Martha L. Bruce

Adapting a Psychosocial Intervention for Smartphone Delivery to Middle-Aged and Older Adults with Serious Mental Illness

OBJECTIVEnTo describe the process of adapting an integrated medical and psychiatric self-management intervention to a smartphone application for middle-aged and older adults with serious mental illness using an adaptive systems engineering framework and user-centered design.nnnMETHODSnFirst, we determined the technical abilities and needs of middle-aged and older adults with serious mental illnesses using smartphones. Then, we developed smartphone content through principles of user-centered design and modified an existing smartphone platform. Finally, we conducted a usability test using think aloud and verbal probing.nnnRESULTSnWe adapted a psychosocial self-management intervention to a smartphone application and tested its usability. Ten participants (mean age: 55.3 years, SD: 6.2 years) with serious mental illness and comorbid chronic health conditions reported a high level of usability and satisfaction with the smartphone application.nnnCONCLUSIONSnMiddle-aged and older adults with serious mental illness and limited technical abilities were able to participate in a process involving user-centered design and adaptation of a self-management intervention to be delivered by a smartphone. High usability ratings suggest that middle-aged and older adults with serious mental illness have the potential to use tailored smartphone interventions. Future research is indicated to establish effectiveness and to determine the type and intensity of clinical support needed to successfully implement smartphone applications as a component of community-based services for older adults with psychiatric and medical conditions.

GERI-BD: A Randomized Double-Blind Controlled Trial of Lithium and Divalproex in the Treatment of Mania in Older Patients With Bipolar Disorder

OBJECTIVEnClinicians treating older patients with bipolar disorder with mood stabilizers need evidence from age-specific randomized controlled trials. The authors describe findings from a first such study of late-life mania.nnnMETHODnThe authors compared the tolerability and efficacy of lithium carbonate and divalproex in 224 inpatients and outpatients age 60 or older with bipolar I disorder who presented with a manic, hypomanic, or mixed episode. Participants were randomly assigned, under double-blind conditions, to treatment with lithium (target serum concentration, 0.80-0.99 mEq/L) or divalproex (target serum valproate concentration, 80-99 μg/mL) for 9 weeks. Participants with an inadequate response after 3 weeks received open adjunctive risperidone. The authors hypothesized that divalproex would be better tolerated and more efficacious than lithium. Tolerability was assessed based on a measure of sedation and on the proportions of participants achieving target concentrations. Efficacy was assessed with the Young Mania Rating Scale (YMRS).nnnRESULTSnAttrition rates were similar for lithium and divalproex (14% and 18% at week 3 and 51% and 44% at week 9, respectively). The groups did not differ significantly in sedation. Participants in the lithium group tended to experience more tremor. Similar proportions of participants in the lithium and divalproex groups achieved target concentrations (57% and 56%, respectively). A longitudinal mixed model of improvement (change from baseline in YMRS score) favored lithium (change in score, 3.90; 97.5% CI=1.71, 6.09). Nine-week response rates did not differ significantly between the lithium and divalproex groups (79% and 73%, respectively). The need for adjunctive risperidone was low and similar between groups (17% and 14%, respectively).nnnCONCLUSIONSnBoth lithium and divalproex were adequately tolerated and efficacious; lithium was associated with a greater reduction in mania scores over 9 weeks.

Incorporating Persistent Pain in Phenotypic Frailty Measurement and Prediction of Adverse Health Outcomes

Background: Frailty, a syndrome of physiological deficits, is prevalent among older adults and predicts elevated risk of adverse health outcomes. Although persistent pain predicts similar risk, it is seldom considered in frailty measurement. This article evaluated the construct and predictive validity of including persistent pain in phenotypic frailty measurement. Methods: Frailty and persistent pain were operationalized using data from the Health and Retirement Study (2006–2012 waves). Among a subset of adults aged 65 and older (n = 3,652), we used latent class analysis to categorize frailty status and to evaluate construct validity. Using Cox proportional hazards models, we compared time to incident adverse outcomes (death, fall, hospitalization, institutionalization, and functional disability) between frailty classes determined by either including or excluding persistent pain as a frailty component. Results: In latent class models, persistent pain occurred with other frailty components in patterns consistent with a medical syndrome. Frail and intermediately frail classes determined by including persistent pain were more strongly associated with all adverse outcomes compared with frail and intermediately frail classes determined excluding persistent pain. Frail respondents had significantly greater risk of death compared with nonfrail respondents when frailty models included rather than excluded persistent pain (respectively, hazard ratio [HR] = 3.87, 95% confidence interval [CI] = 2.99–5.00 (including pain); HR = 2.10, 95% CI = 1.71–2.59 (excluding pain). Conclusions: Findings support consideration of persistent pain as a component of the frailty phenotype. Persistent pain assessment may provide an expedient method to enhance frailty measurement and improve prediction of adverse outcomes.

Adherence to Depression Treatment in Primary Care: A Randomized Clinical Trial

Importance Nonadherence to antidepressant medication is common and leads to poor outcomes. Early nonadherence is especially problematic. Objective To test the effectiveness of a psychosocial intervention to improve early adherence among older patients whose primary care physician newly initiated an antidepressant for depression. Design, Setting, and Participants The Treatment Initiation and Participation Program (TIP) was offered in a 2-site randomized clinical effectiveness study between January 2011 and December 2014 at primary care practices in New York, New York, and Ann Arbor, Michigan. Analyses began in February 2016. All participants were middle-aged and older adults (aged ≥55 years) who received newly initiated depression treatment by their primary care physician and recruited within 10 days of their prescription. Analyses were intention-to-treat. Interventions Participants were randomly assigned to the intervention (TIP) or treatment as usual. Participants in the TIP group identified and addressed barriers to adherence, including stigma, misconceptions, and fears about treatment, before developing a personalized adherence strategy. The Treatment Initiation and Participation Program was delivered in three 30-minute contacts scheduled during a 6-week period just after the antidepressant was prescribed. Main Outcomes and Measures The primary outcome was self-reported adherence on the Brief Medication Questionnaire, with adequate early adherence defined as taking 80% or more of the prescribed doses at 6 and 12 weeks. The secondary outcome was depression severity. Results In total, 231 middle-aged and older adults (167 women [72.3%] and 64 men [27.7%]) without significant cognitive impairment were randomly assigned to the TIP intervention (nu2009=u2009115) or treatment as usual (nu2009=u2009116). Participants had a mean (SD) age of 67.3 (8.4) years. Participants in the TIP group were 5 times more likely to be adherent at 6 weeks (odds ratio,u20095.54; 95% CI, 2.57 to 11.96; &khgr;21u2009=u200919.05; Pu2009<u2009.001) and 3 times more likely to be adherent at both 6 and 12 weeks (odds ratio,u20093.27; 95% CI, 1.73 to 6.17; &khgr;21u2009=u200913.34; Pu2009<u2009.001). Participants in the TIP group showed a significant earlier reduction (24.9%) in depressive symptoms (95% CI, 13.9 to 35.9; t337u2009=u20094.46; adjusted Pu2009<u2009.001). In both groups, participants who were 80% adherent at weeks 6 and 12 had a 15% greater improvement in depressive symptoms from baseline over the course of treatment (95% CI, −0.2 to −30; t369u2009=u20091.93; Pu2009=u2009.051). Conclusions and Relevance The Treatment Initiation and Participation Program is an effective intervention to improve early adherence to pharmacotherapy. Improved adherence can promote improvement in depression. Trial Registration clinicaltrials.gov Identifier: NCT01301859

Feasibility, Acceptability, and Preliminary Effectiveness of a Peer-Delivered and Technology Supported Self-Management Intervention for Older Adults with Serious Mental Illness

To assess the feasibility, acceptability, and preliminary effectiveness of a peer-delivered and technology supported integrated medical and psychiatric self-management intervention for older adults with serious mental illness. Ten older adults with serious mental illness (i.e., schizophrenia, schizoaffective disorder, bipolar disorder, or major depressive disorder) and medical comorbidity (i.e., cardiovascular disease, obesity, diabetes, chronic obstructive pulmonary disease, hypertension, and/or high cholesterol) aged 60xa0years and older received the PeerTECH intervention in their homes. Three certified peer specialists were trained to deliver PeerTECH. Data were collected at baseline, one-month, and three-month. The pilot study demonstrated that a three-month, peer-delivered and technology-supported integrated medical and psychiatric self-management intervention (“PeerTECH”) was experienced by peer specialists and participants as feasible and acceptable. PeerTECH was associated with statistically significant improvements in psychiatric self-management. In addition, pre/post, non-statistically significant improvements were observed in self-efficacy for managing chronic health conditions, hope, quality of life, medical self-management skills, and empowerment. This pre/post pilot study demonstrated it is possible to train peers to use technology to deliver an integrated psychiatric and medical self-management intervention in a home-based setting to older adults with serious mental illness with fidelity. These findings provide preliminary evidence that a peer-delivered and technology-supported intervention designed to improve medical and psychiatric self-management is feasible, acceptable, and is potentially associated with improvements in psychiatric self-management, self-efficacy for managing chronic health conditions, hope, quality of life, medical self-management skills, and empowerment with older adults with serious mental illness and chronic health conditions.

Systematic Review of the Clinical Application of Exposure Techniques to Community-Dwelling Older Adults with Anxiety

ABSTRACT Objectives: Although exposure techniques are a first-line intervention for anxiety, clear evidence is lacking for their efficacy in treating the prevalent and debilitating condition of late life anxiety. This study sought to review the current literature on use of exposure with community-dwelling older patients. Methods: Searches of electronic databases were conducted to identify articles published through December 7, 2016. Inclusion criteria were: 1) sample age > 55, 2) therapy that included exposure, 3) anxiety as a target of the treatment. Exclusion criteria were: 1) not available in English, 2) no quantitative data, 3) inpatient setting. Methodological data and findings were extracted from the articles chosen for review. Results: The 54 eligible articles presented a total of 16 case studies, 9 uncontrolled trials, 24 controlled trials, and 6 secondary studies. A majority of the studies were conducted in the U.S.A with participants who received individual treatment. In vivo and imaginal exposure were the most frequently delivered techniques, and most treatments were multicomponent. Most studies found a reduction in anxiety symptoms. Conclusions: Important research gaps need to be addressed. Clinical Implications: The surveyed research provides a modest foundation of evidence for mental health practitioners who wish to incorporate exposure into treatment plans.

Factors Associated With Accelerated Hospitalization and Re-hospitalization Among Medicare Home Health Patients

BackgroundnPreventing hospitalizations and re-hospitalizations of older adults receiving Medicare home health (HH) services is a key goal for patients and care providers. This study aimed to identify factors related to greater risk of and earlier hospitalizations from HH, a key step in targeting preventive efforts.nnnMethodsnData come from Medicare mandated start-of-care assessments from 87,780 HH patients served by 132 agencies in 32 states, collected from January 2013 to March 2015. Using parametric accelerated failure time (AFT) survival models, we evaluated the association between key patient and environmental characteristics and the hazard of and time until hospitalization and re-hospitalization.nnnResultsnIn total, 15,030 hospitalizations, including 6,539 re-hospitalizations, occurred in the sample within 60 days of start of HH. Factors most strongly associated with substantially greater risk of and earlier hospitalization included male gender, history of hospitalization, polypharmacy, elevated depressive symptoms, greater functional disability, primary diagnoses of heart disease, chronic obstructive pulmonary disease, and urinary tract infection, and government-controlled agency care. In addition to these factors, black race and primary diagnosis of skin wounds were uniquely related to risk of earlier re-hospitalization.nnnConclusionsnResults suggest that factors collected during routine HH patient assessments can provide important information to predict risk of earlier hospitalization and re-hospitalization among Medicare HH patients. Identified factors can help identify patients at greatest risk of early hospitalization and may be important targets for agencies and care providers to prevent avoidable hospitalizations.

Mortality Risk Along the Frailty Spectrum: Data from the National Health and Nutrition Examination Survey 1999 to 2004

To determine the relationship between frailty and overall and cardiovascular mortality.

Hospitalization Risk and Potentially Inappropriate Medications among Medicare Home Health Nursing Patients

BackgroundHospitalizations and potentially inappropriate medication (PIM) use are significant and costly issues among older home health patients, yet little is known about the prevalence of PIM use in home health or the relationship between PIM use and hospitalization risk in this population.ObjectiveTo describe the prevalence of PIM use and association with hospitalization among Medicare home health patients.DesignCross-sectional analysis using data from 132 home health agencies in the US.SubjectsMedicare beneficiaries starting home health nursing services between 2013 and 2014 (nxa0=xa087,780).Main MeasuresPrevalence of individual and aggregate PIM use at start of care, measured using the 2012 Beers criteria. Relative risk (RR) of 30-day hospitalization or re-hospitalization associated with individual and aggregate PIM use, compared to no PIM use.Key ResultsIn total, 30,168 (34.4%) patients were using at least one PIM, with 5969 (6.8%) taking at least two PIMs according to the Beers list. The most common types of PIMs were those affecting the brain or spinal cord, analgesics, and medications with anticholinergic properties. With the exception of nonsteroidal anti-inflammatory drugs (NSAIDs), PIM use across all classes was associated with elevated risk (10–33%) of hospitalization compared to non-use. Adjusting for demographic and clinical characteristics, patients using at least one PIM (excluding NSAIDs) had a 13% greater risk (RRxa0=xa01.13, 95% CI: 1.09, 1.17) of being hospitalized than patients using no PIMs, while patients using at least two PIMs had 21% greater risk (RRxa0=xa01.21, 95% CI: 1.12, 1.30). Similar associations were found between PIMs and re-hospitalization risk among patients referred to home health from a hospital.ConclusionsGiven the high prevalence of PIM use and the association between PIMs and hospitalization risk, home health episodes represent opportunities to substantially reduce PIM use among older adults and prevent adverse outcomes. Efforts to address medication use during home health episodes, hospitalizations, and care transitions are justified.

Operationalisation and validation of the Stopping Elderly Accidents, Deaths, and Injuries (STEADI) fall risk algorithm in a nationally representative sample

Background Preventing falls and fall-related injuries among older adults is a public health priority. The Stopping Elderly Accidents, Deaths, and Injuries (STEADI) tool was developed to promote fall risk screening and encourage coordination between clinical and community-based fall prevention resources; however, little is known about the tool’s predictive validity or adaptability to survey data. Methods Data from five annual rounds (2011–2015) of the National Health and Aging Trends Study (NHATS), a representative cohort of adults age 65 years and older in the USA. Analytic sample respondents (n=7392) were categorised at baseline as having low, moderate or high fall risk according to the STEADI algorithm adapted for use with NHATS data. Logistic mixed-effects regression was used to estimate the association between baseline fall risk and subsequent falls and mortality. Analyses incorporated complex sampling and weighting elements to permit inferences at a national level. Results Participants classified as having moderate and high fall risk had 2.62 (95% CI 2.29 to 2.99) and 4.76 (95% CI 3.51 to 6.47) times greater odds of falling during follow-up compared with those with low risk, respectively, controlling for sociodemographic and health-related risk factors for falls. High fall risk was also associated with greater likelihood of falling multiple times annually but not with greater risk of mortality. Conclusion The adapted STEADI clinical fall risk screening tool is a valid measure for predicting future fall risk using survey cohort data. Further efforts to standardise screening for fall risk and to coordinate between clinical and community-based fall prevention initiatives are warranted.