Impact of Cognitive Function Change on Mortality in Renal Transplant and End-Stage Renal Disease Patients.

BACKGROUND: Limited evidence from small-scale studies, mainly involving end-stage renal disease (ESRD) patients, suggests that kidney transplantation may improve cognitive function. We examined changes in cognitive function after a kidney transplant and its association with survival in advanced chronic kidney disease (CKD)/ESRD patients. METHODS: In a prospective study design, cognitive performance of 90 patients (50.6 ± 13.1 years, 66.7% men, 27.8% blacks, 76% CKD stages 4-5) was assessed at the respective patients' residences using established neurocognitive tests. RESULTS: Among the 90 patients, 44 received a kidney transplant (KTx group) while 46 did not (no-KTx group). After a mean follow-up of ∼19 months, there was no significant change in scores for majority of cognitive tests in either group. Older age, but not diabetes or renal function status (CKD vs. ESRD), was a determinant of poor follow-up cognitive performance. Additionally, poor attention/psychomotor speed and executive performance (as measured by Trails A and Stroop test, respectively) was associated with higher mortality over a mean follow-up of 4.7 years, even after adjustment for age, sex, diabetes, CKD or ESRD status and kidney transplant status. CONCLUSION: Overall, cognitive function does not significantly improve after kidney transplant or significantly decline in non-transplanted, advanced CKD/ESRD patients. Poor attention, psychomotor speed and executive performance independent of transplant status were associated with higher mortality over time.

Medication health literacy measure: development and psychometric properties.

BACKGROUND AND PURPOSE: Low levels of health literacy are prevalent worldwide. This report details development and psychometric properties of a health literacy measure for oral medications based on design of the Newest Vital Sign. METHODS: The measure was completed during the baseline interview. A principal components analysis evaluated dimensionality of the measure. Cronbach's alpha assessed subscale internal consistencies. RESULTS: Internal consistencies and reliability for the subscales were acceptable for a new instrument (alpha = .661, alpha = .686, alpha = .400). A 3-factor structure explained 65.34% of the total variance. Divergent validity with the Rapid Estimate of Adult Literacy in Medicine (REALM) was established. CONCLUSIONS: Our data indicates that the medication health literacy tool is multidimensional, valid, and reliable. This information is important in light of emerging evidence of the impact of health literacy on medication adherence and health.

Pathways of psychosocial factors, stress, and health outcomes after liver transplantation.

The impact of stress and individual factors on health outcomes in general medicine and transplantation are well documented. Few researchers have investigated the complex relationships between these constructs. This longitudinal study assessed coping style, self-regulatory ability, hostility, and social support at baseline among a cohort of 130 adult liver transplant recipients at the Starzl Transplant Institute, University of Pittsburgh Medical Center, and followed those subjects with interview and medical records data about personal and transplant-related stress, physical and mental health outcomes throughout the first post-transplant year. Results show a number of strong bidirectional relationships between coping style, self-regulatory ability, hostility, the caregiver relationship and family environment, personal and transplant-related stress over the second half of the first post-transplant year, and health (especially mental) outcomes at 12 months post-transplant. Stress mediates the relationship between psychosocial factors and mental health outcomes. The importance of those relationships to researchers and clinicians is discussed.

Factors influencing the outcomes of patients with both coronary artery disease and diabetes enrolled in standard cardiac rehabilitation programs: a literature review.

Currently 23.5 million working-age adults 20 years or older have had a diagnosis of both coronary artery disease (CAD) and type 2 diabetes mellitus (T2DM), with estimates that an additional 9% of the total US population will have a diagnosis of this chronic disease combination by the year 2025. Current annual health care costs for this working-age population including medical costs, functional disability, work loss, and premature mortality currently exceed $620 billion. Prior research efforts have shown that 25% to 32% of patients requiring a coronary revascularization procedure have both CAD and T2DM. The primary intervention prescribed for these patients to regain functional ability after revascularization is enrollment in a standard outpatient cardiac rehabilitation (CR) program. These standard programs, ranging in duration from 6 to 12 weeks, have been shown to improve the physical function of CAD patients by up to 15%, but patients diagnosed with both chronic conditions of CAD and T2DM (T2DM+CAD) attending these same programs exhibit only an 8% improvement. Moreover, T2DM+CAD patients experience much lower rates of rehabilitation program appointment adherence as well as greater program attrition (T2DM+CAD: 45%-62% vs CAD: 92%). Current medical literature regarding the relationship between CAD, T2DM, and cardiac rehabilitation will be examined to identify specific factors that could influence the functional outcomes achieved by the T2DM+CAD population when enrolled in a standard CR program and help increase understanding of why the adherence and attrition differences exist.

A family-centered educational program to promote independence in pediatric heart transplant recipients.

CONTEXT: Characteristic adolescent risk-taking behavior, including nonadherence with prescribed medications, can be life-threatening for transplant recipients. Suggestions for managing nonadherence in teen recipients include providing them and their parents with adequate information about medications, talking with and listening to pediatric recipients about problems with the comprehensive regimen, and encouraging age-appropriate responsibility for maintaining health. OBJECTIVE: The clinical goal of this project was to develop a structured age-appropriate educational program to prepare pediatric transplant recipients and their families for the patient's life as a responsible, independent individual. Our primary research goal was to assess patients' and parents' knowledge about critical aspects of heart transplantation and the treatment regimen with brief questionnaires before and after they received the educational materials from their primary nurse coordinator. DESIGN, SETTING, PARTICIPANTS: This descriptive pre-post test study was done to assess the effectiveness of an innovative family-centered educational program among 20 pediatric heart transplant recipients and their parents at Children's Hospital of Pittsburgh, University of Pittsburgh Medical Center. MAIN OUTCOME MEASURE, RESULTS: Percentage change in children's scores on questionnaires given before and after the educational intervention ranged from -8% to 300% (mean, 64.1%). Percentage change in scores from before to after for parents ranged from -19% to 53.8% (mean, 7.2%).

Personality traits and chronic illness: a comparison of individuals with psychiatric, coronary heart disease, and HIV/AIDS diagnoses.

This secondary analysis used the five-factor model of personality to examine personality traits in four samples of patients with chronic disorders. Profiles of personality traits differed across disorders. Although participants with psychiatric disorders and participants with HIV/AIDS had similar patterns of personality traits, patients with psychiatric disorders were more extreme on all traits except agreeableness. Patients with hyperlipidemia and those who had cardiothoracic transplants had similar patterns. Nurses and researchers need to consider personality traits that drive patterns of behavior in designing more effective ways to promote better health and manage disease.

Complementary and alternative medicine in the treatment of pain in fibromyalgia: a systematic review of randomized controlled trials.

OBJECTIVE: The purpose of this study was to systematically review the literature for randomized trials of complementary and alternative medicine (CAM) interventions for fibromyalgia (FM). METHODS: A comprehensive literature search was conducted. Databases included the Cochrane library, PubMed, PsycINFO, Cumulative Index to Nursing and Allied Health, Natural Medicines Comprehensive Database Manual, Alternative and Natural Therapy Index System (MANTIS), Index for Chiropractic Literature, and Allied and Complementary Medicine (AMED). Inclusion criteria were (a) subjects were diagnosed with fibromyalgia and (b) the study design was a randomized controlled trial that compared a CAM therapy vs a control group. Studies were subgrouped by CAM treatment into 11 categories. Evidence tables and forest plots were organized to display quality ratings and effect sizes of each study. RESULTS: The literature search yielded 1,722 results; 102 abstracts were selected as potential articles for inclusion. Sixty studies met criteria and were rated by 2 reviewers; 18 were rated as good quality; 20, moderate; 18, low; and 4, very low. Synthesis of information for CAM categories represented by more than 5 studies revealed that balneotherapy and mind-body therapies were effective in treating FM pain. This study analyzed recent studies and focused exclusively on randomized controlled trials. Despite common use of manual therapies such as massage and manipulation to treat patients with FM, there is a paucity of quality clinical trials investigating these particular CAM categories. CONCLUSION: Most of these studies identified were preliminary or pilot studies, thus had small sample sizes and were likely underpowered. Two CAM categories showed the most promising findings, balneotherapy and mind-body therapies. Most of the other CAM categories showed a trend favoring the treatment group. It appears that several CAM therapies show some preliminary treatment effect for FM pain, but larger trials that are more adequately powered are needed.

Liver transplant recipients: individual, social, and environmental resources.

CONTEXT: Patient characteristics are important in the liver transplant population because of proven associations between individual and environmental factors, treatment adherence, and health outcomes in general medical and other transplant populations. OBJECTIVE: To determine generalizability of the sample to other liver transplant populations and to establish reliability of measures used to assess individual and environmental resources. DESIGN: Cross-sectional analysis of baseline data in a longitudinal study of adherence and health outcomes. PARTICIPANTS, SETTING: Ninety first-time adult liver transplant recipients at the University of Pittsburgh Medical Center completed assessments of sociodemographic, health history, psychosocial, and environmental factors shortly after surgery; adherence and health outcomes were tracked throughout the study. RESULTS: The medical center cohort was older, less racially diverse, and contained more living donors than the national sample. Our sample was generally comparable to the medical center cohort on pretransplant sociodemographic and clinical characteristics. Reliability/internal consistency on psychological measures was similar between our sample and most published norms. The mean scores on all coping scales in our sample were higher than normative. Our patients indicated a more negative perception of family environment and perceived relationships with their primary caregiver more positively than did the normative group. CONCLUSION: The generalizability of our sample to the parent population and reliability of individual and environmental measures reported here will enable us to examine relationships and the value of patient and contextual resources for predicting treatment adherence and health outcomes among liver transplant recipients.

Individual and environmental correlates and predictors of early adherence and outcomes after liver transplantation.

CONTEXT: Little is known about patients' contribution to health outcomes after liver transplantation. Yet, in other transplant recipients, nonadherent behavior is directly related to the leading causes of morbidity and mortality in liver transplant recipients. OBJECTIVE: To examine patient and environmental factors in relation to all aspects of adherence to the posttransplantation regimen and health outcomes in the first 6 months after transplantation. DESIGN: A descriptive analysis of individual and environmental factors in relation to adherence and health outcomes at 6 months after liver transplantation. PARTICIPANTS, SETTING: One hundred fifty-two adult liver transplant recipients at the University of Pittsburgh Medical Center. MAIN OUTCOME MEASURES: Adherence to medication taking, appointment keeping, lifestyle changes, mood, quality of life, and clinical markers of liver function. RESULTS: Nonadherence was prevalent (47% with appointments, 73% with medication); relapse to drug/alcohol use occurred among a few recipients (5.6%), all with a history of substance abuse before transplantation. Patterns of coping, decision making, attitude, and social support were correlated with adherence, clinical markers, and psychological function (r = 0.22-0.45). Avoidant coping, affective dysregulation, and caregiver support emerged as robust predictors of negative clinical and mental health outcomes (beta = .224-.363). CONCLUSION: This information about liver transplant recipients is important for researchers and clinicians. Researchers can develop guidelines by using stable but modifiable characteristics of patients to identify transplant candidates at risk of nonadherence. Such guidelines would enable clinicians to prepare patients better to manage the posttransplant regimen.

Further exploration: maturity and adherence in adolescent and young adult heart transplant recipients.

CONTEXT: Pediatric transplant clinicians note high rates of nonadherence with medications, appointment keeping, and laboratory tests and high rates of engagement in high-risk behaviors among older adolescents and young adult recipients. The caregivers also report symptoms of identity confusion, social immaturity, and failure to appreciate consequences of risky behavior among recipients. OBJECTIVE: To build on an earlier study that identified developmental characteristics that distinguish poor from good adherers. DESIGN: Qualitative methods were used to explore key themes identified in the first study with heart transplant recipients and their significant others. RESULTS: This research confirmed the themes of developmental maturity suggested by the first study: good adherers were able to integrate the transplant into sense of self, become independent adults, and achieve normalcy; poor adherers continued to "push away" the transplant experience and worried that they would never be normal. The good adherers, their parents, and friends had views of relationships that were congruent, acknowledging difficulties, discussing them, and moving toward mutual satisfaction. The poor adherers, their parents, and friends expressed incongruent views of the relationships, avoiding discussion of problems and idealizing relationships. DISCUSSION: Strategies for clinicians, family, and friends to increase maturity and independence among older adolescent and young adult heart transplant recipients are described.

Personality characteristics among cardiothoracic transplant recipients.

Personality characteristics are clinically believed to predict posttransplant adherence and outcome; however, data, as to the prevalence and type of personality disorders (PDs) and distribution of personality traits among transplant (txp) populations, are sparse and inconclusive. This paper reports on the prevalence and type of PD and range of personality traits, according to the Five-Factor model, among 73 adult cardiothoracic txp recipients. It represents the first systematic assessment of PDs and traits in a sample of txp recipients. Personality disorders were assessed with a semistructured diagnostic interview; personality traits were assessed with a self-report instrument. Thirty-three percent of the sample met diagnostic criteria for a PD, approximately three times higher than prevalence of PD previously reported among nonpsychiatric populations. Mean values of personality traits for the sample were in the normative range but with wide variability; extreme values on four of the five traits were scored by subjects with a PD. This unexpectedly high prevalence of PD and the wide variability in traits among heart and lung recipients alert clinicians to consider personality characteristics when planning interventions to increase compliance and maximize quality of life after cardiothoracic transplantation.

Psychosocial vulnerability, physical symptoms and physical impairment after lung and heart-lung transplantation.

BACKGROUND: Many lung and heart-lung transplant recipients experience distressing physical symptoms and elevated physical impairment levels. Although post-transplant complications and secondary illnesses may largely account for these health limitations, patients' psychosocial well-being may influence them as well. We examined the contribution of psychosocial variables to patients' experience of physical symptoms and physical impairment. METHODS: The study consisted of a cross-sectional sample of 50 patients (36 lung, 14 heart-lung) at between 2 and 17 months post-transplant. They were interviewed to assess physical symptoms, current physical impairment and psychosocial well-being in the areas of mental health, sense of mastery and coping. Medical record reviews established the presence of medical complications and secondary illnesses concurrent with the interviews. Descriptive analyses examined the range of symptoms and levels of physical impairment experienced. Bivariate analyses and multivariate linear regression examined relationships between key variables. RESULTS: Average number of physical symptoms and level of physical impairment met or exceeded levels reported in other transplant samples. Elevated depressive and anxiety symptoms, a low sense of mastery, and the presence of concurrent medical complications were each associated with increased number of physical symptoms and physical impairment level. When the impact of concurrent medical complications was controlled, recipients with elevated psychologic distress remained significantly more likely to report more physical symptoms and higher physical impairment levels. CONCLUSIONS: Patients' physical health status may be influenced by many factors. To the extent that psychologic distress increases the likelihood of perceived physical limitations, timely identification and treatment of distress may help to maximize quality of life after lung and heart-lung transplantation.

The impact of cognitive function on medication management: three studies.

OBJECTIVE: Medication nonadherence has been a persistent problem over the past three decades; forgetting and being distracted from regular routines are the barriers most frequently cited by patients. Prior research on cognitive function and medication adherence has yielded mixed results. DESIGN: This report compares findings of three studies: All were longitudinal, two were randomized controlled intervention trials, and one was descriptive. Samples of adult patients taking once daily lipid-lowering medication, diabetic patients with comorbid conditions on complex regimens, and early stage breast cancer patients on hormonal therapy completed similar batteries of standardized, valid, neuropsychological tests at baseline. MAIN OUTCOME MEASURES: Adherence to medication regimens, over time, was tracked with electronic event monitors. RESULTS: Medication nonadherence was prevalent in all studies. Deficits in attention/mental flexibility and/or working memory predicted nonadherence in all studies; impaired executive function was related to poor adherence in one study. CONCLUSION: These findings suggest that better mental efficiency may be the key to better medication adherence with any regimen, and that targeted cognitive functions, which can be easily and quickly assessed, may identify patients at risk of poor adherence regardless of diagnosis or regimen.

Research participation among older adults with mobility limitation.

The purpose of this qualitative descriptive study was to examine reasons for participation in clinical research among older adults with mobility limitation. A purposive sample of 20 men and 20 women aged 70 years or older was recruited. Data were collected by audiotaped telephone interviews using a semistructured interview guide and transcribed verbatim. Participants expect privacy, professionalism by research staff, and respectful treatment. Benefits to protocol adherence include personal education, comparison of their health status with that of others, opportunity to maintain vitality, and altruism. Barriers to protocol adherence are apprehension, in particular a negative impact on their health care, randomization to the control group, and experimental drugs; and inconvenience. Factors promoting study completion are obligation, reciprocity, receipt of test results, health promotion, and socialization. Implications include meeting expectations, providing health education and study results to participants, reducing barriers to participation, and presenting opportunities for interaction with others.

Maturity and adherence in adolescent and young adult heart recipients.

BACKGROUND: Pediatric transplant (txp) teams note high rates of non-adherence and risky behaviors linked to morbidity and mortality among adolescent and young adult recipients. Clinicians and parents alike report symptoms of social immaturity and failure to appreciate consequences of risky behavior; relationships between the two have not been studied in this population. METHOD: This two-phase mixed method study examined adherence, high-risk behaviors, and maturity in a sample of 27 heart recipients, aged 15-31, who underwent transplantation in childhood or adolescence at Children's Hospital of Pittsburgh. All subjects completed a projective ego development measure and a questionnaire about adherence to the post-txp regimen. Nine recipients, purposely selected for good or poor adherence according to criteria determined by the transplant team and matched on age, participated in phase 2 qualitative interviews and mood assessments. RESULTS: Sixty-three percent of the phase 1 sample missed medications, 67% missed appointments, 11% smoked, 37% had difficulty with diet, 89% exercised infrequently, 33% had tattoos, 26% had more than two body piercings, and 11% used street drugs. Six themes and a core construct of maturity were identified with qualitative methodology. Poor adherers were less mature on every theme and consistently scored at a less mature level on the projective measure of ego development. Chronological age was not related to the level of maturity in qualitative or projective data. Most interview subjects reported high levels of anxiety, and two reported clinically significant levels of depression and anger; mood was not related to adherence. CONCLUSIONS: Non-adherence and high-risk behaviors are prevalent among adolescent and young adult heart recipients. Level of maturity appears to be associated with ability to adhere to the treatment regimen and avoid high-risk behaviors.

Cognitive function in adult cardiothoracic transplant candidates and recipients.

Innovative surgical and medical techniques have prolonged the life span of cardiothoracic (CT) transplant recipients and made transplantation an option for many older patients. Cognitive function is a key determinant of the CT transplant recipient's ability to manage the complex treatment regimen and experience optimum benefit of the procedure. As the CT population ages, risk of cognitive dysfunction due to normal aging is compounded by the physical and mental changes associated with end-stage organ disease, comorbid conditions, and transplant-related complications. Cognitive abilities consist of (a) receptive functions (ability to select, acquire, classify, and integrate information); (b) memory and learning (ability to store and retrieve information); (c) thinking (ability to mentally organize and reorganize information; and (d) expressive functions (ability to communicate or act upon information). Although each of these functions represents a distinct type of behavior, they are interdependent. The purpose of this article is to (a) discuss the literature regarding cognitive function before and after adult heart, lung, and heart-lung transplantation; (b) identify methodological problems associated with the studies done to date; and (c) make recommendations for future research in this area.

Psychological and cognitive function: predictors of adherence with cholesterol lowering treatment.

BACKGROUND: Failure to adhere to medication regimes is a significant problem in clinical and research settings yet reliable, consistent identification of key psychosocial predictors remains elusive. Studies of mood and personality related to adherence show mixed results-compliance and objectively measured cognitive function are intuitively related but empirical support is lacking. PURPOSE: This study is a secondary analysis to examine the relations between adherence with a medication regime for lowering serum cholesterol and several domains of psychological and cognitive functioning. METHODS: Participants in the initial study completed a measure of personality and a battery of neuropsychological measures at baseline; anxiety and depression were measured at baseline and at 4-week intervals. Medication adherence was tracked with electronic cap monitors for 24 weeks. RESULTS: Only 23% of the sample was fully adherent to medication regimes at least 80% of the time over the 6-month study period. Conscientiousness, according to the Five Factor Theory of Personality, and estimated IQ remained robust predictors of adherence in hierarchical regression analyses. Depression and anxiety, mental flexibility, and visuospatial-constructional ability were less robust but statistically significant (p <.05) correlates of adherence. CONCLUSIONS: Although results of this analysis explain only a portion of the variance in adherence, they demonstrate the importance of trait psychological and cognitive factors in adherence research.