐institution study.

Application of adapted tango as therapeutic intervention for patients with chronic stroke.

Background and Purpose:Dance has demonstrated beneficial effects on mobility in older individuals with movement disorders; yet, effects of partnered dance remain unexamined in individuals with chronic stroke. The purpose of this study was to describe the effects of adapted tango classes on balance, mobility, gait, endurance, dual-task ability, quality of life (QOL), and enjoyment in an older individual with chronic stroke and visual impairment. Case Description:D.L. was a 73-year-old African American man, 13 years poststroke with spastic hemiplegia, visual impairment, and multiple comorbidities. Intervention:D.L. attended 20 1?-hour tango classes adapted for older individuals with sensory and motor impairments over 11 weeks. Outcomes:Measures of balance, mobility, gait, endurance, dual-task ability, and QOL were evaluated before and after the intervention and at 1-month follow-up. D.L. improved on the Berg Balance Scale, 30-s chair stand, Timed Up and Go (single, manual, and cognitive conditions), 6-Minute Walk Test, and backward gait speed. Not all measures improved: balance confidence decreased, and there was no change in forward and fast gait speed or QOL, as measured by the Short Form-12 and the Visual Function Questionnaire–25. Some gains were maintained at one-month follow-up. D.L. reported enjoying the classes, noted improvement in physical well-being, and wanted to continue the program. Discussion:Thirty hours of adapted tango lessons improved balance, mobility, endurance, and dual-task ability in a participant with chronic stroke. The participant enjoyed the classes, was adherent, and wished to continue. This is the first reported use of adapted tango dance as rehabilitation for an individual with chronic stroke and low vision.

Video‐based educational tool improves patient comprehension of common prostate health terminology

Health care providers often counsel prostate cancer patients about treatment options with medical terminology. However, studies have demonstrated a severe lack of comprehension of these terms, particularly in underserved populations. It was hypothesized that a video‐based educational tool would significantly improve the understanding of key terms related to prostate health in a predominantly lower literacy population.

Amplifying diffusion of health information in low-literate populations through adult education health literacy classes.

Over the next decade, as literacy rates are predicted to decline, the health care sector faces increasing challenges to effective communication with low-literate groups. Considering the rising costs of health care and the forthcoming changes in the American health care system, it is imperative to find nontraditional avenues through which to impart health knowledge and functional skills. This article draws on classroom observations and qualitative interviews with 21 students and 3 teachers in an adult education health literacy class to explore the efficacy of using adult education courses to teach functional health literacy skills to low-literate populations. Data were analyzed using a combination of thematic and content analyses. Results describe the motivation of students to share information within the classroom and with friends and family outside the classroom. This article also provides several recommendations to help ensure accuracy of diffused information both within and outside of the classroom. Ultimately, this study suggests that the adult education system is in a prime position to impart functional health literacy skills to low-literate populations in the classroom. Significantly, this study demonstrates that adult education students themselves may be a powerful vehicle for health communication beyond the walls of the classroom.

Older Patients’ Perspectives on Managing Complexity in CKD Self-Management

BACKGROUND AND OBJECTIVES Patients with CKD are asked to perform self-management tasks including dietary changes, adhering to medications, avoiding nephrotoxic drugs, and self-monitoring hypertension and diabetes. Given the effect of aging on functional capacity, self-management may be especially challenging for older patients. However, little is known about the specific challenges older adults face maintaining CKD self-management regimens. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS We conducted an exploratory qualitative study designed to understand the relationship among factors facilitating or impeding CKD self-management in older adults. Six focus groups (n=30) were held in August and September of 2014 with veterans≥70 years old with moderate-to-severe CKD receiving nephrology care at the Atlanta Veterans Affairs Medical Center. Grounded theory with a constant comparative method was used to collect, code, and analyze data. RESULTS Participants had a mean age (range) of 75.1 (70.1-90.7) years, 60% were black, and 96.7% were men. The central organizing concept that emerged from these data were managing complexity. Participants typically did not have just one chronic condition, CKD, but a number of commonly co-occurring conditions. Recommendations for CKD self-management therefore occurred within a complex regimen of recommendations for managing other diseases. Participants identified overtly discordant treatment recommendations across chronic conditions (e.g., arthritis and CKD). Prioritization emerged as one effective strategy for managing complexity (e.g., focusing on BP control). Some patients arrived at the conclusion that they could group concordant recommendations to simplify their regimens (e.g., protein restriction for both gout and CKD). CONCLUSIONS Among older veterans with moderate-to-severe CKD, multimorbidity presents a major challenge for CKD self-management. Because virtually all older adults with CKD have multimorbidity, an integrated treatment approach that supports self-management across commonly occurring conditions may be necessary to meet the needs of these patients.

Blast exposure and dual sensory impairment: an evidence review and integrated rehabilitation approach.

Combat exposures to blast can result in both peripheral damage to the ears and eyes and central damage to the auditory and visual processing areas in the brain. The functional effects of the latter include visual, auditory, and cognitive processing difficulties that manifest as deficits in attention, memory, and problem solving--symptoms similar to those seen in individuals with visual and auditory processing disorders. Coexisting damage to the auditory and visual system is referred to as dual sensory impairment (DSI). The number of Operation Iraqi Freedom/Operation Enduring Freedom Veterans with DSI is vast; yet currently no established models or guidelines exist for assessment, rehabilitation, or service-delivery practice. In this article, we review the current state of knowledge regarding blast exposure and DSI and outline the many unknowns in this area. Further, we propose a model for clinical assessment and rehabilitation of blast-related DSI that includes development of a coordinated team-based approach to target activity limitations and participation restrictions in order to enhance reintegration, recovery, and quality of life.