Food resources and kitchen skills plus aerobic training (FoRKS+) for black adults with hypertension: A pilot trial protocol.

BACKGROUND: Midlife hypertension is associated with cognitive decline and Alzheimer's disease and related dementia (ADRD), suggesting that blood pressure control may be a therapeutic target for dementia prevention. Given excess hypertension in non-Hispanic Black (NHB) adults, blood pressure control may also reduce ADRD disparities. We describe a pilot randomized controlled trial (RCT) to evaluate the feasibility and preliminary efficacy of a multicomponent lifestyle-based intervention versus enhanced usual care on cognition among middle-aged NHB adults. METHODS AND STUDY DESIGN: The Food Resources and Kitchen Skills plus Aerobic Training (FoRKS+) study is a 2-arm, single-blinded trial that compares those receiving the FoRKS+ program (target N = 64) versus those receiving enhanced usual care (target N = 64) in local federally-qualified health centers. Key eligibility criteria include self-identified NHB adults between ages 35-75 with a mean systolic blood pressure ≥ 130 mm/Hg obtained from 24-h ambulatory blood pressure monitoring. The FoRKS+ program includes 5 weeks of hypertension self-management courses, 11 weeks of nutrition courses, and 12 weeks of aerobic training in dietitian and health coach-led virtual groups. We will collect data on primary cognitive outcomes, feasibility, hypothesized intervention mediators and moderators, and demographic and health covariates at baseline, near intervention weeks 16-, and 28 (primary outcome assessment), and week 52 follow-up. We will use mixed-effects modeling to examine intervention effects on cognition. DISCUSSION: This pilot RCT will examine the feasibility and preliminary effects of a multicomponent lifestyle intervention on cognitive function in NHB adults, which may have implications for reducing health disparities in ADRD.

MIND food and speed of processing training in older adults with low education, the MINDSpeed Alzheimer's disease prevention pilot trial.

BACKGROUND: Multiple national organizations and leaders have called for increased attention to dementia prevention in those most vulnerable, for example persons with limited formal education. Prevention recommendations have included calls for multicomponent interventions that have the potential to improve both underlying neurobiological health and the ability to function despite neurobiological pathology, or what has been termed cognitive reserve. OBJECTIVES: Test feasibility, treatment modifier, mechanism, and cognitive function effects of a multicomponent intervention consisting of foods high in polyphenols (i.e., MIND foods) to target neurobiological health, and speed of processing training to enhance cognitive reserve. We refer to this multicomponent intervention as MINDSpeed. DESIGN: MINDSpeed is being evaluated in a 2 × 2 randomized factorial design with 180 participants residing independently in a large Midwestern city. Qualifying participants are 60 years of age or older with no evidence of dementia, and who have completed 12 years or less of education. All participants receive a study-issued iPad to access the custom study application that enables participants, depending on randomization, to select either control or MIND food, and to play online cognitive games, either speed of processing or control games. METHODS: All participants complete informed consent and baseline assessment, including urine and blood samples. Additionally, up to 90 participants will complete neuroimaging. Assessments are repeated immediately following 12 weeks of active intervention, and at 24 weeks post-randomization. The primary outcome is an executive cognitive composite score. Secondary outcomes include oxidative stress, pro-inflammatory cytokines, and neuroimaging-captured structural and functional metrics of the hippocampus and cortical brain regions. SUMMARY: MINDSpeed is the first study to evaluate the multicomponent intervention of high polyphenol intake and speed of processing training. It is also one of the first dementia prevention trials to target older adults with low education. The results of the study will guide future dementia prevention efforts and trials in high risk populations.

Context-Sensitive Ecological Momentary Assessment: Application of User-Centered Design for Improving User Satisfaction and Engagement During Self-Report.

BACKGROUND: Ecological momentary assessment (EMA) can be a useful tool for collecting real-time behavioral data in studies of health and health behavior. However, EMA administered through mobile technology can be burdensome, and it tends to suffer from suboptimal user engagement, particularly in low health-literacy populations. OBJECTIVE: This study aimed to report a case study involving the design and evaluation of a mobile EMA tool that supports context-sensitive EMA-reporting of location and social situations accompanying eating and sedentary behavior. METHODS: An iterative, user-centered design process with obese, middle-aged women seeking care in a safety-net health system was used to identify the preferred format of self-report measures and the look, feel, and interaction of the mobile EMA tool. A single-arm feasibility field trial with 21 participants receiving 12 prompts each day for momentary self-reports over a 4-week period (336 total prompts per participant) was used to determine user satisfaction with interface quality and user engagement, operationalized as response rate. A second trial among 38 different participants randomized to receive or not to receive a feature designed to improve engagement was conducted. RESULTS: The feasibility trial results showed high interface satisfaction and engagement, with an average response rate of 50% over 4 weeks. Qualitative feedback pointed to the need for auditory alerts. We settled on 3 alerts at 10-min intervals to accompany each EMA-reporting prompt. The second trial testing this feature showed a statistically significant increase in the response rate between participants randomized to receive repeat auditory alerts versus those who were not (60% vs 40%). CONCLUSIONS: This paper reviews the design research and a set of design constraints that may be considered in the creation of mobile EMA interfaces personalized to users' preferences. Novel aspects of the study include the involvement of low health-literacy adults in design research, the capture of data on time, place, and social context of eating and sedentary behavior, and reporting prompts tailored to an individual's location and schedule. TRIAL REGISTRATION: ClinicalTrials.gov NCT03083964; https://clinicaltrials.gov/ct2/show/NCT03083964.

Addressing people and place microenvironments in weight loss disparities (APP-Me): Design of a randomized controlled trial testing timely messages for weight loss behavior in low income Black and White Women.

BACKGROUND: Behavioral interventions for weight loss have been less effective in lower income and black women. These poorer outcomes may in part be related to these women having more frequent exposures to social and physical situations that are obesogenic, i.e., eating and sedentary cues or situations. OBJECTIVES: Working with obese, lower income Black and White Women, Addressing People and Place Microenvironments (APP-Me) was designed to create awareness of self-behavior at times and places of frequent eating and sedentary behavior. DESIGN: APP-Me is being evaluated in a randomized controlled trial with 240 participants recruited from federally qualified health centers located in a single Midwestern city. All participants complete four weeks of ecological momentary assessments (EMA) of situations and behavior. At the end of the four weeks, participants are randomized to enhanced usual care (UC) or UC plus APP-Me. METHODS: APP-Me is an automated short messaging system (SMS). Messages are text, image, audio, or a combination, and are delivered to participants' mobile devices with the intent of creating awareness at the times and places of frequent eating or sedentary behavior. The EMA data inform the timing of message deliveries. SUMMARY: This project aims to create and test timely awareness messages in a subpopulation that has not responded well to traditional behavioral interventions for weight loss. Novel aspects of the study include the involvement of a low income population, the use of data on time and place of obesogenic behavior, and message delivery time tailored to an individual's behavioral patterns.

Identifying Contextual and Emotional Factors to Explore Weight Disparities between Obese Black and White Women.

BACKGROUND: Obese black women enrolled in weight loss interventions experience 50% less weight reduction than obese white women. This suggests that current weight loss strategies may increase health disparities. OBJECTIVE: We evaluated the feasibility of identifying daily contextual factors that may influence obesity. METHODS: In-home interviews with 16 obese (body mass index ≥ 30) black and white urban poor women were performed. For 14 days, ecological momentary assessment (EMA) was used to capture emotion and social interactions every other day, and day reconstruction method surveys were used the following day to reconstruct the context of the prior day's EMA. RESULTS: Factors included percentage of participants without weight scales (43.8%) or fitness equipment (68.8%) in the home and exposed to food at work (55.6%). The most frequently reported location, activity, and emotion were home (19.4 ± 8.53), working (7.1 ± 8.80), and happy (6.9 ± 10.03), respectively. CONCLUSION: Identifying individual contexts may lead to valuable insights about obesogenic behaviors and new interventions to improve weight management.

Does targeted cognitive training reduce educational disparities in cognitive function among cognitively normal older adults?

OBJECTIVE: The aim of this study was to investigate educational differences in treatment responses to memory, reasoning, and speed of processing cognitive training relative to no-contact control. METHODS: Secondary analyses of the Advanced Cognitive Training for Independent and Vital Elderly trial were conducted. Two thousand eight hundred older adults were randomized to memory, reasoning, or speed of processing training or no-contact control. A repeated-measures mixed-effects model was used to investigate immediate post-training and 1-year outcomes with sensitivity analyses out to 10 years. Outcomes were as follows: (1) memory composite of Hopkins Verbal Learning Test, Rey Auditory Verbal Learning Test, and Rivermead Behavioral Memory Test; (2) reasoning composite of letter series, letter sets, and word series; and (3) speed of processing measured using three trials of useful field of view and the digit symbol substitution test. RESULTS: The effects of reasoning and memory training did not differ by educational attainment. The effect of speed of processing training did. Those with fewer than 12 years of education experienced a 50% greater effect on the useful field of view test compared with those with 16 or more years of education. The training advantage for those with fewer than 12 years of education was maintained to 3 years post-training. CONCLUSION: Older adults with less than a secondary education are at elevated risk of dementia, including Alzheimer's disease. The analyses here indicate that speed of processing training is effective in older adults with low educational attainment.

Age Differences in the Association Between Body Mass Index Class and Annualized Medicare Expenditures.

OBJECTIVE: The aim of the study is to assess the relationship between body mass index (BMI) class and Medicare claims among young-old (65-69), old (70-74), and old-old (75+) adults over a 10-year period. METHOD: We assessed costs by BMI class and age group among 9,300 respondents to the 1998 Health and Retirement Study (HRS) with linked 1998-2008 Medicare claims data. BMI was classified as normal (18.5-24.9), overweight (25-29.9), mild obesity (30-34.9), or severe obesity (35 or above). RESULTS: Annualized total Medicare claims adjusted for age, gender, ethnicity, education, and smoking history were 109% greater for severely obese young-old adults in comparison with normal weight young-old adults (US$9,751 vs. US$4,663). Total annualized claim differences between the normal weight and severely obese in the old and old-old groups were not statistically significant. DISCUSSION: Excess Medicare expenditures related to obesity may be concentrated among severely obese young-old adults. Preventing severe obesity among middle and older aged adults may have large cost implications for society.

Validity of self-reported fitness across black and white race, gender, and health literacy subgroups.

PURPOSE: To compare concurrent criterion validity of the Self-Reported Fitness (SRFit) Survey, a new fitness measure, between black and white race, gender, and health literacy groups. DESIGN: Cross-sectional. SETTING: Midwest urban primary care center and commercial fitness center. SUBJECTS: One hundred one black, white, male, and female primary care patients aged ≥40 years. MEASURES: Measures included demographics, the Rapid Estimate of Adult Literacy in Medicine, the SRFit Survey, and the Rikli and Jones Senior Fitness Test battery of physical tests. The BodPod determined percentage of body fat. Body mass index was calculated. ANALYSIS: Concurrent validity was assessed using Pearson and Spearman rank order correlations between corresponding physical tests and SRFit survey items. RESULTS: Correlations between physical tests and SRFit items ranged from r = .52 to .76 (ρ = .41-.85) in males, r = .40 to .79 (ρ = .33-.80) in females, r = .45 to .79 (ρ = .53-.82) in blacks, and r = .49 to .77 (ρ = .33-.82) in whites. Correlations were r = .58 (ρ = .58) to r = .77 (ρ = .79) in persons with low health literacy and r = .50 to .79 (ρ = .39-.85) among persons with moderate to high health literacy. CONCLUSION: SRFit shows similar concurrent validity across race, gender, and health literacy subgroups.

Improving the validity of activity of daily living dependency risk assessment.

OBJECTIVES: Efforts to prevent activity of daily living (ADL) dependency may be improved through models that assess older adults' dependency risk. We evaluated whether cognition and gait speed measures improve the predictive validity of interview-based models. METHOD: Participants were 8,095 self-respondents in the 2006 Health and Retirement Survey who were aged 65 years or over and independent in five ADLs. Incident ADL dependency was determined from the 2008 interview. Models were developed using random 2/3rd cohorts and validated in the remaining 1/3rd. RESULTS: Compared to a c-statistic of 0.79 in the best interview model, the model including cognitive measures had c-statistics of 0.82 and 0.80 while the best fitting gait speed model had c-statistics of 0.83 and 0.79 in the development and validation cohorts, respectively. CONCLUSION: Two relatively brief models, one that requires an in-person assessment and one that does not, had excellent validity for predicting incident ADL dependency but did not significantly improve the predictive validity of the best fitting interview-based models.

Preparing for an aging population and improving chronic disease management.

New models of health care delivery are inevitable. There is likely to be increasing emphasis on patient self-monitoring, health care delivery at patient homes, interdisciplinary treatment plans, a greater percentage of medical care delivered by non-physician health professionals, targeted health educational materials, and greater involvement and training of informal caregivers. The Information Technologies (IT) infrastructure of health systems will need to adapt. We have begun sorting out the implications of this future within a County public hospital system: defining the desirable features, relevant technologies, necessary modifications to the network, and additional data elements to be captured. We seek to build an infrastructure that will support new patient-focused technologies designed to more efficiently and effectively support older individuals. We hypothesize utility to further exploring the impact that new health care delivery models will have on health systems' IT infrastructures.

The meaning and significance of self-management among socioeconomically vulnerable older adults.

OBJECTIVES: The aim of this study was to describe and contrast perceptions of self-management among socioeconomically vulnerable and nonvulnerable older adults. METHODS: We used in-depth, in-home interviews guided by identity theory. Analyses included reviewing audiotapes, creating and comparing field notes, coding transcripts, and identifying themes based on case summaries. Interviews took place in patients' homes. Participants were 23 vulnerable older adults with incomes at or below 200% of the federal poverty level and no private insurance and 12 older adults with private health insurance. RESULTS: The vulnerable sample had lower educational attainment and lower health literacy than the privately insured sample. Keeping doctor visits and taking prescription medications largely defined self-management for the vulnerable sample but were just two of a number of roles noted by the privately insured group, who expressed health promotion as the key to healthy aging. The vulnerable interviewees relayed few examples of healthy aging and did not have expectations for healthful aging. In contrast, the privately insured interviewees gave examples and had expectations of living long and healthfully into old age. DISCUSSION: Improved understanding of the role of social context in expectations regarding aging, and awareness of and priorities for self-management, could lead to improvements in self-management support and thus chronic care outcomes.

Geriatric care management for low-income seniors: a randomized controlled trial.

CONTEXT: Low-income seniors frequently have multiple chronic medical conditions for which they often fail to receive the recommended standard of care. OBJECTIVES: To test the effectiveness of a geriatric care management model on improving the quality of care for low-income seniors in primary care. DESIGN, SETTING, AND PATIENTS: Controlled clinical trial of 951 adults 65 years or older with an annual income less than 200% of the federal poverty level, whose primary care physicians were randomized from January 2002 through August 2004 to participate in the intervention (474 patients) or usual care (477 patients) in community-based health centers. INTERVENTION: Patients received 2 years of home-based care management by a nurse practitioner and social worker who collaborated with the primary care physician and a geriatrics interdisciplinary team and were guided by 12 care protocols for common geriatric conditions. MAIN OUTCOME MEASURES: The Medical Outcomes 36-Item Short-Form (SF-36) scales and summary measures; instrumental and basic activities of daily living (ADLs); and emergency department (ED) visits not resulting in hospitalization and hospitalizations. RESULTS: Intention-to-treat analysis revealed significant improvements for intervention patients compared with usual care at 24 months in 4 of 8 SF-36 scales: general health (0.2 vs -2.3, P = .045), vitality (2.6 vs -2.6, P < .001), social functioning (3.0 vs -2.3, P = .008), and mental health (3.6 vs -0.3, P = .001); and in the Mental Component Summary (2.1 vs -0.3, P < .001). No group differences were found for ADLs or death. The cumulative 2-year ED visit rate per 1000 was lower in the intervention group (1445 [n = 474] vs 1748 [n = 477], P = .03) but hospital admission rates per 1000 were not significantly different between groups (700 [n = 474] vs 740 [n = 477], P = .66). In a predefined group at high risk of hospitalization (comprising 112 intervention and 114 usual-care patients), ED visit and hospital admission rates were lower for intervention patients in the second year (848 [n = 106] vs 1314 [n = 105]; P = .03 and 396 [n = 106] vs 705 [n = 105]; P = .03, respectively). CONCLUSIONS: Integrated and home-based geriatric care management resulted in improved quality of care and reduced acute care utilization among a high-risk group. Improvements in health-related quality of life were mixed and physical function outcomes did not differ between groups. Future studies are needed to determine whether more specific targeting will improve the program's effectiveness and whether reductions in acute care utilization will offset program costs. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT00182962.

Educational disparities in the prevalence and consequence of physical vulnerability.

OBJECTIVES: The purpose of this study was to estimate educational differences in the prevalence and mortality consequence of physical vulnerability among older adults in the United States. METHODS: Data came from the 1998 and 2000 waves of the Health and Retirement Study, a nationally representative cross-sectional and prospective cohort study of community-based adults aged 65 and older. We created a physical vulnerability score from age, gender, and self-reported disability measures and measured socioeconomic status via educational attainment. Mortality data came from the National Death Index. RESULTS: In the 1998 cohort, high physical vulnerability was more than 3 times more prevalent in individuals with less than 12 years of education compared to those with 16 or more years of education. Although less educated older adults had a higher probability of death overall, evidence of educational differences in the mortality consequence of high physical vulnerability was limited. In 2000, 2.16 million older adults had high physical vulnerability, and more than one half (53%) of these adults had less than 12 years of education. DISCUSSION: In persons 65 years of age or older, educational differences are more apparent in the prevalence of physical vulnerability than in the mortality consequence of that vulnerability.

Geriatric Resources for Assessment and Care of Elders (GRACE): a new model of primary care for low-income seniors.

The majority of older adults receive health care in primary care settings, yet many fail to receive the recommended standard of care for preventive services, chronic disease management, and geriatric syndromes. The Geriatric Resources for Assessment and Care of Elders (GRACE) model of primary care for low-income seniors and their primary care physicians (PCPs) was developed to improve the quality of geriatric care so as to optimize health and functional status, decrease excess healthcare use, and prevent long-term nursing home placement. The catalyst for the GRACE intervention is the GRACE support team, consisting of a nurse practitioner and a social worker. Upon enrollment, the GRACE support team meets with the patient in the home to conduct an initial comprehensive geriatric assessment. The support team then meets with the larger GRACE interdisciplinary team (including a geriatrician, pharmacist, physical therapist, mental health social worker, and community-based services liaison) to develop an individualized care plan including activation of GRACE protocols for evaluating and managing common geriatric conditions. The GRACE support team then meets with the patient's PCP to discuss and modify the plan. Collaborating with the PCP, and consistent with the patient's goals, the support team then implements the plan. With the support of an electronic medical record and longitudinal tracking system, the GRACE support team provides ongoing care management and coordination of care across multiple geriatric syndromes, providers, and sites of care. The effectiveness of the GRACE intervention is being evaluated in a randomized, controlled trial.

Reliability and validity of a steadiness score.

OBJECTIVES: To determine the internal consistency and construct and predictive validity of three survey questions regarding steadiness in a sample of community-dwelling lower-income older adults. DESIGN: A 6-month prospective cohort study. SETTING: Community-based. PARTICIPANTS: Three hundred fifty-seven older adults who completed a baseline and 6-month follow-up interviewer-administered survey. These older adults received care at a single, public health system and were judged by insurance status to be of low income. MEASUREMENTS: Self-report measures of steadiness while walking and transferring; difficulty in mobility, activities of daily living (ADLs), and instrumental activities of daily living (IADLs); chronic illness; falls; hospitalization; and sociodemographic characteristics. RESULTS: The three steadiness questions showed good internal consistency (0.88); construct validity in Pearson correlations with mobility (0.57), ADL (0.53), and IADL scores (0.41); and predictive validity. With regard to predictive validity, steadiness was predictive of falls, hospitalization, and decline in ADL and IADL function over a subsequent 6-month period. CONCLUSION: Steadiness questions are a potentially valuable addition to survey research and clinical screening to identify persons with current impairment status and falls and disability risk.

Relationships between exercise self-definitions and exercise participation among urban women in primary care.

Exercising prevents the development of coronary artery disease and reduces the incidence of cardiovascular risk factors; however, the mechanisms that underlie participation in an exercise program are not well understood. On the basis of theories of the self, we hypothesized that exercise self-definitions would be significantly related to exercise participation and that such definitions would increase over time. The study sample consisted of 192 middle-aged to older women who were leading a mostly sedentary life and the majority had at least one cardiovascular risk factor. Exercise participation was defined as the number of exercise sessions completed at 8 and 24 weeks. We found an interesting pattern of significant relationships between exercise definitions and exercise participation. Six-month scores were significantly higher than baseline scores, suggesting that exercise self-definitions strengthened over time. If this result is found to be supported in future studies, nurses may want to consider assessing self-definitions when helping patients initiate and maintain an exercise program.

A conceptual framework to study medication adherence in older adults.

BACKGROUND: Adults aged > or =50 years often have multiple chronic diseases requiring multiple medications. However, even drugs with well-documented benefits are often not taken as prescribed, for a variety of reasons. OBJECTIVE: The objective of this article was to provide background information about medication adherence and its measurement, the development of the conceptual model for use in adherence research, and supportive intervention strategies such as pharmaceutical care by pharmacists to improve chronic medication use in older adults. METHODS: English-language literature published from 1990 to 2000 was searched on MEDLINE, International Pharmaceutical Abstracts, and AARP Ageline using the terms aged, heart failure, CHF, adherence, chronic heart failure, compliance, and related terms. The authors used their personal files and libraries to obtain seminal literature and textbooks published before 1990. RESULTS: Although the cognitive processes needed to manage and take medications decline with aging, the number of prescription and nonprescription medications consumed increases. Other factors such as vision, hearing, health literacy, disability, and social and financial resources may all complicate the ability of older adults to adhere to the pharmacologic prescription. CONCLUSIONS: Many factors are associated with medication adherence and related health outcomes in older adults. Therefore, strategies to improve adherence will need to be multidimensional, including improvements in pharmacy services that consider age-related factors (eg, declining cognitive and physical functions) as well as a variety of environmental and social factors.

The effects of health and environment on exercise-class participation in older, urban women.

This research investigated the effects of health and environmental factors on the dropout and intermittent nonattendance of an exercise program designed specifically for older, female, primary-care patients living in the inner city. Class-attendance records (n = 21,538) from a cohort 110 women were analyzed. Women who dropped out early had poorer perceived health and were more likely to report pain as an exercise barrier at baseline. Those who lived in a census tract where a larger percentage of workers walk to work were less likely to drop out early. Intermittent nonattendance was associated with adverse weather conditions including heat index above 90 degrees F, wind-chill index below 20 degrees F, overcast sky, and snow. Better attendance was associated with greater atmospheric pressure, as well as lower number of sunlight hours per day. This research highlights the need to better understand environmental barriers when promoting physical activities in older women.

Correlates of health-related quality of life among lower-income, urban adults with congestive heart failure.

BACKGROUND: Improving health-related quality of life (HRQL) is a primary goal in the treatment of patients with congestive heart failure (CHF), yet few studies have explored correlates of HRQL among CHF patients. OBJECTIVES: We report on the association of demographic and pathophysiologic measures, social-cognitive measures, and environmental variables with HRQL as measured by the Kansas City Cardiomyopathy Questionnaire (KCCQ), Chronic Heart Failure (CHQ), and a single question of perceived overall health (PH). METHODS: Cross-sectional data were obtained from the baseline interview and electronic medical records of 212 patients 50 years of age and older who were enrolled during the first 7 months of a medication adherence study. RESULTS: Mean age was 63; 32% were male; 53% were black; the mean Charlson comorbidity score was 3.7; and the mean New York Heart Association class was 2.1. Correlations between KCCQ and CHQ subscale scores and PH ranged from 0.16 to 0.37. Multivariate regression analyses showed that the pathophysiologic measures ejection fraction and comorbidity were not associated with any of the HRQL measures. Overall PH was associated with greater age and more positive health beliefs. Persons of greater age, males, and black respondents had higher CHF-specific HRQL scores, as did persons reporting more positive health beliefs, greater income, social support, and communication with their physician. Variance explained ranged from 14 to 33%. CONCLUSION: These cross-sectional data highlight the potential significance of social and behavioral factors in CHF-specific HRQL.