The impact of veteran support and resources for diabetes (iNSPiRED) on diabetes distress: Results from a randomized, parallel-group trial.

OBJECTIVE: The primary objective of this research was to assess the impact of a novel, peer-directed intervention (iNSPiRED) on diabetes distress (DD) among veterans with type 2 diabetes and DD. Secondary objectives were to assess iNSPiRED's impact on anxiety, depression, and diabetes self-management behaviors. METHOD: A single-blinded, randomized, parallel-group trial was conducted. Participants (n = 218) were recruited through a Veterans Affairs medical center and community agencies in a major metropolitan area from September 2019 through January 2022. Certified mental health peer specialists delivered iNSPiRED, a three-month goal-setting and resource navigation intervention. Outcomes were assessed at baseline, postintervention, and month six. Multilevel random-intercept linear regression models with treatment x time interaction terms were used to assess treatment effects. RESULTS: Frequency of following a healthy eating plan was higher for iNSPiRED vs usual care at month three relative to baseline (B = 0.58; p = 0.03) after adjusting for race and socioeconomic status. No other treatment effects differed significantly from zero (ps ≥ 0.05). CONCLUSION: Peer-directed interventions have the potential to deliver low-cost, highly scalable care. However, based on the largely negative findings of the current study, it is likely that more intense, multimodal interventions are needed to address DD.

The efficacy of tobacco cessation treatment for African American adults: a systematic review.

Despite proliferation of evidence-based tobacco cessation treatments, African American adults still suffer higher rates of tobacco-related diseases than White adults. Although tobacco cessation treatment is efficacious, there is a need to reassess the efficacy of tobacco cessation treatment for African American adults. Previous reviews of tobacco cessation treatment studies conducted through 2007 among African American adults highlight the limited research in this area and inconsistent findings on treatment characteristics impacting efficacy. This systematic review examined the efficacy of combined behavioral and pharmacological tobacco cessation treatment for African American adults. Database searches were used to identify studies examining tobacco cessation treatment for predominantly African American samples (>50%). Eligible studies were completed between 2007 and 2021 and (i) involved randomization comparing active combined treatment to a control comparison group and (ii) reported abstinence outcomes at 6 and/or 12 months. Ten studies met inclusion criteria. Active treatment groups typically consisted of a combination of nicotine replacement therapy and behavioral counseling. Abstinence rates for African American adults ranged from 10.0% to 34% in active treatment groups compared to 0.0%-40% in comparison control groups. Our results support the efficacy of combined treatment for tobacco cessation among African American adults. However, cessation rates for African American adults found in this review are lower than those in the general adult population (15%-88%). Additionally, our findings highlight the limited number of studies examining African American tobacco cessation rates and testing of tailored treatment for this population.

African American adults are more likely to develop disease when using tobacco products than other adults. Previous reviews of literature assessing tobacco cessation treatment have been conducted on research until 2007. Therefore, we assessed how well tobacco cessation treatments that were tested 2007­2021 work to decrease tobacco use for this population. We found that 10 studies tested tobacco cessation treatment with majority African American participants, in comparison to more standard treatment. Overall, tobacco cessation treatment that combines behavioral and pharmacological approaches decreases tobacco use for African American adults. However, quit rates among African American adults are lower than those found in the general population. Our findings indicate that very few studies have focused on African American adult tobacco cessation treatment outcomes, which has potentially contributed to health inequity.

The detrimental association between fear of falling and motor performance in older cancer patients with chemotherapy-induced peripheral neuropathy.

BACKGROUND: Cancer patients with chemotherapy-induced peripheral neuropathy (CIPN) are at increased risk of falls and developing fear of falling (FoF). Although FoF may continue to impair motor performance and increase the risk of falling even further, this association remains unexplored in CIPN. RESEARCH QUESTION: Does high FoF in patients with CIPN further deteriorate motor performance beyond the impairment from CIPN-related sensory deficits? METHODS: In this secondary analysis of data collected from two clinical trials, gait parameters during habitual walking condition and postural sway parameters during 30-second quiet standing (eye-open and eyes-closed) were compared among older participants (≥ 65 years) with CIPN and high FoF (CIPN FoF+; n=16), older participants with CIPN and low FoF (CIPN FoF-; n=19) and normal older controls (i.e., non-cancer, non-diabetic, non-neurologic, and non-orthopedic; n=16). We measured gait and postural sway parameters using wearable sensors (BioSensics, Newton, MA, USA), and FoF severity using the Falls Efficacy Scale-International. RESULTS: The largest between-group differences were found in gait speed. The CIPN FoF + group had significantly slower gait speed (0.78 ± 0.21 m/s) than the CIPN FoF- (0.93 ± 0.17 m/s) and normal control groups (1.17 ± 0.13 m/s) (all p < .05; effect sizes = 0.79 and 2.23, respectively). We found a significant association between gait speed and FoF severity (R2 = 0.356; p < .001) across all participants with CIPN. Among participants with CIPN, no significant differences in postural sway parameters were found between the CIPN FoF+and CIPN FoF- groups. SIGNIFICANCE: Our results suggest that gait performance further deteriorates in patients with CIPN and high FoF beyond the impairment from CIPN-related sensory deficits. Our results also suggest further research is needed regarding FoF, and fall risk, as FoF is a simple tool that healthcare providers can use in clinical practice.

Predictors of CNS-Active Medication Use and Polypharmacy Among Homebound Older Adults With Depression.

OBJECTIVE: The authors assessed central nervous system (CNS) polypharmacy among low-income, racially diverse homebound older adults with depression (N=277) and its associations with the participants' ratings of depressive symptoms and pain. METHODS: CNS-active and other psychotropic and analgesic medications intake was collected from patients' medication containers. Depressive symptoms were assessed with the 24-item Hamilton Depression Rating Scale, and pain intensity was measured on an 11-point numerical rating scale. Covariates were disability (World Health Organization Disability Assessment Schedule 2.0) and perceived social support (Multidimensional Scale of Perceived Social Support). RESULTS: Of the patients, 16% engaged in CNS polypharmacy, taking three or more CNS-active medications. Of these, 69%, 69%, and 89% were using selective serotonin reuptake inhibitors, benzodiazepines, and opioids, respectively. Higher pain intensity ratings were associated with CNS polypharmacy. Benzodiazepine users were more likely than nonusers to use opioids. CONCLUSIONS: Medication reviews and improved access to evidence-based psychotherapeutic treatments are needed for these older individuals with depression.

Associations between psychological distress and health-related behaviors among adults with chronic kidney disease.

Chronic kidney disease (CKD) affects 15% of the US general population, and this rate is projected to increase. A healthy lifestyle is important for individuals with CKD to reduce risk for CKD progression and adverse heath events. Adults with CKD also have high rates of psychological distress, which may be associated with unhealthy behaviors. Using the 2013-2017 public use data files of the US National Health Interview Survey, we compared health behaviors (smoking, alcohol use, and physical activity [PA]) and psychological distress (assessed with the Kessler-6 scale) between adults with a CKD diagnosis in the preceding year and a matched sample of adults without a CKD diagnosis. We then examined the association between psychological distress and health behaviors among adults with CKD (n = 3923) using multinomial logistic regression models. Compared to those without CKD, those with CKD had lower rates of smoking, heavy alcohol use, and engagement in any type of PA 3+ times a week and higher rates of psychological distress. In addition to the health concerns posed by the high smoking rate (17%) and low physical activity rate (34%) among those with CKD, smoking and lack of PA were associated with greater risk of mild-moderate and/or serious psychological distress. Compared to no unhealthy behaviors, 2-3 unhealthy behaviors were associated with 4.72 (95% CI = 2.97-7.48) times greater risk of serious psychological distress. Adults with CKD and unhealthy behaviors need help with lifestyle modifications and assessment and treatment of psychological distress to reduce CKD progression and prevent other health complications.

Identifying potential long-stay residents in veterans health administration nursing homes.

Veterans Affairs nursing homes (Community Living Centers; CLCs) have largely shifted focus to providing short-term rehabilitative care, preferring longer-term care to be provided in contract nursing homes or at home. The goal of this retrospective cohort study is to identify resident characteristics associated with longer length of stay using the CLC Minimum Data Set (n = 35,114). Length of stay was defined as three groups: short (<90 days), moderate (91-365 days), and long (beyond 365 days). Residents who remained beyond 90 days were more likely to be black and to have a diagnosis of Alzheimer's disease, dementia, or schizophrenia, lived in another facility prior to admission, had a financial power of attorney, and had greater dependence in activities of daily living. Unique predictors of those who remained beyond 365 days were older age, cancer diagnosis, cognitive impairment, and admission from assisted living. Our findings can help CLC staff with admission decisions.

Psychiatric hospitalists and continuity of care: a comparison of two models.

The Michael E. DeBakey Veterans Affairs (VA) Medical Center inpatient psychiatry program underwent a series of substantial changes that led to a shift from a continuity of care (COC) model to a hospitalist environment in 2007. Although similar changes in other fields of medicine (general medicine, pediatrics, surgery, cardiology, and neurology) have been associated with several care benefits, no studies to date have evaluated the potential effects of such a change in models in psychiatry. The shift at the Michael E. DeBakey VA Medical Center thus provided a unique opportunity to compare these two models of care and gather evidence about which model may be more beneficial to patients. Data were derived retrospectively from two separate periods of time, one representative of the COC model (July-December 2006) and one representative of the hospitalist model (July-December 2008). The total number of discharges increased significantly from the first to the second period. Although the average length of stay remained similar, the number of readmissions occurring within 30 days of discharge was much lower during the hospitalist period. In addition, patients discharged in the hospitalist period were more likely to attend their outpatient mental health appointments. Findings suggest a preference for the hospitalist model over a COC model.

Telephone-administered cognitive behavioral therapy: a case study of anxiety and depression in Parkinson's disease.

Parkinson's disease (PD) is a chronic medical illness with a high incidence of psychiatric comorbidity, specifically depression and anxiety. Research on treatment of such psychiatric complications is scarce. Non-pharmaceutical treatment options are especially attractive. Cognitive behavioral therapy (CBT) is a psychotherapeutic treatment option that has been successful in other chronically medically ill populations with comorbid depression and anxiety. The current research had two aims. The first was to pilot the feasibility of screening and identifying PD patients with symptoms of anxiety and depression in a specialized outpatient clinic. The second aim was to pilot the feasibility of telephone-administered CBT for the treatment of depression and anxiety in persons with PD, which was done through a case series comparing telephone-administered CBT to a Support strategy. A fairly large portion (67.5%) of patients screened in the outpatient clinic were identified as having symptoms of anxiety and/or depression. Results also indicated that CBT delivered via the telephone is a useful approach for targeting psychiatric symptoms in this population. A case example is given to illustrate the clinical considerations associated with delivering therapy via telephone to persons with PD.

The utility of the Generalized Anxiety Disorder Severity Scale (GADSS) with older adults in primary care.

BACKGROUND: The Generalized Anxiety Disorder Severity Scale (GADSS) is an interview rating scale designed specifically for assessing symptom severity of generalized anxiety disorder (GAD), which has demonstrated positive psychometric data in a sample of adult primary care patients with GAD and panic disorder. However, the psychometric properties of the GADSS have not been evaluated for older adults. METHODS: This study evaluated the psychometric properties of the GADSS, administered via telephone, with a sample of older primary care patients (n=223) referred for treatment of worry and/or anxiety. RESULTS: The GADSS demonstrated adequate internal consistency, strong inter-rater reliability, adequate convergent validity, poor diagnostic accuracy, and mixed discriminant validity. CONCLUSIONS: Results provide mixed preliminary support for use of the GADSS with older adults.

Incorporating religion and spirituality to improve care for anxiety and depression in older adults.

Recent research has suggested that religion/spirituality may be linked to improved physical and emotional health, although the patient's motivation and method of using religious/spiritual beliefs appear to be a key factor in obtaining benefit. Studies have shown that there is a high level of religion/spirituality among older adults in the United States and significant patient-reported desire to include such beliefs in health care settings. This article provides a brief overview of the support for considering religion/spirituality in the health care of older adults and reviews potential drawbacks and methods for providers to assess and use patient beliefs to improve anxiety/depression.

Preventing aggression in persons with dementia.

Persons with dementia often present with non-cognitive clinical symptoms, such as aggression, which can be distressing and dangerous to both caregiver and patient. Depression, pain, caregiver burden, and the quality of the caregiver-patient relationship can contribute to the onset of aggression. Given the risks involved with medication, there is a strong need for preventive and nonpharmacological interventions before such behaviors occur. This article gives practical recommendations for primary care physicians on how to prevent aggression in dementia patients by screening for and treating predictive factors. Clinically useful assessment instruments and treatment options are discussed, in addition to referral sources.

Racial and ethnic differences in the treatment of seriously ill patients: a comparison of African-American, Caucasian and Hispanic veterans.

BACKGROUND: No national data exist regarding racial/ethnic differences in the use of interventions for patients at the end of life. OBJECTIVES: To test whether among 3 cohorts of hospitalized seriously ill veterans with cancer, noncancer or dementia the use of common life-sustaining treatments differed significantly by race/ethnicity. DESIGN: Retrospective cohort study during fiscal years 1991-2002. PATIENTS: Hospitalized veterans >55 years, defined clinically as at high-risk for 6-month mortality, not by decedent data. MEASUREMENTS: Utilization patterns by race/ethnicity for 5 life-sustaining therapies. Logistic regression models evaluated differences among Caucasians, African Americans and Hispanics, controlling for age, disease severity and clustering of patients within Veterans Affairs (VA) medical centers. RESULTS: Among 166,059 veterans, both differences and commonalities across diagnostic cohorts were found. African Americans received more or the same amount of end-of-life treatments across disease cohorts, except for less resuscitation [OR = 0.84 (0.77-0.92), p = 0.002] and mechanical ventilation [OR = 0.89 (0.85-0.94), p < or = 0.0001] in noncancer patients. Hispanics were 36% (cancer) to 55% (noncancer) to 88% (dementia) more likely to receive transfusions than Caucasians (p < 0.0001). They received similar rates as Caucasians for all other interventions in all other groups, except for 161% higher likelihood for mechanical ventilation in patients with dementia. Increased end-of-life treatments for both minority groups were most pronounced in the dementia cohort. Differences demonstrated a strong interaction with the disease cohort. CONCLUSIONS: Differences in level of end-of-life treatments were disease specific and bidirectional for African Americans. In the absence of generally accepted, evidence-based standards for end-of-life care, these differences may or may not constitute disparities.

Treating depression in terminally ill patients can optimize their physical comfort at the end of life and provide them the opportunity to confront and prepare for death.

The dying process is characterized by feelings of sadness and fear. It is normal for patients at the end of life to worry and grieve the loss of their health. However, when these feelings become excessive and interfere with all aspects of the patient's life, they are abnormal responses to the stress of terminal illness. Screening for depression in terminally ill patients can optimize their physical comfort at the end of life and provide them the opportunity to confront and prepare for death.

Aggression in individuals newly diagnosed with dementia.

Aggression is often associated with dementia. In this study, aggression in veterans newly diagnosed with dementia was examined and characterized. Participants were >or=60 years diagnosed with dementia at the Michael E. DeBakey Veterans Affairs Medical Center in Houston, Texas, from 2001 to 2004. Aggression was defined as a positive caregiver response to 1 or more of 3 probes from the Ryden Aggression Scale, administered during a telephone screen. Of 1276 contacts, 385 (30%) were eligible and agreed to participate; at initial screening, 75 (19.5%) were aggressive (23 [31%] verbally, 9 [12%] physically, 24 [32%] verbally and physically, and 19 [25%] with unspecified aggression). The surprisingly high prevalence of aggression in individuals newly diagnosed with dementia suggests the potential usefulness of early screening for aggression in this population.

A practical screening tool for anxiety and depression in patients with chronic breathing disorders.

Obstructive lung diseases are associated with high rates of depression and anxiety, yet many patients are never screened or treated. This study evaluated the five-question Depression and Anxiety modules of the Primary Care Evaluation of Mental Disorders (PRIME-MD) Patient Questionnaire as a telephone screen in 1,632 patients with chronic breathing disorders at a Veterans Affairs Medical Center in Houston, TX. Subsequent testing of 828 patients with the Beck Depression Inventory-II and the Beck Anxiety Inventory showed that the sensitivity and specificity, respectively, of the Depression and Anxiety modules of the PRIME-MD Patient Questionnaire screening were 94.6% and 49.5% (Depression); 93.7% and 32.2% (Anxiety); and 97.7%, and 36.0% (combined screen), with an overall accuracy of 80.7%. In such populations, these two modules of the PRIME-MD Patient Questionnaire may be a useful screening tool.

Do testosterone levels relate to aggression in elderly men with dementia?

The aim of this study was to determine if testosterone and estrogen levels correlate with aggression in older men with dementia. Plasma total and free testosterone and estrogen levels and scores for behavioral disturbances, in particular aggression, were measured in 50 elderly males who had a diagnosis of dementia. Aggression was analyzed separately from agitation. Pearson correlations were calculated to determine the association between testosterone and estrogen and aggression. Linear regression analyses determined the influence of hormone levels on aggression, controlling for age, medical burden, and dementia severity. Free testosterone levels showed significant positive correlations with measures of aggression. Estrogen levels showed significant negative correlations with measures of aggression.