Valory N. Pavlik

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.

Management of type 2 diabetes in the primary care setting: A practice-based research network study

PURPOSE We wanted to describe how primary care clinicians care for patients with type 2 diabetes. METHODS We undertook a cross-sectional study of 95 primary care clinicians and 822 of their established patients with type 2 diabetes from 4 practice-based, primary care research networks in the United States. Clinicians were surveyed about their training and practice. Patients completed a self-administered questionnaire about their care, and medical records were reviewed for complications, treatment, and diabetes-control indicators. RESULTS Participating clinicians (average age, 45.7 years) saw an average of 32.6 adult patients with diabetes per month. Patients (average age, 59.7 years) reported a mean duration of diabetes of 9.1 years, with 34.3% having had the disease more than 10 years. Nearly one half (47.5%) of the patients had at least 1 diabetes-related complication, and 60.8% reported a body mass index greater than 30. Mean glycosylated hemoglobin (HbA1c) level was 7.6% (SD 1.73), and 40.5% of patients had values <7%. Only 35.3% of patients had adequate blood pressure control (<130/85 mm Hg), and only 43.7% had low-density lipoprotein cholesterol (LDL-C) levels <100 mg/dL. Only 7.0% of patients met all 3 control targets. Multilevel models showed that patient ethnicity, practice type, involvement of midlevel clinicians, and treatment were associated with HbA1c level; patient age, education level, and practice type were associated with blood pressure control; and patient ethnicity was associated with LDL-C control. CONCLUSIONS Only modest numbers of patients achieve established targets of diabetes control. Reengineering primary care practice may be necessary to substantially improve care.

Persistent treatment with cholinesterase inhibitors and/or memantine slows clinical progression of Alzheimer disease

IntroductionThere are no empiric data to support guidelines for duration of therapy with antidementia drugs. This study examined whether persistent use of antidementia drugs slows clinical progression of Alzheimer disease (AD) assessed by repeated measures on serial tests of cognition and function.MethodsSix hundred forty-one probable AD patients were followed prospectively at an academic center over 20 years. Cumulative drug exposure was expressed as a persistency index (PI) reflecting total years of drug use divided by total years of disease symptoms. Baseline and annual testing consisted of Mini-Mental State Examination (MMSE), Alzheimers Disease Assessment Scale-Cognitive Subscale (ADAS-Cog), Baylor Profound Mental Status Examination (BPMSE), Clinical Dementia Rating-Sum of Boxes (CDR-SB), Physical Self-Maintenance Scale (PSMS), and Instrumental Activities of Daily Living (IADL). Annual change in slope of neuropsychological and functional tests as predicted by follow-up time, PI, and the interaction of these two variables was evaluated.ResultsPI was associated with significantly slower rates of decline (with, without adjustment for covariates) on MMSE (P < 0.0001), PSMS (P < 0.05), IADL (P < 0.0001), and CDR-SB (P < 0.001). There was an insignificant trend (P = 0.053) for the PI to be associated with slower rate of decline on BPMSE. The association of PI with ADAS-Cog followed a quadratic trend (P < 0.01). Analysis including both linear and quadratic terms suggests that PI slowed ADAS-Cog decline temporarily. The magnitude of the favorable effect of a rate change in PI was: MMSE 1 point per year, PSMS 0.4 points per year, IADL 1.4 points per year, and CDR-SB 0.6 points per year. The change in mean test scores is additive over the follow-up period (3 ± 1.94 years).ConclusionsPersistent drug treatment had a positive impact on AD progression assessed by multiple cognitive, functional, and global outcome measures. The magnitude of the treatment effect was clinically significant. Positive treatment effects were even found in those with advanced disease.

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.

Weight loss maintenance in African-American women: focus group results and questionnaire development.

BACKGROUNDAfrican-American women are disproportionately affected by obesity. Weight loss can occur, but maintenance is rare. Little is known about weight loss maintenance in African-American women.OBJECTIVES(1) To increase understanding of weight loss maintenance in African-American women; (2) to use the elicitation procedure from the theory of planned behavior (TPB) to define the constructs of attitude, subjective norms, and perceived behavioral control regarding weight loss and maintenance; and (3) to help develop a relevant questionnaire that can be used to explore weight loss and maintenance in a large sample of African Americans.DESIGNSeven focus groups were conducted with African-American women: four with women successful at weight loss maintenance, three with women who lost weight but regained it. Discussions centered on weight loss and maintenance experiences.PARTICIPANTSThirty-seven African-American women.APPROACHContent analysis of focus group transcripts.RESULTSWeight loss maintainers lost 22% of body weight. They view positive support from others and active opposition to cultural norms as critical for maintenance. They struggle with weight regain, but have strategies in place to lose weight again. Some maintainers struggle with being perceived as sick or too thin at their new weight. Regainers and maintainers struggle with hairstyle management during exercise. The theoretical constructs from TPB were defined and supported by focus group content.CONCLUSIONSA weight loss questionnaire for African Americans should include questions regarding social support in weight maintenance, the importance of hair management during exercise, the influence of cultural norms on weight and food consumption, and concerns about being perceived as too thin or sick when weight is lost.

Plasma sphingomyelins are associated with cognitive progression in Alzheimer's disease.

Plasma sphingolipids have been shown to predict cognitive impairment and hippocampal volume loss, but there is little research in patients with Alzheimers disease (AD). In this study we sought to determine whether plasma ceramides, dihydroceramides (DHCer), sphingomyelins (SM), or dihydrosphingomyelin (DHSM) levels and ratios of SM/ceramide or DHSM/DHCer were predictive of progression in AD. Probable AD patients (n = 120) were enrolled in the Alzheimers Disease and Memory Disorders Center at Baylor College of Medicine. Plasma sphingolipids were assessed using ESI/MS/MS. Linear mixed effects models were used to examine the relation between baseline plasma sphingolipid levels and cross-sectional and longitudinal performance on the Mini-Mental State Exam (MMSE), Alzheimers Disease Assessment Scale-Cognitive Subscale (ADAS-Cog), and Clinical Dementia Rating-Sum of Boxes (CDR-Sum). Participants were followed a mean of 4.2 visits and 2.3 years. There were no cross-sectional associations. In longitudinal analyses, high levels of DHCer and ceramide were associated with greater progression, but findings did not reach significance (p > 0.05). In contrast, higher plasma levels of SM, DHSM, SM/ceramide, and DHSM/DHCer ratios were associated with less progression on the MMSE and ADAS-Cog; the ratios were the strongest predictors of clinical progression. Compared to the lowest tertiles, the highest tertiles of DHSM/DHCer and SM/ceramide ratios declined 1.35 points (p = 0.001) and 1.19 (p = 0.004) points less per year on the MMSE and increased 3.18 (p = 0.001) and 2.42 (p = 0.016) points less per year on the ADAS-Cog. These results suggest that increased SM/ceramide and DHSM/DHCer ratios dose-dependently predict slower progression among AD patients and may be sensitive blood-based biomarkers for clinical progression.

Predicting progression of Alzheimer's disease

IntroductionClinicians need to predict prognosis of Alzheimers disease (AD), and researchers need models of progression to develop biomarkers and clinical trials designs. We tested a calculated initial progression rate to see whether it predicted performance on cognition, function and behavior over time, and to see whether it predicted survival.MethodsWe used standardized approaches to assess baseline characteristics and to estimate disease duration, and calculated the initial (pre-progression) rate in 597 AD patients followed for up to 15 years. We designated slow, intermediate and rapidly progressing groups. Using mixed effects regression analysis, we examined the predictive value of a pre-progression group for longitudinal performance on standardized measures. We used Cox survival analysis to compare survival time by progression group.ResultsPatients in the slow and intermediate groups maintained better performance on the cognitive (ADAScog and VSAT), global (CDR-SB) and complex activities of daily living measures (IADL) (P values < 0.001 slow versus fast; P values < 0.003 to 0.03 intermediate versus fast). Interaction terms indicated that slopes of ADAScog and PSMS change for the slow group were smaller than for the fast group, and that rates of change on the ADAScog were also slower for the intermediate group, but that CDR-SB rates increased in this group relative to the fast group. Slow progressors survived longer than fast progressors (P = 0.024).ConclusionsA simple, calculated progression rate at the initial visit gives reliable information regarding performance over time on cognition, global performance and activities of daily living. The slowest progression group also survives longer. This baseline measure should be considered in the design of long duration Alzheimers disease clinical trials.

Survival among patients with dementia from a large multi-ethnic population.

Survival among patients with dementia is critical information needed for planning and assessing the overall impact of dementia. Attrition from longitudinal cohorts often limits the confidence in survival estimates. For this study, we examined survival among dementia patients from a large multi-ethnic population with excellent longitudinal follow-up. Subjects were all Baylor Alzheimers Disease Center patients residing in the greater Houston area at the time of initial diagnosis. Vital status was available for all subjects. We estimated median survival time (Kaplan-Meier) from first symptom onset and from diagnosis, and examined the effects of baseline patient characteristics on survival. Median survival time for patients with any form of dementia was 10.5 years from onset and 5.7 years from diagnosis. Similarly, median survival time for probable Alzheimer disease patients was 11.3 years from onset and 5.7 years from diagnosis. Significant trends of decreasing survival with increasing age group (<70; 70-79, ≥80) were evident for all dementia patients and for patients with Alzheimer disease. Our findings are consistent with previous studies and provide compelling evidence that survival from onset or diagnosis of dementia depends more on age than any other factor.

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.

Changing Patient Characteristics and Survival Experience in an Alzheimer’s Center Patient Cohort

Background:Large and diverse dementia patient cohorts can further a variety of research programs aimed at improving diagnosis, treatment, and meaningful survival in AD. Method: We recruited 1,502 dementia patients between 1989 and 2002, subclassified using standardized criteria and laboratory procedures, and treated according to established guidelines. Baseline clinical and psychometric measures were repeated annually, in person or by use of a multi-modal telephone follow-up program that included many of the measures obtained at in-person visits. We tracked vital status of all subjects at 6-month intervals and offered autopsies to all participants. We assessed for cohort effects in baseline characteristics by 2-year intervals, examined the characteristics and outcomes for those who remained active compared to those who were eventually lost to follow-up, examined survival times for demographic or diagnostic subgroups, and assessed the accuracy of clinical diagnoses versus neuropathology. Results: The average age at entry, average educational level, and baseline MMSE scores for subjects are increasing over time, and probable AD diagnoses are also increasing. Most (80.6%) subjects have remained active in our Center; those who did not were more likely to have a non-AD diagnosis. Survival averages 5.2 years (CI 4.98–5.37) and is influenced by age and gender, but not by diagnosis of probable versus possible AD. Our diagnostic accuracy is 89.6%, with high sensitivity to the presence of AD (96%). Conclusions: In a large and representative clinical cohort, the demographics of AD are changing over time. Careful analyses of those who continue and those who drop out from follow-up suggest that atypical diagnosis, rather than severity or demographic issues accounts for most of the attrition. Clinicians are likely to encounter increasingly older patients with milder disease, and these trends have implications for the design of clinical trials. Survival from the onset of first symptoms, similar for probable and possible AD cases, may be increasing over time.