Depressive, functional status, and neuropsychiatric symptom trajectories before an Alzheimer's disease diagnosis.

OBJECTIVES: This short report relied on multiyear data from the National Alzheimer's Coordinating Center - Uniform Data Set (NACC-UDS) to examine whether significant changes occurred in functional status, neuropsychiatric symptoms, and depressive symptoms in the years before receiving an Alzheimer's disease (AD) diagnosis. METHOD: The secondary analysis used a retrospective cohort design. The NACC-UDS is a publicly accessible, longitudinal database that includes standardized data on neuropsychiatric symptoms, functional status, and depressive symptoms for Alzheimer's Disease Center (ADC) participants in the USA based on their annual visits from 2005 to 2011. ADC participants were considered diagnosed with AD if a follow-up data form indicated an affirmative response to whether the ADC participant had 'probable AD (National Institute of Neurological and Communicative Disorders and Stroke (NINCDS)/Alzheimer's Disease and Related Disorders Association (ADRDA))' or 'possible AD (NINCDS/ADRDA).' This yielded an analytic sample of 2478 individuals (139 with an eventual probable AD diagnosis, 109 individuals with an eventual possible AD diagnosis, and 2230 without any AD diagnosis) representing a total of 11,358 visits/points of data. RESULTS: Multilevel linear models revealed significant decreases (p < 0.05) in functional status prior to a probable or possible AD diagnosis and significant increases in depressive symptoms prior to a probable AD diagnosis. DISCUSSION: Changes in functional and depressive symptoms were partly independent of cognitive decline. The longitudinal results lend additional support to conceptual and empirical models of pre-diagnosis declines in AD.

Family caregiving and all-cause mortality: findings from a population-based propensity-matched analysis.

Previous studies have provided conflicting evidence on whether being a family caregiver is associated with increased or decreased risk for all-cause mortality. This study examined whether 3,503 family caregivers enrolled in the national Reasons for Geographic and Racial Differences in Stroke (REGARDS) Study showed differences in all-cause mortality from 2003 to 2012 compared with a propensity-matched sample of noncaregivers. Caregivers were individually matched with 3,503 noncaregivers by using a propensity score matching procedure based on 15 demographic, health history, and health behavior covariates. During an average 6-year follow-up period, 264 (7.5%) of the caregivers died, which was significantly fewer than the 315 (9.0%) matched noncaregivers who died during the same period. A proportional hazards model indicated that caregivers had an 18% reduced rate of death compared with noncaregivers (hazard ratio = 0.823, 95% confidence interval: 0.699, 0.969). Subgroup analyses by race, sex, caregiving relationship, and caregiving strain failed to identify any subgroups with increased rates of death compared with matched noncaregivers. Public policy and discourse should recognize that providing care to a family member with a chronic illness or disability is not associated with increased risk of death in most cases, but may instead be associated with modest survival benefits for the caregivers.

Primary prophylactic aspirin use and incident stroke: reasons for geographic and racial differences in stroke study.

BACKGROUND: Studies have shown that aspirin used for secondary prevention significantly reduces cardiovascular and stroke risk. The data for aspirin and primary prevention of cardiovascular disease, and in particular stroke, are less clear, especially among blacks. OBJECTIVE: To evaluate prophylactic aspirin use and incident stroke in a large cohort of black and white participants. METHODS: The Reasons for Geographic and Racial Differences in Stroke study is a national, population-based, longitudinal study of 30,239 African Americans and whites, older than 45 years. Participants with stroke at baseline were excluded, reducing the cohort to 27,219. Proportional hazard models were used to estimate the association of incident stroke with prophylactic aspirin use, adjusted for confounding factors. Separate analyses were performed for subjects who self-reported baseline aspirin use for primary prevention of vascular disease compared with those using aspirin use for other indications. RESULTS: In all, 10,177 participants taking prophylactic aspirin were followed for a mean of 4.6 years. Univariate analysis showed an increased stroke risk for prophylactic aspirin use (hazard ratio [HR]: 1.37; 95% confidence interval: 1.16-1.62), but the association was attenuated (HR: 1.06; 95% CI: .86-1.32) with multivariable adjustment, adjusting for demographic factors (age, race, sex, and region), socioeconomic factors (income and education), perceived general health, cardiovascular disease (CVD) risk factors (hypertension, diabetes, dyslipidemia, cigarette smoking, and alcohol use), and finally the Framingham Stroke Risk Score (in a separate model). No racial, sex, or regional differences in the association were demonstrated. CONCLUSIONS: In this observational study, prophylactic aspirin use was not associated with risk of first stroke, and there were no sex, race, or regional differences.

Awareness and management of chronic disease, insurance status, and health professional shortage areas in the REasons for Geographic And Racial Differences in Stroke (REGARDS): a cross-sectional study.

BACKGROUND: Limited financial and geographic access to primary care can adversely influence chronic disease outcomes. We examined variation in awareness, treatment, and control of hypertension, diabetes, and hyperlipidemia according to both geographic and financial access to care. METHODS: We analyzed data on 17,458 participants in the REasons for Geographic And Racial Differences in Stroke (REGARDS) study with either hypertension, hyperlipidemia, or diabetes and living in either complete Health Professional Shortage Area (HPSA) counties or non-HPSA counties in the U.S. All analyses were stratified by insurance status and adjusted for sociodemographics and health behaviors. RESULTS: 2,261 residents lived in HPSA counties and 15,197 in non-HPSA counties. Among the uninsured, HPSA residents had higher awareness of both hypertension (adjusted OR 2.30, 95% CI 1.08, 4.89) and hyperlipidemia (adjusted OR 1.50, 95% CI 1.01, 2.22) compared to non-HPSA residents. Also among the uninsured, HPSA residents with hypertension had lower blood pressure control (adjusted OR 0.45, 95% CI 0.29, 0.71) compared with non-HPSA residents. Similar differences in awareness and control according to HPSA residence were absent among the insured. CONCLUSIONS: Despite similar or higher awareness of some chronic diseases, uninsured HPSA residents may achieve control of hypertension at lower rates compared to uninsured non-HPSA residents. Federal allocations in HPSAs should target improved quality of care as well as increasing the number of available physicians.

Racial and geographic differences in prevalence, awareness, treatment and control of dyslipidemia: the reasons for geographic and racial differences in stroke (REGARDS) study.

BACKGROUND/AIMS: There are racial and geographic disparities in stroke mortality, with higher rates among African Americans (AAs) and those living in the southeastern US ('stroke belt'). Racial and geographic differences in dyslipidemia prevalence, awareness, treatment and control may, in part, account for the observed disparities in stroke mortality. METHODS: Reasons for Geographic and Racial Differences in Stroke (REGARDS) is a national observational study of community-dwelling black and white participants aged 45 and older, with oversampling from the stroke belt. As of January 15, 2007, 26,122 participants were enrolled and a fasting lipid panel was available of 21,068. Awareness, treatment and control of dyslipidemia were estimated overall and compared across race-sex-region strata. RESULTS: There were 55% of the participants with dyslipidemia and no racial differences in prevalence. Adjusting for demographic and established stroke risk factors, AAs had a lower prevalence (OR 0.74; 95% CI: 0.66, 0.77) and were less likely to be aware (0.69; 0.61, 0.78), treated (0.77; 0.67, 0.89) and controlled (0.67; 0.58, 0.77) than whites. There was lower control outside of the stroke belt (0.87; 0.76, 0.99). CONCLUSION: Racial, but not geographic, differences in dyslipidemia management may play a role in the excess stroke burden in the Southeast.

Obtaining medical records from healthcare facilities under the HIPAA Privacy Rule: the experience of a national longitudinal cohort study.

The processes for acquiring medical records from healthcare facilities in longitudinal cohort studies have not been well examined post-HIPAA Privacy Rule. We examined the response rates, correlates of response rates, and response times for obtaining patient medical records from healthcare facilities under the HIPAA Privacy Rule. Medical records were requested from facilities across the country on adults 45 or older enrolled in the national longitudinal cohort study REGARDS (Reasons for Geographic and Racial Differences in Stroke) who reported physician encounters for potential stroke events. From October 2003 to October 2006, 1,439 medical records were received out of 1,518 reported eligible events (94.7%), with 39 (2.6%) requests pending at the time of the analysis. The refusal rate for record requests from healthcare facilities was only 0.4%. The median length of time to receipt of a record was 26 days (range 1-679 days). Hospitals had the fastest return time (22 days from date of request to date of receipt) compared with outpatient clinics (28 days), doctor's offices (31 days), and long-term care facilities (55 days, p < 0.01). Healthcare facilities located in the Southern region had fastest return time compared with those in the Northwestern region (23 vs. 46 days, p = 0.048). Medical records retrieval in prospective research studies is still feasible under HIPAA regulation.

Long-term impact of stroke on family caregiver well-being: a population-based case-control study.

OBJECTIVE: Three-year changes in well-being were studied among family caregivers of an epidemiologically derived sample of stroke survivors from the Reasons for Geographic and Racial Differences in Stroke (REGARDS) study and compared to matched noncaregivers. METHODS: Family caregivers of REGARDS participants who experienced a stroke event completed telephone interviews assessing depressive symptoms, mental and physical health quality of life (QOL), life satisfaction, and leisure satisfaction at approximately 9, 18, 27, and 36 months after the stroke (n = 235). For each stroke caregiver, a family member of a stroke-free REGARDS participant was enrolled as a matched noncaregiving control (n = 235) and completed similar interviews. RESULTS: Multilevel longitudinal models found that caregivers showed poorer well-being at 9 months poststroke than controls on all measures except physical health QOL. Significant differences were sustained for 22 months after the stroke event for depressive symptoms, 31 months for mental health QOL, and 15 months for life satisfaction. For leisure satisfaction, differences were still significant at 36 months poststroke. Caregiving effects were similar across race and sex. CONCLUSIONS: Stroke caregiving is associated with persistent psychological distress, but life satisfaction, depression, and mental health QOL became comparable to noncaregivers by 3 years after stroke. Caregiver leisure satisfaction was chronically lower than in noncaregivers. Intervention for stroke caregivers should recognize both the strains faced by caregivers and their capacity for successful coping over time.

Aspirin as Primary Prevention of Acute Coronary Heart Disease Events.

BACKGROUND/OBJECTIVE: Aspirin for primary prophylaxis is controversial. This study evaluated associations between prophylactic aspirin use and incident acute coronary heart disease (CHD) events. METHODS AND RESULTS: The Reasons for Geographic and Racial Differences in Stroke (REGARDS) Study was accessed for aspirin use examining black and white hazards for incident CHD, for men and women, each adjusting incrementally for sampling, sociodemographics, and CHD risk factors. Stratified models examined risks across strata of the Framingham risk score, and all-cause mortality. 23,949 participants (mean 64 yo), had 503 incident events over a 3.5 year follow-up. Prophylactic aspirin use was not associated with incident acute CHD, HR 1.05 (95% CI 0.86, 1.29). Modeling had little impact on the HR (1.09 {95% CI 0.89, 1.33) nor did the addition of risk factors (HR 1.00 {95% CI 0.81, 1.23). Aspirin use was not associated with incident CHD for any Framingham risk level. Findings were similar when including all aspirin users (not just those taking aspirin prophylactically), and when examining associations with all-cause mortality. There was no excess hospitalized bleeding in the aspirin users. CONCLUSION: Aspirin was not associated with lower risk for incident acute CHD overall, or within race, gender, or Framingham Risk Score.

Nutritional risk and body mass index predict hospitalization, nursing home admissions, and mortality in community-dwelling older adults: results from the UAB Study of Aging with 8.5 years of follow-up.

BACKGROUND: Nutritional risk and low BMI are common among community-dwelling older adults, but it is unclear what associations these factors have with health services utilization and mortality over long-term follow-up. The aim of this study was to assess prospective associations of nutritional risk and BMI with all-cause, nonsurgical, and surgical hospitalization; nursing home admission; and mortality over 8.5 years. METHODS: Data are from 1,000 participants in the University of Alabama at Birmingham Study of Aging, a longitudinal, observational study of older black and white residents of Alabama aged 65 and older. Nutritional risk was assessed using questions associated with the DETERMINE checklist. BMI was categorized as underweight (<18.5), normal weight (18.5-24.9), overweight (25.0-29.9), class I obese (30.0-34.9), and classes II and III obese (≥35.0). Cox proportional hazards models were fit to assess risk of all-cause, nonsurgical, and surgical hospitalization; nursing home admission; and mortality. Covariates included social support, social isolation, comorbidities, and demographic measures. RESULTS: In adjusted models, persons with high nutritional risk had 51% greater risk of all-cause hospitalization (95% confidence interval: 1.14-2.00) and 50% greater risk of nonsurgical hospitalizations (95% confidence interval: 1.11-2.01; referent: low nutritional risk). Persons with moderate nutritional risk had 54% greater risk of death (95% confidence interval: 1.19-1.99). BMI was not associated with any outcomes in adjusted models. CONCLUSIONS: Nutritional risk was associated with all-cause hospitalizations, nonsurgical hospitalizations, and mortality. Nutritional risk may affect the disablement process that leads to health services utilization and death. These findings point to the need for more attention on nutritional assessment, interventions, and services for community-dwelling older adults.

Calorie restriction in overweight seniors: response of older adults to a dieting study: the CROSSROADS randomized controlled clinical trial.

We conducted a study designed to evaluate whether the benefits of intentional weight loss exceed the potential risks in a group of community-dwelling obese older adults who were at increased risk for cardiometabolic disease. The CROSSROADS trial used a prospective randomized controlled design to compare the effects of changes in diet composition alone or combined with weight loss with an exercise only control intervention on body composition and adipose tissue deposition (Specific Aim #1: To compare the effects of changes in diet composition alone or combined with weight loss with an exercise only control intervention on body composition, namely visceral adipose tissue), cardiometabolic disease risk (Specific Aim #2: To compare the effects of a change in diet composition alone or combined with weight loss with an exercise only control intervention on cardiometabolic disease risk), and functional status and quality of life (Specific Aim #3: To compare the effects of a change in diet composition alone or combined with weight loss with an exercise only control intervention on functional status and quality of life). Participants were randomly assigned to one of three groups: Exercise Only (Control) Intervention, Exercise + Diet Quality + Weight Maintenance Intervention, or Exercise + Diet Quality + Weight Loss Intervention. CROSSROADS utilized a lifestyle intervention approach consisting of exercise, dietary, and behavioral components. The development and implementation of the CROSSROADS protocol, including a description of the methodology, detailing specific elements of the lifestyle intervention, assurances of treatment fidelity, and participant retention; outcome measures and adverse event monitoring; as well as unique data management features of the trial results, are presented in this article.

Analysis of cognitive, functional, health service use, and cost trajectories prior to and following memory loss.

OBJECTIVES: This brief report examines whether significant changes in cognition, functional dependence, health service use, and out-of-pocket medical expenditures (OOPMD) occur in the years prior to a physician-identified memory problem in a nationally representative sample of older adults. METHOD: Longitudinal data from the RAND-Health and Retirement Survey were utilized. Those who reported a physician-identified memory problem (n = 387) were compared with a randomly selected control group of similar age, race, and gender who did not indicate a memory problem (n = 387). Multilevel linear models were used to construct trajectories for various measures of cognition, function, health service use, and OOPMD in the years prior to and following memory problem identification. RESULTS: Several trajectories demonstrated significant rates of change in the years leading up to a physician-identified memory problem, including symptoms (mental status, fine motor skills, and instrumental activities of daily living) and utilization (OOPMD and overnight stays in hospital). DISCUSSION: Preclinical declines in mental status and function and increases in hospital use and OOPMD are apparent prior to the formal identification of memory problems. Earlier identification of these changes might provide a basis for interventions that could alter the clinical course of dementia.

Symptom burden predicts hospitalization independent of comorbidity in community-dwelling older adults.

OBJECTIVES: To determine whether cumulative symptom burden predicts hospitalization or emergency department (ED) visits in a cohort of older adults. DESIGN: Prospective, observational study with a baseline in-home assessment of symptom burden. SETTING: Central Alabama. PARTICIPANTS: Nine hundred eighty community-dwelling adults aged 65 and older (mean 75.3 ± 6.7) recruited from a random sample of Medicare beneficiaries stratified according to sex, race, and urban/rural residence. MEASUREMENTS: Symptom burden score (range 0-10). One point was given for each symptom reported: shortness of breath, tiredness or fatigue, problems with balance or dizziness, leg weakness, poor appetite, pain, stiffness, constipation, anxiety, and loss of interest in activities. Dependent variables were hospitalizations and ED visits, assessed every 6 months during the 8.5-year follow-up period. Using Cox proportional hazards models, time from the baseline in-home assessment to the first hospitalization and first hospitalization or ED visit was determined. RESULTS: During the 8.5-year follow-up period, 545 (55.6%) participants were hospitalized or had an ED visit. Participants with greater symptom burden had higher risk of hospitalization (hazard ratio (HR) = 1.09, 95% confidence interval (CI) = 1.05-1.14) and hospitalization or ED visit (HR = 1.10, 95% CI = 1.06-1.14) than those with lower scores. Participants living in rural areas had significantly lower risk of hospitalization (HR = 0.83, 95% CI = 0.69-0.99) and hospitalization or ED visit (HR = 0.80, 95% CI = 0.70-0.95) than individuals in urban areas, independent of symptom burden and comorbidity. CONCLUSION: Greater symptom burden was associated with higher risk of hospitalization and ED visits in community-dwelling older adults. Healthcare providers treating older adults should consider symptom burden to be an additional risk factor for subsequent hospital utilization.

Awareness, treatment and control of hypertension, diabetes and hyperlipidemia and area-level mortality regions in the Reasons for Geographic and Racial Differences in Stroke (REGARDS) study.

BACKGROUND: Health Professional Shortage Areas (HPSA) receive extra federal resources, but recent reports suggest that HPSA may not consistently identify areas of need. PURPOSE: To assess areas of need based on county-level ischemic heart disease (IHD) and stroke mortality regions. METHODS: Need was defined by lack of awareness, treatment, or control of hypertension, diabetes, or hyperlipidemia. Counties were categorized into race-specific tertiles of IHD and stroke mortality using 1999-2006 CDC data. Multivariable logistic regression was used to model the relationships between IHD and stroke mortality region and each element of need. RESULTS: Awareness and treatment of cardiovascular (CVD) risk factors were similar for residents in counties across IHD and stroke mortality tertiles, but control tended to be lower in counties with the highest mortality. CONCLUSIONS: High stroke and IHD mortality identify distinct regions from current HPSA designations, and may be an additional criterion for designating areas of need.

Inflammatory biomarkers as predictors of hospitalization and death in community-dwelling older adults.

Individuals with multimorbidity may be at increased risk of hospitalization and death. Comorbidity indexes do not capture severity of illness or healthcare utilization; however, inflammation biomarkers that are not disease-specific may predict hospitalization and death in older adults. We sought to predict hospitalization and mortality of older adults using inflammation biomarkers. From a prospective, observational study, 370 community-dwelling adults 65 years or older from central Alabama participated in an in-home assessment and provided fasting blood samples for inflammation biomarker testing in 2004. We calculated an inflammation summary score (range 0-4), one point each for low albumin, high C-reactive protein, low cholesterol, and high interleukin-6. Utilizing Cox proportional hazards models, inflammation summary scores were used to predicted time to hospitalization and death during a 4-year follow up period. The mean age was 73.7 (±5.9 yrs), and 53 (14%) participants had summary scores of 3 or 4. The rates of dying were significantly increased for participants with inflammation summary scores of 2, 3, or 4 (hazard ratio (HR) 2.22, 2.78, and 7.55, respectively; p<0.05). An inflammation summary score of 4 significantly predicted hospitalization (HR 5.92, p<0.05). Community-dwelling older adults with biomarkers positive for inflammation had increased rates of being hospitalized or dying during the follow up period. Assessment of the individual contribution of particular inflammation biomarkers in the prediction of health outcomes in older populations and the development of validated summary scores to predict morbidity and mortality are needed.

Health Professional Shortage Areas, insurance status, and cardiovascular disease prevention in the Reasons for Geographic and Racial Differences in Stroke (REGARDS) Study.

Individuals with cardiovascular disease (CVD) living in Health Professional Shortage Areas (HPSA) may receive less preventive care than others. The Reasons for Geographic And Racial Differences in Stroke Study (REGARDS) surveyed 30,239 African American (AA) and White individuals older than 45 years of age between 2003-2007. We compared medication use for CVD prevention by HPSA and insurance status, adjusting for sociodemographic factors, health behaviors, and health status. Individuals residing in partial HPSA counties were excluded. Mean age was 64±9 years, 42% were AA, 55% were women, and 93% had health insurance; 2,545 resided in 340 complete HPSA counties and 17,427 in 1,145 non-HPSA counties. Aspirin, beta-blocker, and ACE-inhibitor use were similar by HPSA and insurance status. Compared with insured individuals living in non-HPSA counties, statin use was lower among uninsured participants living in non-HPSA and HPSA counties. Less medication use for CVD prevention was not associated with HPSA status, but less statin use was associated with lack of insurance.