Kathleen C. Insel

Recruitment of Older Adults: Success May Be in the Details

PURPOSE Describe recruitment strategies used in a randomized clinical trial of a behavioral prospective memory intervention to improve medication adherence for older adults taking antihypertensive medication. RESULTS Recruitment strategies represent 4 themes: accessing an appropriate population, communication and trust-building, providing comfort and security, and expressing gratitude. Recruitment activities resulted in 276 participants with a mean age of 76.32 years, and study enrollment included 207 women, 69 men, and 54 persons representing ethnic minorities. Recruitment success was linked to cultivating relationships with community-based organizations, face-to-face contact with potential study participants, and providing service (e.g., blood pressure checks) as an access point to eligible participants. Seventy-two percent of potential participants who completed a follow-up call and met eligibility criteria were enrolled in the study. The attrition rate was 14.34%. IMPLICATIONS The projected increase in the number of older adults intensifies the need to study interventions that improve health outcomes. The challenge is to recruit sufficient numbers of participants who are also representative of older adults to test these interventions. Failing to recruit a sufficient and representative sample can compromise statistical power and the generalizability of study findings.

Differences in Illness Representation among Pulmonary Patients and their Providers

This investigation examined how patient and provider groups represent 11 descriptors (concepts) of breathing and breathlessness. Two patient groups, those with chronic obstructive pulmonary disease (COPD) and those with asthma, and two provider groups, pulmonologists and nurse specialists (PNS), rated the dissimilarity between each of 55 pairs of concepts on visual analogue scales (VAS). The results demonstrate differences between the groups in illness representation. The findings have implications for understanding differences in illness representation between patient groups and providers.

A multifaceted prospective memory intervention to improve medication adherence: Design of a randomized control trial

Adherence to prescribed antihypertensive agents is critical because control of elevated blood pressure is the single most important way to prevent stroke and other end organ damage. Unfortunately, nonadherence remains a significant problem. Previous interventions designed to improve adherence have demonstrated only small benefits of strategies that target single facets such as understanding medication directions. The intervention described here is informed by prospective memory theory and performance of older adults in laboratory-based paradigms and uses a comprehensive, multifaceted approach to improve adherence. It incorporates multiple strategies designed to support key components of prospective remembering involved in taking medication. The intervention is delivered by nurses in the home with an education control group for comparison. Differences between groups in overall adherence following the intervention and 6 months later will be tested. Systolic and diastolic blood pressure levels also will be examined between groups and as they relate to adherence. Intra-individual regression is planned to examine change in adherence over time and its predictors. Finally, we will examine the association between executive function/working memory and adherence, predicting that adherence will be related to executive/working memory in the control group but not in the intervention group.

The negative association of independent personality and medication adherence.

Objectives: This investigation examines the association of personality factors and medication adherence among older adults. Method: The Six-Factor Personality Questionnaire was mailed to participants involved in a medication adherence investigation. Medication adherence was monitored with an electronic monitoring cap for 8 weeks for one prescribed daily medication. Results: Sixty older adults, mean age 77 years (range 67 to 93 years), returned the questionnaire (69% response rate). Stepwise regression analysis demonstrates that when age and level of education are controlled, independence predicts medication adherence. This factor demonstrates a negative relationship with adherence suggesting that higher levels of independence may be related to lower adherence to prescribed medication. The facet component self-reliance is predictive of poor medication adherence. Discussion: The finding that higher self-reliance is associated with lower adherence in an older population deserves further investigation and clinical consideration.

Family caregiving of older Chinese people with dementia: testing a model.

Background:The process of taking care of older people with dementia at home is complex and influenced by cultural factors, necessitating a better understanding of the interrelationships of factors within the context of culture. Objectives:The aim of this study was to test the proposed Dementia Caregiving Model, specifying how caregiving appraisal, coping, perceived social support, and familism influence the impact of caregiving stressors on the psychological health of caregivers. Methods:A cross-sectional correlational design with a convenience sample (n = 96) from three outpatient clinics of hospitals in China was used. Questionnaires were utilized to measure the variables in the model. Path analysis was used to assess model fit and paths. Results:The original proposed model did not fit the data, butminor modifications produced a very good model fit (&khgr;2(10, n = 96) = 8.14, p = .62; goodness-of-fit index = .98, comparative fit index = 1.00, and root mean square error of approximation < .001). Care recipients’ behavioral problems had direct and indirect negative effects on caregivers’ psychological health. Perceived social support had direct and indirect positive effects on caregivers’ psychological health. Familism had indirect positive effects on caregivers’ psychological health in relation with caregiving satisfaction and coping. Caregiving appraisal and coping were mediators in the model. Conclusions:The model findings lend support that caregivers’ cognitive appraisal and coping explain some observed individual differences in stress response and outcomes. The findings broaden understanding of the effects of familism on caregivers’ psychological health. In the future, programs should include interventions for caregivers, as well as interventions for care recipients.

Association between change in systolic blood pressure and cognitive decline among elderly Mexican Americans: Data from the hispanic established population for epidemiology study of the elderly

Abstract The longitudinal association between the rate of change in blood pressure and cognitive decline was examined in an area probability sample from a population-based survey of elderly Mexican Americans, 65 years of age or older obtained in 1993–1994, 1995–1996, 1998–1999, and 2000–2001 (n = 2859). The sample was divided into two groups at baseline: hypertensives had a systolic blood pressure (SBP) ≥ 140 mm Hg, a diastolic blood pressure (DBP) ≥ 90 mm Hg, or indicated a prior diagnosis of hypertension, and the normotensive group. Cognition was indexed by the Mini-Mental State Examination (MMSE). Neither SBP nor DBP at baseline predicted cognitive decline. However, the mean slope for SBP in the normotensive group showed an increase of 4.55 mm Hg (increase from Time 1 to Time 2 was 123 mm Hg to 132 mm Hg) and was significant in a regression model predicting cognitive decline even after adjusting for covariates. These findings suggest an association between increasing SBP and cognitive decline for normotensive elderly in this study population.

High perceived stress is linked to afternoon cortisol levels and greater symptom distress in patients with localized prostate cancer.

Background: Patients treated with radical prostatectomy (RP) or radiation therapy (RT) for prostate cancer can experience stress and symptoms that impact quality of life. Objective: The objectives of this study were to describe cortisol levels, perceived stress, symptoms, and symptom distress; compare differences in variables measured between RP and RT; and identify associations among cortisol levels, perceived stress, symptoms, and symptom distress in patients treated for localized prostate cancer. Methods: A descriptive, cross-sectional study was conducted with 53 patients (RP n = 24, RT n = 29). Data from saliva, questionnaires, and interviews were collected within 3 months of treatment. Saliva samples were collected at 4 times over 2 consecutive days. Data were analyzed using descriptive statistics, correlations, and regressions. Results: A robust diurnal rhythm of cortisol secretion with heightened levels in the early morning and lowered levels late in the day was found. On average, the entire sample had moderate symptoms and symptom distress for urinary, bowel, and sexual dysfunction. The RP group reported significantly more urinary and sexual dysfunction symptoms and fewer bowel symptoms than did the RT group. Perceived stress was positively correlated with higher afternoon cortisol levels and greater symptom distress. Conclusion: Moderate symptoms and symptom distress found in our sample indicate the need for interventions to address these outcomes in men treated for prostate cancer. Self-reported perceived stress can be used to assess the stress level and symptom distress in clinic setting. Implications for Practice: Patients treated for prostate cancer with RP or RT should be assessed for symptoms and symptom distress and targeted for early symptom management interventions.

Biomarkers for Cognitive Aging Part I Telomere Length, Blood Pressure and Cognition Among Individuals with Hypertension

Chronological age is used as a marker for age-associated changes in cognitive function. However, there is great interindividual variability in cognitive ability among people of the same age. Physiological age rather than chronological age should be more closely associated with age-related cognitive changes because these changes are not universal and are likely dependent on several factors in addition to the number of years lived. Cognitive function is associated with successful self-management, and a biological marker that reflects physiological age and is associated with cognitive function could be used to identify risk for failure to self-manage. The purpose of this study was to investigate the association between telomere length, a known biomarker of age; blood pressure; cognitive assessments; and adherence to antihypertensive medication among community-dwelling middle-aged and older adults. The authors administered a battery of cognitive assessments to 42 participants (M = 69 years of age), collected blood samples, and isolated peripheral blood mononuclear leukocytes for genomic DNA. The authors determined relative telomere length using Cawthon’s method for real-time quantitative polymerase chain reaction (RT-qPCR) and measured medication adherence using an electronic medication monitoring system (MEMS by Aardex) over 8 weeks. Findings indicate that telomere length was inversely associated with systolic blood pressure (r = −.38, p < .01) and diastolic blood pressure (r = −.42, p < .01) but not with cognitive assessments or adherence. The authors discuss the nonsignificant findings between telomere length and cognitive assessments including the potential modifying role of gender.

Associations between working memory, health literacy, and recall of the signs of stroke among older adults.

ABSTRACT Stroke remains a major cause of mortality and disability among older adults. Although early treatment after stroke is known to reduce both mortality and disability, the first step in seeking early treatment is dependent on the rapid recognition of the signs of stroke. Recall of the signs of stroke may be dependent on factors that exist before the stroke itself. Although it is known that both working memory and health literacy decline with advancing age, these factors have not been thoroughly examined with respect to recall of the signs of stroke. Therefore, the purpose of the current study was to investigate associations between working memory, health literacy, and recall of the signs of stroke among older adults. Community dwelling older adults (≥65 years of age) were recruited from two senior centers. Fifty-six participants meeting inclusion criteria provided demographic and health information and were asked to read a public service brochure listing the five warning signs of stroke. Working memory was then assessed using the Wechsler Adult Intelligence Scale 3rd Edition Working Memory Index. Health literacy was assessed by the Short Test of Functional Health Literacy in Adults. Participants’ recall of the five warning signs of stroke was evaluated. The mean age was 80.4 years. The mean number of the signs of stroke recalled was 2.9 ± 1.33. Working memory and health literacy were positively correlated with recall of the signs of stroke (r = .38, p < 0.01; r = .44, p < 0.01). In a simultaneous regression, only health literacy remained a significant predictor of recall. There was no statistically significant interaction between working memory and health literacy. Findings from this study indicate that working memory and health literacy were associated with successful recall of the warning signs of stroke in older adults. Further studies are needed to determine if programs that include cognitive and literacy assessments could identify older adults who need additional support to learn and recall the signs of stroke.

Biomarkers for Cognitive Aging Part II Oxidative Stress, Cognitive Assessments, and Medication Adherence

The purpose of this study was to further examine potential biomarkers of cognitive aging by looking at the associations among oxidative stress, cognitive abilities, and medication adherence in a community-based sample of middle-aged and older adults (n = 42; mean age = 69 years) prescribed at least one medication for hypertension. In addition to measures described in Part I, “Biomarkers for Cognitive Aging,” a 12-hr urine collection for F2-isoprostanes served as an indicator of oxidative stress. Participants completed a battery of cognitive assessments and 8 weeks of electronic medication monitoring for adherence to one antihypertensive agent. Oxidative stress was significantly associated with logical memory, immediate (r = −.38, p < .01) and delayed recall (r = −.42, p < .01), and recognition memory (r = −.42, p < .01) from the Wechsler Memory Scale III, number of perseveration errors (r = .26, p < .05) and categories achieved (r = −.26, p < .01) on the Wisconsin Card Sorting Test (WSCT), and medication adherence (r = −.34, p <.05). Findings indicate that a biomarker of oxidative stress, F2-isoprostanes corrected for vitamin E, is significantly associated with cognitive measures and a functional outcome.