Characteristics and Service Use of Older Adults with Schizoaffective Disorder Versus Older Adults with Schizophrenia and Bipolar Disorder.

OBJECTIVE: The purpose of this study was to determine if schizoaffective disorder in older adults is differentiated from schizophrenia and bipolar disorder with respect to community functioning, cognitive functioning, psychiatric symptoms, and service use. DESIGN: Secondary analysis of baseline data collected from the Helping Older People Experience Success psychosocial skills training and health management study. SETTING: Three community mental health centers in New Hampshire and Massachusetts. PARTICIPANTS: Adults over the age of 50 (N = 139, mean age: 59.7 years, SD: 7.4 years) with persistent functional impairment and a diagnosis of schizoaffective disorder (N = 52), schizophrenia (N = 51), or bipolar disorder (N = 36). MEASUREMENTS: Health status (36-Item Short Form Health Survey [SF-36]), performance-based community living skills (UCSD Performance-Based Skills Assessment), neuropsychological functioning (Delis-Kaplan Executive Functioning subtests), psychiatric symptoms (Brief Psychiatric Rating Scale, Center for Epidemiologic Studies Depression Scale, Scale for the Assessment of Negative Symptoms), medical severity (Charlson comorbidity index), and acute service use. RESULTS: Older adults with schizoaffective disorder had depressive symptoms of similar severity to bipolar disorder, and thought disorder symptoms of similar severity to schizophrenia. Schizoaffective disorder compared with schizophrenia was associated with better community functioning, but poorer subjective physical and mental health functioning as measured by the SF-36. Older adults with schizoaffective disorder had greater acute hospitalization compared with adults with schizophrenia, though their use of acute care services was comparable to individuals with bipolar disorder. CONCLUSIONS: Findings from this study suggest that schizoaffective disorder in older adults occupies a distinct profile from either schizophrenia or bipolar disorder with respect to community functional status, symptom profile, and acute services utilization.

Mental health treatment preferences and challenges of living with multimorbidity from the veteran perspective.

OBJECTIVE: To explore middle-aged and older veterans' current disease-management practices, mental health treatment preferences, and challenges of living with multiple chronic health conditions (i.e., multimorbidity). METHODS: Semi-structured qualitative interviews and self-report measures were collected from 28 middle-aged and older (50 years of age or older) veterans with multimorbidity. RESULTS: Our sample of veterans with multimorbidity was, on average, mildly depressed and anxious with elevated stress and disability. Veterans acknowledged the interaction of physical and emotional symptoms, which caused greater difficulty with health care management and daily functioning. Veterans had many concerns regarding their physical and emotional health conditions, such as continued disease progression and the addition of other emotional and physical health complications. Veterans also identified specific self-care approaches for disease management (e.g., medication, healthy lifestyle practices, and psychological stress management techniques), as well as barriers to engaging in care (e.g., money, transportation, and stigma). Participants preferred a combination of medication, psychotherapy, and healthy lifestyle practices for mental health treatment. The majority of participants (88.5%) agreed that these mental health treatments would be beneficial to integrate into disease management for older veterans with multimorbidity. Lastly, veterans provided an array of recommendations for improving Veteran's Administration services and reducing mental health stigma. CONCLUSIONS: These findings provide support for patient-centered approaches and integrated mental and physical health self-management in the Veteran's Administration for middle-aged and older veterans with multiple chronic conditions. Copyright © 2016 John Wiley & Sons, Ltd.

Body Mass Index and Rural Status on Self-Reported Health in Older Adults: 2004-2013 Medicare Expenditure Panel Survey.

PURPOSE: To ascertain whether rural status impacts self-reported health and whether the effect of rural status on self-reported health differs by obesity status. METHODS: We identified 22,307 subjects aged ≥60 from the Medical Expenditure Panel Survey 2004-2013. Body mass index (BMI) was categorized as underweight, normal, overweight, or obese. Physical and mental component scores of the Short Form-12 assessed self-reported health status. Rural/urban status was defined using metropolitan statistical area. Weighted regression models ascertained the relative contribution of predictors (including rural and BMI) on each subscale. FINDINGS: Mean age was 70.7 years. Rural settings had higher proportions classified as obese (30.7 vs 27.6%; P < .001), and rural residents had lower physical health status (41.7 ± 0.3) than urban (43.4 ± 0.1; P < .001). Obese or underweight persons had lower physical health status (39.5 ± 0.20 and 37.0 ± 0.82, respectively) than normal (44.7 ± 0.18) or overweight (44.6 ± 0.16) persons (P < .001). BMI category stratification was associated with differences in physical health between rural/urban by BMI. Individuals classified as underweight or obese had lower physical health compared to normal, while the differences were less pronounced for mental health. No differences in mental health existed between rural/urban status. A BMI * rural interaction was significant for physical but not mental health. CONCLUSIONS: Rural residents report lower self-reported physical health status compared to urban residents, particularly older adults who are obese or underweight. No interaction was observed between BMI and rural status.

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

Background: Preventing 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. Methods: Data 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. Results: In 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. Conclusions: Results 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.

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.

Lifestyle interventions for weight loss among overweight and obese adults with serious mental illness: A systematic review and meta-analysis.

OBJECTIVE: To conduct a systematic review and meta-analysis to estimate effects of lifestyle intervention participation on weight reduction among overweight and obese adults with serious mental illness. METHOD: We systematically searched electronic databases for randomized controlled trials comparing lifestyle interventions with other interventions or usual care controls in overweight and obese adults with serious mental illness, including schizophrenia spectrum or mood disorders. Included studies reported change in weight [kg] or body mass index (BMI) [kg/m2] from baseline to follow-up. Standardized mean differences (SMD) were calculated for change in weight from baseline between intervention and control groups. RESULTS: Seventeen studies met inclusion criteria (1968 participants; 50% male; 66% schizophrenia spectrum disorders). Studies were grouped by intervention duration (≤6-months or ≥12-months). Lifestyle interventions of ≤6-months duration showed greater weight reduction compared with controls as indicated by effect size for weight change from baseline (SMD=-0.20; 95% CI=-0.34, -0.05; 10 studies), but high statistical heterogeneity (I2=90%). Lifestyle interventions of ≥12-months duration also showed greater weight reduction compared with controls (SMD=-0.24; 95% CI=-0.36, -0.12; 6 studies) with low statistical heterogeneity (I2=0%). CONCLUSION: Lifestyle interventions appear effective for treating overweight and obesity among people with serious mental illness. Interventions of ≥12-months duration compared to ≤6-months duration appear to achieve more consistent outcomes, though effect sizes are similar for both shorter and longer duration interventions.

Qualitative Analysis of Resources and Barriers Related to Treatment of Borderline Personality Disorder in the United States.

OBJECTIVE: Resources and treatment for individuals with borderline personality disorder (BPD) are limited and often difficult to obtain. This article aimed to identify key resources for and barriers to obtaining supportive and treatment services for BPD from the perspective of individuals seeking information or services related to BPD ("BPD care seekers"). METHODS: Data came from transcripts of resource requests to the Borderline Personality Disorder Resource Center from January 2008 to December 2015 (N=6,253). Basic statistics, including the type of service requested, demographic information for the BPD care seeker, and national distribution of requests, were generated for all eligible transcripts. Qualitative analysis of a random subset of 500 transcripts was used to identify themes, challenges, and common experiences reported by BPD care seekers. RESULTS: The greatest number of requests for primary services or resources among the random subset of transcripts was for outpatient services (51%), informational materials (13%), and day programs (9%). Family services, crisis intervention, and mental health literacy were identified as areas where available resources did not meet current demand and that could be improved or expanded. Factors identified as potential barriers to finding and obtaining appropriate treatment for BPD included stigmatization and marginalization within mental health care systems, financial concerns, and comorbidity with psychiatric or medical disorders. CONCLUSIONS: BPD care seekers face numerous barriers to obtaining appropriate care. Expanded services and resources to connect individuals with treatment are needed to meet the current demands and preferences of those seeking care.

Mood Disorders in Middle-Aged and Older Veterans With Multimorbidity.

OBJECTIVE: This study identified the prevalence of and relationship between mood disorders and multimorbidity in middle-aged and older veterans. METHOD: Cross-sectional data were obtained from veterans who received primary care services at VA Pittsburgh Healthcare System from January 2007 to December 2011 ( n = 34,786). RESULTS: Most veterans had three or more organ systems with chronic disease (95.3%), of which 4.1% had a depressive disorder, 2.5% had an anxiety disorder, and 0.7% had co-occurring depression and anxiety. The odds of having a mood disorder increased with each additional organ system with chronic disease, with odds being the greatest in those with 10 to 13 organ systems with chronic disease. Younger age, female gender, non-married marital status, and having a service connected disability were also significant predictors of having a mood disorder. DISCUSSION: These findings suggest a need to integrate mental health assessment and treatment in chronic health care management for veterans.

Prevalence of and Factors Related to Prescription Opioids, Benzodiazepines, and Hypnotics Among Medicare Home Health Recipients.

High rates of controlled prescription drugs are associated with cognitive impairment, falls, and misuse and dependence. Little is known about the prevalence of these medications among older adults receiving home healthcare. The purpose of this study was to determine the frequency of, and the factors related to, opioid analgesics, benzodiazepines (BNZ), and nonbenzodiazepine (NBNZH) hypnotics among a large sample of older adults entering home healthcare services. The data came from administrative records of 133 Certified Home healthcare Agencies located across 32 states. Patients (age ≥ 65) receiving Medicare home healthcare services and who received a start-of-care Medicare OASIS assessment between January 1, 2013, and December 31, 2014, were included in the study (n = 87,780). Rates of controlled medication use were compared across patient-level sociodemographic, clinical, functional, and environmental variables. The prevalence of controlled medication was high, with 58% prescribed at least one class of controlled drug, 44% were prescribed an opioid, 19% were prescribed a BNZ, and almost 7% were prescribed a NBZDH. Factors independently associated with higher levels of controlled medication usage include younger-old age, white race, postsurgical status, injuries, referral from inpatient settings, and rural location. Home healthcare clinicians are well positioned to review and reconcile medication, oversee referrals and follow-up care, and provide ongoing assessment of risk regarding the use of opioids, BNZ, and hypnotics among home healthcare patients.

CareHeroes Web and Android™ Apps for Dementia Caregivers: A Feasibility Study.

The purpose of the current feasibility study was to examine the use, utility, and areas for refinement of a newly developed web-based and Android™ application (app) (i.e., CareHeroes) with multiple features to support individuals caring for loved ones with Alzheimer's disease or other forms of dementia (AD). The study was performed over an 11-week period with triads of AD caregivers, assigned home care case managers, and primary care providers (PCP). The study involved quantitative and qualitative methodologies. Eleven AD caregivers (seven daughters, two sons, and two spouses), six case managers, and five PCPs participated. Data demonstrate participants were mostly satisfied with the multiple features and ability to access and use CareHeroes. Barriers for use include concerns about time constraints and not being familiar with technology. Although the study findings are promising, a longer term study to evaluate the impact of the CareHeroes app is indicated.

Systematic Review of Integrated General Medical and Psychiatric Self-Management Interventions for Adults With Serious Mental Illness.

OBJECTIVE: Adults with serious mental illness are disproportionately affected by general medical comorbidity, earlier onset of disease, and premature mortality. Integrated self-management interventions have been developed to address both general medical and psychiatric illnesses. This systematic review examined evidence about the effect of self-management interventions that target both general medical and psychiatric illnesses and evaluated the potential for implementation. METHODS: Databases, including CINAHL, Cochrane Central, Ovid MEDLINE, PsycINFO, and Web of Science, were searched for articles published between 1946 and July 2015. Studies evaluating integrated general medical and psychiatric self-management interventions for adults with schizophrenia spectrum or mood disorders and general medical comorbidity were included. RESULTS: Fifteen studies (nine randomized controlled trials and six pre-post designs) reported on nine interventions: automated telehealth, Health and Recovery Peer program, Helping Older People Experience Success, Integrated Illness Management and Recovery, Life Goals Collaborative Care, Living Well, Norlunga Chronic Disease Self-Management program, Paxton House, and Targeted Training in Illness Management. Most studies demonstrated feasibility, acceptability, and preliminary effectiveness; however, clinical effectiveness could not be established in most studies because of methodological limitations. Factors identified that may deter implementation included operating costs, impractical length, and workforce requirements. CONCLUSIONS: Integrated general medical and psychiatric illness self-management interventions appear feasible and acceptable, with high potential for clinical effectiveness. However, implementation factors were rarely considered in intervention development, which may contribute to limited uptake and reach in real-world settings.