Factors associated with adherence to medication regimens in older primary care patients: the Steel Valley Seniors Survey.

OBJECTIVE: The aim of this study was to explore associations between 2 specific cognitive domains and aspects of medication management among older primary care patients. METHODS: A sample of patients aged >or=65 years drawn from several small-town primary care practices was carefully characterized by cognitive testing and use of prescription medications. Two primary outcome variables were examined: (1) self-reports of setting up schedules to manage their own medications and (2) overall research assessment of adherence to prescribed medications. Predictor variables included scores on tests of verbal memory (Hopkins Verbal Learning Test) and executive function (Part B of the Trail Making Test); prescription insurance status; number of medications; and dosing frequency, adjusting for age, sex, and level of education. Multiple logistic regression and generalized estimating equation models were used for multivariable analyses. RESULTS: The analytic sample included 343 patients (238 women, 105 men; mean [SD] age, 77.52 [6.71] years). Higher scores on the verbal memory test were independently associated with successfully setting up a medication schedule, after adjusting for covariates (compared with scores in the <10th percentile, odds ratio [OR] for scores between the 10th and 50th percentiles: 5.02 [95% CI, 2.22-11.33; P < 0.001]; OR for scores in the >50th percentile: 6.52 [95% CI, 2.76-15.42; P < 0.001]). Higher scores on the executive function test were associated with treatment adherence (compared with scores in the <10th percentile, OR for scores between the 10th and 50th percentiles: 3.25 [95% CI, 1.13-9.33; P = 0.03]; OR for scores in the >50th percentile: 4.32 [95% CI, 2.76-15.68; P = 0.02]). Compared with using or=5 drugs was also associated with poor adherence (OR: 0.45 [95% CI, 0.21-0.95; P = 0.04]) as measured by research nurses' assessment of adherence. CONCLUSIONS: In this sample of older patients assessed for medication management, independent cognitive processes were associated with the ability to set up a medication schedule and overall adherence to prescriptions. Better verbal memory functioning was strongly and independently associated with setting up a medication schedule, while better executive functioning was strongly and independently associated with being fully adherent to prescription instructions. Deficits in either cognitive ability could result in medication errors due to nonadherence.

Cognitive assessment of older primary care patients with and without memory complaints.

BACKGROUND: Dementia screening is currently recommended only for symptomatic patients. OBJECTIVE: To evaluate memory complaints, a mental status test, and several cognitive tests as dementia screens in primary care. DESIGN: Cross-sectional clinical epidemiologic study. PARTICIPANTS: Three hundred thirty-nine comprehensively assessed, primary care patients aged > or = 65 years. MEASUREMENTS: Memory complaints were abstracted from chart review. Scores on Mini-Mental State Examination (MMSE) and domain-specific cognitive testing were compared to a dementia diagnosis based on Clinical Dementia Rating score > or = 1, and areas under the receiver operating characteristic curves (AUC) were calculated. Classification and regression tree analyses were performed on memory complaints and tests with the highest AUCs. RESULTS: Of 33 patients with dementia, only 5 had documented memory complaints. In 25 patients with documented memory complaints, no cognitive tests further improved identification of the 5 with dementia. In 28 patients with dementia but without memory complaints, an MMSE score < 20 identified 8 cases; among those with MMSE scores 20-21, a visual memory test identified a further 11 cases. Further cognitive testing could not detect 9 dementia cases without memory complaints and with MMSE scores > or = 22. CONCLUSIONS: In older primary care patients with memory complaints, cognitive screening does not help identify those who require further examination for dementia. Most patients with dementia do not report memory complaints. In these asymptomatic individuals, general mental status testing, supplemented by a memory test when the mental status score is equivocal, will identify lower-scoring patients who need dementia assessment. However, high-scoring asymptomatic dementia cases will remain undetected.

The clock drawing test is an independent predictor of incident use of 24-hour care in a retirement community.

BACKGROUND: It is unclear how early cognitive impairment affects future care needs. Furthermore, the Mini-Mental State Examination (MMSE), a commonly used screening tool in the clinical setting, tends to have a ceiling effect for early cognitive decline. One of the earliest changes in cognitive function is executive impairment. We examined the relationship between executive function, measured with a clock drawing protocol (CLOX1) designed to capture executive impairment, and incident need for increased level of care and total mortality. METHODS: Residents (n = 230) in independent living at a continuing care retirement community were followed for incident need for 24-hour care (mean 2.5 years). Baseline assessment included health status and physical and cognitive function. Time to event analysis was performed to determine the association of the CLOX1 score with the outcomes. RESULTS: Forty percent of residents had a CLOX1 score <12, and 10% had an MMSE score <26. The event rate for a CLOX1 score <12 was 30 per 100 person-years (p-y) and 13 per 100 p-y for a score > or =12. Similarly, the event rate was 34 per 100 p-y versus 17 per 100 p-y for MMSE <26 and MMSE > or =26, respectively. A CLOX1 score <12 was associated with a twofold higher risk of incident use of 24-hour care (hazard ratio 2.2; 95% confidence interval: 1.5-3.4) and death (hazard ratio 2.3; 95% confidence interval: 1.1-4.8) even after controlling for age, sex, comorbidity, and MMSE scores. The MMSE score was not an independent predictor of incident use of 24-hour care or mortality. CONCLUSION: The clock drawing test, scored for executive impairment, but not the MMSE, predicted incident use of 24-hour care and mortality in this cohort of independent older adults.

Clinical Global Impression of Change in Physical Frailty: development of a measure based on clinical judgment.

OBJECTIVES: To expand the ability to assess physical frailty by developing a Clinical Global Impression of Change in Physical Frailty (CGIC-PF) instrument. DESIGN: Qualitative and quantitative instrument development. SETTING: Academic centers. PARTICIPANT: s Six expert panel members, 46 clinicians, 24 patients, and 12 caregivers. MEASUREMENTS: Literature review and structured group processes with experts, clinicians, and consumers were used to generate an initial list of domains and indicators. Structured interviews with clinical experts in the area of frailty were used to establish relevance and feasibility of measurement of domains. Interrater reliability was assessed through a Web-based study. Geriatricians pilot tested the feasibility of the baseline CGIC-PF with 10 patients. RESULTS: The CGIC-PF includes six intrinsic domains (mobility, balance, strength, endurance, nutrition, and neuromotor performance) and seven consequences domains (medical complexity, healthcare utilization, appearance, self-perceived health, activities of daily living, emotional status, and social status). Each domain has two to four clinical indicators. Change is scored on a 7-point scale from markedly worse to markedly improved. Average interrater reliability of the CGIC-PF for the Web-based cases was 0.97. Geriatricians completed a baseline CGIC-PF on their own patients in 10 minutes or less. CONCLUSION: The CGIC-PF is a structured assessment of change in physical frailty with defined content and process. It has strong face validity, reliability, and feasibility for use in clinical research. It may be useful as one criterion of change and as an anchor for change in other measures.

Cognitive decline and mortality in a community-based cohort: the Monongahela Valley Independent Elders Survey.

OBJECTIVES: To compare, in a longitudinal cohort study, declines in specific cognitive domains on their ability to predict time to death, in the presence and absence of dementia, and to explore an explanatory role for vascular disease. DESIGN: Prospective population-based epidemiological study. SETTING: The mid-Monongahela valley of southwestern Pennsylvania from 1987 to 2002. PARTICIPANTS: Nine hundred eighty-nine community-dwelling adults aged 65 and older enrolled in the Monongahela Valley Independent Elders Survey. MEASUREMENTS: Biennial assessments of a range of cognitive domains for up to 12 years. Mortality was modeled as a function of decline in each domain, adjusting for vascular diseases and stratified according to age (< or =75 (younger-old) and >75 (older-old)) using Cox proportional hazards modeling. RESULTS: Average annual declines in almost all cognitive domains were significant predictors of mortality in the cohort as a whole. However, after adjustment for dementia, only general cognition, processing speed, the language composite, and the executive function composite remained significant. Adjustment for vascular diseases did not alter the results. In the younger-old group, decline in memory (hazard ratio (HR)=21.4) and executive function (HR=25.5) remained strong predictors after adjustment for dementia and vascular disease. In the older-old group, decline in processing speed was a strong predictor of mortality before (HR=7.4) and after (HR=5.3) controlling for dementia and vascular diseases. CONCLUSION: Decline in most cognitive domains predicted mortality across the cohort, but declines in memory and learning were not independent of dementia. Different domains predicted mortality in the younger and older subgroups.

Simple balance and mobility tests can assess falls risk when cognition is impaired.

To examine the ability of the Romberg test and the original untimed version of the Get-Up-and-Go test (GUG) to elders at risk for falls. At baseline and two annual follow-up visits, nurses administered the Romberg and GUG tests to 358 primary care patients aged 65+ years. Logistic regression models examined cross-sectional and longitudinal associations between abnormal balance tests and self-reported falls over the preceding year. Models were adjusted for age, sex, education and self-rated health (and, in the longitudinal models, for baseline falls), and the Mini-Mental State Examination (MMSE) as a measure of cognitive status. In cross-sectional analyses, falls reported at baseline were significantly associated with concurrently abnormal Romberg and GUG tests, after adjustment for covariates. In longitudinal analyses, abnormal GUG remained significantly associated with future falls, adjusting for covariates. Among those with low MMSE, GUG remained a significant predictor of future falls. Both balance tests were associated with low MMSE among those reporting no falls. Simple balance tests can help assess falls risk, particularly in cognitively impaired elderly who have elevated falls risk and might not accurately recall previous falls.

The association between congestive heart failure and cognitive performance in a primary care population of elderly adults: the Steel Valley Seniors Survey.

BACKGROUND: Evidence suggests an association between congestive heart failure (CHF) and cognitive function, particularly in heart transplant patients and patients hospitalized for CHF. We examined the association between CHF and cognitive performance in stable outpatients recruited from primary care. METHODS: This is a cross-sectional secondary data analysis of the Steel Valley Seniors Survey, an epidemiological study of elderly primary care outpatients. Participants aged >/= 65 years were recruited in primary care clinics. The study cohort (n = 354) is a subgroup, composed of subjects with Mini-mental State Examination score < 25, and a random sample of the remaining, who underwent a baseline assessment in the home. The assessment included demographics, comorbid illnesses, depressive symptoms, functional status, a neurological examination and a neuropsychological battery. CHF is defined by self-report and/or chart review, and stable CHF as not being hospitalized in the year prior to the assessment. The associations between CHF and specific cognitive tests were examined by bivariate analysis and logistic regression, controlling for demographic variables. RESULTS: Subjects with CHF performed worse on tests of visual memory [10.1 (S.D. 5.4) vs. 12.7 (S.D. 5.2), p = 0.007], Trailmaking B [0.1 (0.1) vs. 0.2 (0.1), p = 0.002], category fluency [11.1 (4.4) vs. 13.4 (4.5), p = 0.008], and clock drawing [5.6 (1.9) vs. 6.7 (1.4), p < 0.001] compared to subjects without CHF, after adjustment for relevant demographic variables. CONCLUSION: CHF is associated with lower cognitive functioning in a population of patients with stable heart failure in primary care settings.