Stella Jouldjian

Sleep Quality in Residents of Assisted Living Facilities: Effect on Quality of Life, Functional Status, and Depression

OBJECTIVES: To describe sleep patterns in older adults living in assisted living facilities (ALFs) and to explore the relationship between sleep disturbance and quality of life, functional status, and depression over 6 months of follow‐up.

Poor Self-Reported Sleep Quality Predicts Mortality within One Year of Inpatient Post-Acute Rehabilitation among Older Adults

STUDY OBJECTIVE To evaluate the association between self-reported sleep quality among older adults during inpatient post-acute rehabilitation and one-year survival. DESIGN Prospective, observational cohort study. SETTING Two inpatient post-acute rehabilitation sites (one community and one Veterans Administration). PARTICIPANTS Older patients (aged ≥ 65 years, n = 245) admitted for inpatient post-acute rehabilitation. INTERVENTIONS None. MEASUREMENTS AND RESULTS Within one year of post-acute rehabilitation, 57 participants (23%) were deceased. Cox proportional hazards models showed that worse Pittsburgh Sleep Quality Index (PSQI) total scores during the post-acute care stay were associated with increased mortality risk when controlling for amount of rehabilitation therapy received, comorbidities, and cognitive functioning (Hazard ratio [95% CI] = 1.11 [1.02-1.20]). Actigraphically estimated sleep was unrelated to mortality risk. CONCLUSIONS Poorer self-reported sleep quality, but not objectively estimated sleep parameters, during post-acute rehabilitation was associated with shorter survival among older adults. This suggests self-reported poor sleep may be an important and potentially modifiable risk factor for negative outcomes in these vulnerable older adults. Studies of interventions to improve sleep quality during inpatient rehabilitation should therefore be undertaken, and the long-term health benefits of improved sleep should be explored.

Veterans Health Administration and Indian Health Service: Healthcare Utilization by Indian Health Service Enrollees

Background:The Veterans Health Administration (VHA) and Indian Health Service (IHS) have executed an agreement to share resources to improve access and health outcomes for American Indian and Alaska Native (AIAN) veterans. Objectives:To describe the extent of dual use, health needs, and utilization patterns for IHS-enrollees served by VHA and IHS. Our objective is to fill those gaps in knowledge to inform strategic planning between these federal agencies. Methods:Secondary data analysis of linked and merged VHA and IHS centralized administrative data from FY02 and FY03. Results:Of 64,746 IHS enrollees who used VHA and/or IHS, 25% accessed care at both healthcare organizations, whereas most used either the VHA (28%) or the IHS (46%). The proportion of dual users varied markedly by state. Like all other VHA users, these AIAN veterans have the same 3 most frequent diagnoses associated with healthcare encounters: posttraumatic stress disorder, hypertension, and diabetes. VHA-IHS dual users were more likely to receive primary care from IHS and to receive diagnostic and behavioral healthcare from VHA. Many dual users who had been diagnosed with diabetes, hypertension, and/or cardiovascular disease received overlapping attention in VHA and IHS. Conclusions:Strategies to improve outcomes for AIAN veterans should target those receiving care in both systems and include information sharing or coordination of clinical care to reduce the potential for duplication and for treatment conflicts. Strategies to improve access may differ regionally.

Insomnia and Symptoms of Post-traumatic Stress Disorder Among Women Veterans

Women will account for 10% of the Veteran population by 2020, yet there has been little focus on sleep issues among women Veterans. In a descriptive study of 107 women Veterans with insomnia (mean age = 49 years, 44% non-Hispanic white), 55% had probable post traumatic stress disorder (PTSD) (total score ≥33). Probable PTSD was related to more severe self-reported sleep disruption and greater psychological distress. In a regression model, higher PTSD Checklist-Civilian (PCL-C) total score was a significant independent predictor of worse insomnia severity index score while other factors were not. Women Veterans preferred behavioral treatments over pharmacotherapy in general, and efforts to increase the availability of such treatments should be undertaken. Further research is needed to better understand the complex relationship between insomnia and PTSD among women Veterans.

Dual Use of Veterans Health Administration and Indian Health Service: Healthcare Provider and Patient Perspectives

ABSTRACTBACKGROUNDMany American Indian and Alaska Native veterans are eligible for healthcare from Veterans Health Administration (VHA) and from Indian Health Service (IHS). These organizations executed a Memorandum of Understanding in 2003 to share resources, but little was known about how they collaborated to deliver healthcare.OBJECTIVETo describe dual use from the stakeholders’ perspectives, including incentives that encourage cross-use, which organization’s primary care is “primary,” and the potential problems and opportunities for care coordination across VHA and IHS.PARTICIPANTSVHA healthcare staff, IHS healthcare staff and American Indian and Alaska Native veterans.APPROACHFocus groups were conducted using a semi-structured guide. A software-assisted text analysis was performed using grounded theory to develop analytic categories.MAIN RESULTSDual use was driven by variation in institutional resources, leading patients to actively manage health-seeking behaviors and IHS providers to make ad hoc recommendations for veterans to seek care at VHA. IHS was the “primary” primary care for dual users. There was little coordination between VHA and IHS resulting in delays and treatment conflicts, but all stakeholder groups welcomed future collaboration.CONCLUSIONSFostering closer alignment between VHA and IHS would reduce care fragmentation and improve accountability for patient care.

Cognitive Behavioral Therapy for Insomnia in Older Veterans Using Nonclinician Sleep Coaches: Randomized Controlled Trial

To test a new cognitive behavioral therapy for insomnia (CBT‐I) program designed for use by nonclinicians.

Prevalence and symptoms of occult sleep disordered breathing among older veterans with insomnia.

STUDY OBJECTIVES To determine the prevalence of occult sleep disordered breathing (SDB) and describe the relationship between classic SDB symptoms (e.g., loud snoring) and occult SDB in older veterans with insomnia. METHODS We analyzed baseline survey and in-home sleep study data for 435 veterans (mean age = 72.0 years [SD 8.0]) who had no known history of SDB, met International Classification of Sleep Disorders 2(nd) Edition criteria for insomnia, and were enrolled in a behavioral intervention trial for insomnia. Variables of interest included apnea-hypopnea index (AHI) ≥ 15, age, race/ethnicity, marital status, body mass index (BMI), insomnia subtype (i.e., onset, maintenance, or terminal), self-reported excessive daytime sleepiness, snoring, and witnessed breathing pause items from the Berlin Questionnaire. We computed the frequency of AHI ≥ 15 and assessed whether each classic SDB symptom was associated with an AHI ≥ 15 in 4 separate multivariate logistic regression models. RESULTS Prevalence of AHI ≥ 15 was 46.7%. Excessive daytime sleepiness (adjusted odds ratio 1.63, 95% CI 1.02, 2.60, p = 0.04), but not snoring loudness, snoring frequency, or witnessed breathing pauses was associated with occult SDB (AHI ≥ 15). Insomnia subtypes were not significantly associated with occult SDB (p > 0.38). CONCLUSIONS In our sample of older veterans with insomnia, nearly half had occult SDB, which was characterized by reported excessive daytime sleepiness, but not loud or frequent snoring or witnessed breathing pauses. Insomnia subtype was unrelated to the presence of occult SDB.

Sleep Disturbance Among Older Adults in Assisted Living Facilities

OBJECTIVES To evaluate whether objectively and subjectively measured sleep disturbances persist among older adults in assisted living facilities (ALFs) and to identify predictors of sleep disturbance in this setting. DESIGN Prospective, observational cohort study. SETTING AND PARTICIPANTS A total of 121 residents, age ≥ 65 years, in 18 ALFs in the Los Angeles area. MEASUREMENTS Objective (actigraphy) and subjective (Pittsburgh Sleep Quality Index) sleep measures were collected at baseline and 3- and 6-month follow-up. Predictors of baseline sleep disturbance tested in bivariate analyses and multiple regression models included demographics, Mini-Mental State Examination score, number of comorbidities, nighttime sedating medication use, functional status (activities of daily living; instrumental activities of daily living), restless legs syndrome, and sleep apnea risk. RESULTS Objective and subjective sleep measures were similar at baseline and 3- and 6-month follow-up (objective nighttime total sleep [hours] 6.3, 6.5, and 6.4; objective nighttime percent sleep 77.2, 77.7, and 78.3; and Pittsburgh Sleep Quality Index total score 8.0, 7.8, and 7.7, respectively). The mean baseline nighttime percent sleep decreased by 2% for each additional unit increase in baseline comorbid conditions (measured as the number of conditions), and increased by 4.5% for each additional unit increase in baseline activities of daily living (measured as the number of activities of daily living), in a multiple regression model. CONCLUSIONS In this study, we found that objectively and subjectively measured sleep disturbances are persistent among ALF residents and are related to a greater number of comorbidities and poorer functional status at baseline. Interventions are needed to improve sleep in this setting.

Association Between Sleep and Physical Function in Older Veterans in an Adult Day Healthcare Program

To examine whether sleep disturbance is associated with poor physical function in older veterans in an adult day healthcare (ADHC) program.

Health care for American Indian and Alaska native women.

BACKGROUND Many American Indian and Alaska Native (AIAN) women serve in the military and are eligible for healthcare from both the Veterans Health Administration (VHA) and the Indian Health Service (IHS). Little was known about these womens patterns of health care utilization when VHA and IHS executed a resource-sharing agreement in 2003 to improve access and health outcomes. OBJECTIVE We sought to describe womens healthcare utilization in VHA and IHS. METHODS We conducted a descriptive secondary data analysis of linked IHS and VHA administrative records from fiscal years 2002 and 2003 for women among all IHS beneficiaries who were veterans or used VHA for health care (n = 64,746). RESULTS Among these IHS beneficiaries, 4,338 (6.7%) were female veterans and 1,518 (2.8%) were female nonveterans. Comparing IHS services to VHA, the VHA provided the majority of outpatient specialty care to veterans, providing 89.9% of diagnostic and imaging services, 84.4% of mental health care, and 78.1% of physical medicine and rehabilitation. Conversely, the IHS provided the majority of ambulatory and inpatient care for obstetrics and gynecology to these veterans. Dual users received primary care from both organizations. Nonveterans generally accessed VHA under sharing agreements and their use of health care was generally limited to outpatient diagnostic and imaging. CONCLUSIONS The VHA seems to supplement healthcare provided by the IHS for female AIAN veterans, as well as for a small proportion of nonveterans. The VHA and the IHS have developed specialized and complementary expertise, which might be aligned to serve the needs of female AIAN veterans.