Relationship of Cognitive and Social Engagement to Health and Psychological Outcomes in Community-Dwelling Older Adults.

BACKGROUND: Cognitive and social engagement is an important yet underdocumented aspect of older adult engagement and function. OBJECTIVE: The purpose of this study was to examine relationships between cognitive and social engagement and health and psychological outcomes in a cohort of community-dwelling older adults aged approximately 55-70 years. METHODS: Analysis of data from the Wisconsin Registry for Alzheimer's Prevention, a multiwave cohort study with 1,582 participants, using a 1:1 prospective case-control design to examine whether lower cognitive and social engagement at Visit 4 (baseline) is associated with worse health and psychological outcomes at Visit 5 (2 years after Visit 4). Wisconsin Registry for Alzheimer's Prevention participants were included in this study if they had complete data on cognitive and social engagement and self-rated health at both visits. RESULTS: After matching potential covariates using propensity scores, participants with low cognitive and social engagement (cases) at baseline continued to have significantly lower cognitive and social engagement than the controls (participants with high cognitive and social engagement at baseline) at Visit 5, and they had lower self-rated health and higher surgery rate. Depressive symptoms, cognitive status, and hospitalization at Visit 5 did not significantly differ between cases and controls. DISCUSSION: This study provides evidence supporting cognitive and social engagement as an important marker of early decline in activity engagement that may indicate a potential later decline in functional, psychological, and health outcomes.

The Characteristics of Pain in Patients Diagnosed with Depression and Heart Failure.

Heart failure (HF) is a costly and growing health problem that is routinely complicated by chronic pain and depression. The purpose of this paper is to describe the characteristics of pain and pain management in depressed HF patients. In this descriptive cross-sectional study, we analyzed data from 62 participants with depression and class II-IV HF. Study variables of interest were collected from the Brief Pain Inventory, Beck Depression Inventory, and Rand-36. Almost all participants (98%) had some pain in the past month and most had pain in the last 24 hours (66%). The median pain score was 4 (0-10 scale) with the majority reporting moderate to severe pain. The median pain interference score was 4.42 (0-10 scale) with the majority reporting moderate to extreme interference. Medication to treat pain was used by all participants who reported pain, with only 5% also using nonpharmacologic treatment. The majority of participants reported moderate or severe pain while also having moderate to extreme pain interference. Nonpharmacologic pain treatments were severely underused. Women were more likely to have higher levels of pain intensity and more pain interference than men, suggesting that additional screening for the impact of pain is especially important in women. The wide variety of body areas affected, along with moderate to high intensity pain and considerable interference scores reported, indicate that pain was ineffectively treated. Nonpharmacologic treatments should be considered to decrease the impact of pain.

The Relationships Among Pain, Depression, and Physical Activity in Patients With Heart Failure.

INTRODUCTION: Increasing patients' physical activity levels holds many opportunities to facilitate health and well-being among those with heart failure (HF) by improving HF symptoms and decreasing depression and pain. Given low exercise participation rates, an essential first step to increase exercise rates is to evaluate how pain and depression may further influence engagement in exercise programs. AIMS: The aims of this study were to describe the level of physical activity and exercise that patients with HF with depression achieve and to investigate the relationships among pain, depression, total activity time, and sitting time. METHODS: In this correlational cross-sectional study, we analyzed data from 61 participants with depression and New York Heart Association class II to IV HF. RESULTS AND CONCLUSIONS: The total time spent being active was less than 1 hour per day. Depressed patients with HF have much lower physical activity levels than the general public. Decreasing sitting time and increasing light activity levels hold promise to improve pain and depression symptoms.

A potent and selective Sirtuin 1 inhibitor alleviates pathology in multiple animal and cell models of Huntington's disease.

Protein acetylation, which is central to transcriptional control as well as other cellular processes, is disrupted in Huntington's disease (HD). Treatments that restore global acetylation levels, such as inhibiting histone deacetylases (HDACs), are effective in suppressing HD pathology in model organisms. However, agents that selectively target the disease-relevant HDACs have not been available. SirT1 (Sir2 in Drosophila melanogaster) deacetylates histones and other proteins including transcription factors. Genetically reducing, but not eliminating, Sir2 has been shown to suppress HD pathology in model organisms. To date, small molecule inhibitors of sirtuins have exhibited low potency and unattractive pharmacological and biopharmaceutical properties. Here, we show that highly selective pharmacological inhibition of Drosophila Sir2 and mammalian SirT1 using the novel inhibitor selisistat (selisistat; 6-chloro-2,3,4,9-tetrahydro-1H-carbazole-1-carboxamide) can suppress HD pathology caused by mutant huntingtin exon 1 fragments in Drosophila, mammalian cells and mice. We have validated Sir2 as the in vivo target of selisistat by showing that genetic elimination of Sir2 eradicates the effect of this inhibitor in Drosophila. The specificity of selisistat is shown by its effect on recombinant sirtuins in mammalian cells. Reduction of HD pathology by selisistat in Drosophila, mammalian cells and mouse models of HD suggests that this inhibitor has potential as an effective therapeutic treatment for human disease and may also serve as a tool to better understand the downstream pathways of SirT1/Sir2 that may be critical for HD.

Improving antipsychotic agent use in nursing homes: development of an algorithm for treating problem behaviors in dementia.

Many issues related to safety and quality care emerge from reports that nearly one in three nursing home residents is treated with antipsychotic medication, a rate that exceeds levels that led to nursing home reform more than 2 decades ago. Atypical antipsychotic medications have become the mainstay of treatment for behavioral problems among residents with dementia, despite federal "black box" warnings about health risks and research demonstrating their limited effectiveness. The purpose of this article is to briefly describe a dissemination research project designed to increase appropriate antipsychotic prescribing for older adults with dementia. A step-wise problem-solving algorithm designed to reduce unnecessary psychotropic medication use is described. Formative evaluation results provided by nursing home personnel are reviewed. Discussion focuses on nursing home culture as an important influence on the adoption of evidence-based practices and changes needed to promote use of behavioral interventions in dementia care and reduction of reliance on antipsychotic medications.

Depression training in nursing homes: lessons learned from a pilot study.

Late-life depression is common among nursing home residents, but often is not addressed by nurses. Using a self-directed CD-based depression training program, this pilot study used mixed methods to assess feasibility issues, determine nurse perceptions of training, and evaluate depression-related outcomes among residents in usual care and training conditions. Of 58 nurses enrolled, 24 completed the training and gave it high ratings. Outcomes for 50 residents include statistically significant reductions in depression severity over time (p < 0.001) among all groups. Depression training is an important vehicle to improve depression recognition and daily nursing care, but diverse factors must be addressed to assure optimal outcomes.

Palbociclib and letrozole in hormone-receptor positive advanced breast cancer: Predictive response and prognostic factors.

CDK 4/6 inhibitors have been yielding propitious results when with hormone therapy in the management of Her2-negative and hormone-receptor (HR)-positive metastatic breast cancer, palbociclib being one of the first molecules investigated in this setting. However, the response to CDK4/6 inhibitors is variable. To identify predictive and prognostic factors of response to this therapeutic regimen. Eligible patients were females with HR+ and Her2- advanced breast cancer, receiving Palbociclib in combination with Letrozole. PFS was the primary endpoint in the evaluation of response to treatment. This survival was then further segregated according to various characteristics: histological (type, grade, hormone receptors), metastatic site, line of treatment, response type at initial assessment, and best response achieved. The data was then processed by two statistical analysis models: Kaplan-Meier and univariate preceding multivariate Cox proportional risks. Sixty patients were included and followed for a median follow-up duration of 15.98 months. PFS recorded a median of 19.07 months (95% CI=15.43-22.71). PFS had a median of 12.99 months in the absence of progesterone receptors (vs 20.05 months in the case of positive estrogen and progesterone receptors; P = 0.046), a median of 13.02 months in the presence of liver metastases (vs 22.98 months in the absence of liver metastases; P = 0.007), and 15.94 months in the case of second-line and beyond (vs 22.98 months in the case of first-line; P = 0.033). Regarding the Hazard Ratio of progression, we note age (HR 0.941; P = 0.019), liver metastases (HR 2.751; P = 0.051), response at initial evaluation (HR<1; P < 0.001) and best response (HR<1; P = 0.003). PFS reached similar figures to those of international studies. The absence of progesterone receptors, presence of liver metastases, and use as second-line or beyond are associated with a reduced median PFS. One year age increase (protective factor), liver metastases (risk factor), response at initial evaluation, and best response achieved are identified as the most predictive factors of the response to this treatment regimen and of the progression risk.

Risk stratifying gastric ulcers: development and validation of a scoring system.

Objective: Debate is ongoing regarding the need for universal endoscopic follow-up to ensure gastric ulcer healing. We aimed to assess the value of follow-up oesophago-gastro-duodenoscopies (OGDs) for gastric ulcer healing and stratify patients according to risk of malignancy by developing a risk score. Design/method: All patients in National Health Service (NHS) Lothian with an index OGD and a diagnosis of gastric ulcer between 1 January 2014 and 31 December 2018 were identified. Data were analysed with logistic regression to identify factors significantly associated with a diagnosis of cancer; a risk score was derived and externally validated. Results: 778 patients were identified and 60.3% (469/778) of patients had a follow-up OGD. 8.6% (66/778) of patients were diagnosed with cancer. No cases of cancer were found on follow-up OGD of a benign appearing ulcer with negative biopsies. Macroscopic suspicion of malignancy was present at index OGD in 100% (3/3) of those diagnosed with cancer on subsequent OGDs. Older age (p=0.014), increased ulcer size (p<0.001) and non-antral location (p=0.030) were significantly associated with malignancy. A risk score (area under the curve (AUC) 0.868, p<0.001, minimum score=0, maximum score=6) was derived from these variables. 78.0% of patients with malignant ulcers scored ≥3, only 15.8% with benign ulcers scored ≥3 (negative predictive value (NPV) 97.4%). External validation yielded an AUC of 0.862 (p<0.001) and NPV of 98.6%; 84.0% of those with malignant ulcers scored ≥3. Conclusion: Ulcers with a combination of macroscopically benign appearances, at least six negative biopsies and a low risk score do not necessarily need endoscopic follow-up.

Dietary intake in hemodialysis patients does not reflect a heart healthy diet.

OBJECTIVE: Cardiovascular disease is highly prevalent and has a major effect on morbidity and mortality in patients undergoing maintenance hemodialysis (MHD). Dietary factors that may contribute to cardiovascular disease have not been well studied in this population. We hypothesize that dietary intake in this population does not meet the guidelines for cardiovascular risk reduction. DESIGN: A cross-sectional study was completed using the validated "Block Dialysis 1 Food Frequency Questionnaire" to assess dietary intake of MHD patients. SETTING AND PATIENTS: A total of 70 patients undergoing MHD at our outpatient dialysis center completed the questionnaire under the supervision of a trained dietitian. The population consisted of 38 men and 32 women. MAIN OUTCOME MEASURE: Dietary intake was the main outcome measure, with a focus on calories, soluble fiber, saturated fatty acid (SFA), unsaturated fatty acid intake (UFA), and protein. RESULTS: The mean fiber intake was 10.77 (±5.87) g/day, and only 2 of 71 (2.9%) were in compliance with the recommended daily intake of >25 g/day. As percentage of total calories, of the 70 patients, 5 (7.1%) had a fat intake of <30%, 22 (31.4%) had SFA intake of <10%, 64 (91.4%) had a UFA of ≤30%, 22 (31.4%) had a protein-based diet of ≥15%, and 66 (94.3%) had a carbohydrate diet of <60%. CONCLUSIONS: Most patients did not meet the dietary guidelines for reducing the risk of cardiovascular disease. Substituting UFA or soluble fiber for SFA improves low density lipoprotein (LDL) cholesterol levels without negative effects on other lipid parameters.

Breast arterial calcifications on mammograms do not predict coronary heart disease at coronary angiography.

PURPOSE: To examine, in women who underwent cardiac catheterization, whether breast arterial calcifications (BACs) seen at screening mammography correlate with coronary heart disease (CHD) seen at coronary angiography. MATERIALS AND METHODS: In an institutional review board-approved, HIPAA-compliant study, 172 women (mean age, 64.29 years +/- 11.97 [standard deviation]) who underwent coronary angiography were recruited, interviewed, and assigned to two groups: those with (CHD+) and those without (CHD-) CHD. The severity and location of the CHD were considered. Their mammograms were reviewed by a breast imaging specialist who was blinded to the CHD status. Student t test, chi(2), and multiple logistic regression tests were performed as appropriate. Presence of BAC was noted and correlated with presence of CHD and presence of cardiac risk factors. RESULTS: There were 104 women with and 68 women without CHD. Thirty-seven (36%) women in the CHD+ group versus 20 (29%) in the CHD-group (P = .40) had BAC. The mean age of the patients with BAC, 72 years +/- 9.8, was significantly older than the mean age of the patients without BAC, 60.4 years +/- 11.1 (P < .001). Therefore, subjects were divided into those younger than 65 years and those 65 years and older. No correlation existed, despite the fact that BAC was associated with some cardiac risk factors. CONCLUSION: The authors did not observe a correlation between BAC and coronary angiography-detected CHD, even when CHD severity was considered. On the basis of these results, caution should be exercised when using screening mammography-detected BAC to identify patients with CHD.

Effects of parathyroid hormone on immune function.

Parathyroid hormone (PTH) function as immunologic mediator has become interesting with the recent usage of PTH analogue (teriparatide) in the management of osteoporosis. Since the early 1980s, PTH receptors were found on most immunologic cells (neutrophils, B and T cells). The in vitro evaluations for a possible role of PTH as immunomodulator have shown inconsistent results mainly due to methodological heterogeneity of these studies: it used different PTH formulations (rat, bovine, and human), at different dosages and different incubating periods. In some of these studies, the lymphocytes were collected from uremic patients or animals, which renders the interpretation of the results problematic due to the effect of uremic toxins. Parathyroidectomy has been found to reverse the immunologic defect in patients with high PTH levels. Nonetheless, the clinical significance of these findings is unclear. Further studies are needed to define if PTH does have immunomodulatory effects.

Anxiety, depression, and cognitive impairment in dementia-specific and traditional assisted living.

With the rapid growth of the assisted living (AL) industry, the number of AL residences providing dementia care continues to increase. The purpose of this article is to describe and compare demographic characteristics; frequency and type of psychiatric diagnoses; level of cognition, depression, and anxiety symptoms; and use of psychotropic medication among older adults in dementia-specific assisted living (DSAL) and traditional assisted living (TAL) residences. Secondary analysis of screening data collected during a cross-sectional, descriptive pilot project compared 18 participants from two DSAL facilities and 28 participants from three TAL facilities. DSAL participants with dementia were more cognitively impaired than TAL participants with dementia (p < 0.001) and used more antipsychotic (67%), anxiolytic (60%), antidepressant (53%), and cognitive-enhancing (87%) medications. No statistically significant differences in demographic factors or levels of anxiety or depression were observed among residents in either setting.

Age-associated trends of vulvar cancer in the US.

OBJECTIVE: Medical societies have over the years moved away from recommending routine pelvic examinations in older, asymptomatic women above age 65. Consequently, vulvar examination is a largely neglected component of the physical examination, unless sent to a specialist for gynecological evaluation. In recognition of these recommendations, we analyzed US trends in vulvar cancer incidence, age, and stage at diagnosis, survival, and association with human papillomavirus (HPV). METHODS: Cases of vulvar and cervical cancer from 1992 to 2014 were extracted from the National Cancer Institute's Surveillance, Epidemiology, and End Results and Centers for Disease Control's data on age at diagnosis, stage of disease, and HPV-association were analyzed and compared. Incidence and mortality rates were extracted and calculated. RESULTS: From 1992-2014, there was a 14.3% increase in vulvar cancer rates. The absolute average incidence rate was 2.25, with HPV still being seen in vulvar carcinomas in women 65 years and above. Cervical cancer mortality rates declined by 34.2%, while vulvar cancer death rates were unchanged. We show increased intervals for cervical cancer screening is associated with later stage vulvar cancer detection. The proportion of vulvar cancer cases diagnosed in women age <50 steadily decreased, from 42.05% of cases in 1992-1996 to 19.75% of total cases in 2012-2015. Meanwhile, vulvar cancer cases diagnosed in women > 65 yo increased from 36.62% of cases in 1992-1996 to 49.82% of cases in 2012-2015. CONCLUSION: The incidence of vulvar cancer increases with age, with the median age of diagnosis 67 years, with HPV (+) tumors occurring into 70's and 80's. Though medical societies do not routinely recommend an external genital examination in women 65 years and above, we show this is a missed opportunity to improve cancer outcomes in some older females.

Video Summary:http://links.lww.com/MENO/A678.

Vocal pattern detection of depression among older adults.

Depression is a serious problem for many older adults but is too often undetected by the person, family or providers. Although vocal patterns have been successfully used to detect and predict depression in adults aged 18 to 65 years, no studies to date have included older adults. The study purpose was to determine whether vocal patterns associated with clinical depression in younger people also signify depression in older adults. An observational, repeated measures design was used to enroll 46 volunteer older adults who completed a semi-structured interview composed the 9-item Patient Health Questionnaire or PHQ-9 depression scale and selected speech measures. Recorded interviews were analysed by machine learning algorithms to evaluate whether vocal patterns may predict presence of depression in older adults. In this study, using the PHQ-9 and a supervised machine learning algorithm accurately predicted high and low depression scores between 86% and 92% of the time. Change in raw PHQ-9 scores between interview cycles was predicted within 1.17 points. These results provide strong and promising evidence that vocal patterns can be used effectively to detect clinical depression in adults who are 65 years and older.

Speed of processing training and depression in assisted and independent living: A randomized controlled trial.

Late life depression is widely associated with lower quality of life and greater disability, making it an important target for prevention. Earlier randomized controlled trials [RCTs] demonstrated that speed of processing training [SOPT] led to reductions in depressive symptoms and clinical depression in community-dwelling adults. Our purpose was to evaluate depression outcomes related to SOPT among older adults who live in supported senior living settings. This two-arm, parallel RCT included 351 participants aged 55-102 years who resided in assisted and independent settings in 31 senior living communities. Participants were randomized within sites to computerized SOPT vs. computerized crossword puzzles with a targeted dose of 10 hours of playtime at baseline plus 4 hours of booster training at five and eleven months. Depression outcomes included the 9-item Patient Health Questionnaire [PHQ-9] scores, categorical levels, and dichotomous indicators. Random effects linear mixed effect models estimated SOPT effects in intention-to-treat complete case and multiple imputation analyses. Mean age of the sample was 81.0 years, 72.2% were women, and 41.0% resided in assisted living. At baseline 65.7% had no depression [PHQ-9 scores < 5] and 6.6% had clinically meaningful depression [PHQ-9 scores ≥ 10]. At 12 months we found significantly increased PHQ-9 scores [p = 0.006] and categorical levels [p = 0.003], and higher percentages of PHQ-2 scores > 3 [p = 0.016] and major depressive syndrome [p = 0.045] among the assisted living SOPT group. No significant change in depression was observed in the independent living SOPT or attention control groups. In summary, the SOPT known as Road Tour/Double Decision significantly increased, rather than decreased, the burden of depressive symptoms among participants residing in assisted living. Given these risks, this SOPT program should be avoided among older people in assisted living settings, and other SOPT interventions should be combined with systematic depression monitoring.

Improving access to breast health services with an interdisciplinary model of care.

This article reports a hospital's experience confronting a community crisis, stemming from local and national breast health access issues, and evaluates the subsequent effectiveness of the initiative to improve breast care service. An interdisciplinary Breast Care Facility was developed adjacent to a Community Hospital. Patients receiving breast cancer screening during the year prior to the Breast Center opening (2002) were compared with patients in subsequent years (2003-2005). Program effectiveness was evaluated by examining screening mammography volume, wait times and cancer detection rates. Screening volume increased by 29.6%. Wait times declined from 30 weeks to 3.5 weeks. Initially, patients with a suspicious screening mammography had a 2-3 week delay for diagnostic mammography and the subsequent evaluation took another 3-4 weeks. Both times improved to an average of 2-5 days. Screening cancer detection rates increased from 3.2 per 1,000, to 6.3 per 1,000. In addition, the number of cancers identified by screening increased from 40% to 58%, p = 0.002. Patient satisfaction measured by survey was over 95%, in areas of courtesy, counseling, and overall care. Our study demonstrates that a comprehensive breast center model can increase access to breast care services, improve patient satisfaction and address focal areas of shortage. Furthermore, in the years after the opening of the breast center the cancer detection rate during screening increased, an important observation that needs to be investigated with future studies.

Tales from the field: what the nursing research textbooks will not tell you.

The process of conducting nursing research can be far more complicated than what is described in nursing textbooks, particularly when the investigation is conducted in a new and unfamiliar care setting. This article describes a number of unexpected events and outcomes associated with implementing what was considered, at the onset, a well-designed research study under the leadership of experienced investigators. Lessons learned, which are believed to be valuable to both neophyte and seasoned researchers, are reviewed.

Dementia care in assisted living: needs and challenges.

Assisted living (AL) is an increasingly popular long-term care option for older adults with dementia. Recent reports suggest that as many as 68% of AL residents have dementia, and that frequency of both behavioral symptoms and psychotropic medications are high. This pilot project explored the feasibility of research methods for use in AL facilities. Findings suggest that most AL residents with dementia have moderate to severe dementia, and the majority are taking one or more psychotropic medication. Descriptive and qualitative findings related to health records, caregiver perceptions of behavioral symptoms, and practicality of assessment methods undertaken are described and implications for psychiatric nursing practice and research are reviewed.