Relationship Between Antihypertensive Medications and Cognitive Impairment: Part II. Review of Physiology and Animal Studies.

PURPOSE OF REVIEW: There is an established association between hypertension and increased risk of poor cognitive performance and dementia including Alzheimer's disease; however, associations between antihypertensive medications (AHM) and dementia risk are less clear. An increased interest in AHM has resulted in expanding publications; however, none of the recent reviews provide comprehensive review. Our extensive review includes 24 mechanistic animal and human studies published over the last 5 years assessing relationship between AHM and cognitive function. RECENT FINDINGS: All classes of AHM showed similar result patterns in animal studies. The mechanism by which AHM exert their effect was extensively studied by evaluating well-established pathways of AD disease process, including amyloid beta (Aß), vascular, oxidative stress and inflammation pathways, but only few studies evaluated the blood pressure lowering effect on the AD disease process. Methodological limitations of the studies prevent comprehensive conclusions prior to further work evaluating AHM in animals and larger human observational studies, and selecting those with promising results for future RCTs.

Relationship Between Antihypertensive Medications and Cognitive Impairment: Part I. Review of Human Studies and Clinical Trials.

PURPOSE OF REVIEW: There is an established association between hypertension and increased risk of poor cognitive performance and dementia including Alzheimer's disease; however, associations between antihypertensive medications (AHMs) and dementia risk are less consistent. An increased interest in AHM has resulted in expanding publications; however, none of the recent reviews are comprehensive. Our extensive review includes 15 observational and randomized controlled trials (RCTs) published over the last 5 years, assessing the relationship between AHM and cognitive impairment. RECENT FINDINGS: All classes of AHM showed similar result patterns in human studies with the majority of study results reporting point estimates below one and only a small number of studies (N = 15) reporting statistically significant results in favor of a specific class. Only a small number of studies reported statistically significant results in favor of a specific class of AHM. Methodological limitations of the studies prevent definitive conclusions. Further work is now needed to evaluate the class of AHM and cognitive outcomes in future RCTs, with a particular focus on the drugs with the promising results in both animals and human observational studies.

Assessing the wellbeing of family caregivers of multimorbid and homebound older adults-A scoping literature review.

BACKGROUND: The prevalence of homebound older adults in the United States more than doubled during the COVID-19 pandemic with greater burden on family caregivers. Higher caregiver burden, more specifically higher treatment burden, contributes to increased rates of nursing home placement. There exist a multitude of tools to measure caregiver well-being and they vary substantially in their focus. Our primary aim was to perform a scoping literature review to identify tools used to assess the facets of caregiver well-being experienced by caregivers of persons with multiple chronic conditions (MCC) with a special focus on those caregivers of homebound adult patients. METHODS: The search was conducted in accordance with the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) extension for scoping reviews. After refining search terms, searches were performed of the peer-reviewed and gray literature. RESULTS: After removal of duplicate studies, a total of 5534 total articles were screened for relevance to our study. After all screening and review were completed, 377 total articles remained for full review which included 118 different quantitative tools and 20 different qualitative tools. We identified the 15 most commonly utilized tools in patients with MCC. The Zarit Burden Interview was the most commonly used tool across all of the studies. Of the 377 total studies, only eight of them focused on the homebound population and included 13 total tools. CONCLUSIONS: Building on prior categorization of well-being tools, our work has identified several tools that can be used to measure caregiver well-being with a specific focus on those caregivers providing support to older adults with MCC. Most importantly, we have identified tools that can be used to measure caregiver well-being of family caregivers providing support to homebound older adults, an ever-growing population who are high cost and high utilizers of health care services.

The Value of Home-Based Primary Care: Qualitative Exploration of Homebound Participant Perspectives.

Older adults' preference to age in place and health systems' commitment to cost-effective quality care has set the stage for a growing interest in home-based primary care (HBPC). The objective of this study was to explore what patients and caregivers value about HBPC and what modifications could improve its value. Semi-structured individual interviews (n = 20) were audio-recorded, transcribed, and coded for themes. Four themes emerged: (a) HBPC offers peace of mind because patients can access care without leaving the home and can reach the primary care team at all hours, (b) HBPC supports aging in place by providing in-home care, (c) HBPC supports provider rapport building because of the intimate setting and continuity of care, (d) HBPC patients and caregivers have significant nonmedical needs. Findings suggest that teams developing or expanding on HBPC programs should prioritize access to providers, rapport building with patients and families, and supporting patients' and caregivers' nonmedical needs.

A Home-Based Care Research Agenda by and for Homebound Older Adults and Caregivers.

Homebound older adults have not had a voice in establishing a research agenda relevant to their needs and perspectives. We engaged homebound older adults receiving home-based primary care and caregivers to serve as stakeholder advisors to develop a patient- and caregiver-centered research agenda for home-based care. Over 9 months, we facilitated eight tablet-enabled videoconference meetings. We oriented advisors to patient-centered outcome research and research question development. Advisors developed and prioritized a list of 14 research domains and 127 associated research questions. The top three prioritized research domains in descending rank order (number of associated research questions) were out-of-pocket costs of caregiving (10), access to home-based care and related policy issues (19), and relationship with doctors (15). This research agenda can guide researchers' efforts to focus on areas of importance to the ultimate end users of their research.

Understanding the Daily Experiences and Perceptions of Homebound Older Adults and Their Caregivers: A Qualitative Study.

More than 7.3 million older adults in the United States have difficulty leaving their homes or are completely homebound, yet little data exist on the experiences of homebound older adults and their caregivers. We conducted 30 semi-structured qualitative interviews with homebound older adults and caregivers recruited through home-based medical care practices in Baltimore and San Francisco. Thematic template analyses revealed that homebound older adults experience varying degrees of independence in activities of daily living, although their degree of dependence increases over time. Caregivers have a multifaceted, round-the-clock role. Both patients and caregivers experience burdens including social isolation and guilt. Navigating medical care and caregiving was further complicated by the complexity of the U.S. health care system; however, home-based medical care was viewed as a high-quality alternative to hospitals or nursing homes. Our findings suggest that providers and health care systems should expand the availability and accessibility of home-based care and improve caregiver support opportunities.

Challenges Related to Safety and Independence.

Advancing age is associated with increasing risk of activities important for independence, such as driving and living alone. Cognitive impairment is more common with older age; financial resources and social support may dwindle. Risk, cognitive impairment, and decisional capacity each change over time. Transparent decision making and harm reduction help balance risk and safety. When a patient lacks decisional capacity, an option that considers the patient's preferences and shows respect for the person is favored. Vulnerable patients making choices that are high risk, and patients for whom others are making such choices, may require state intervention.

The Resurgence of Home-Based Primary Care Models in the United States.

This article describes the forces behind the resurgence of home-based primary care (HBPC) in the United States and then details different HBPC models. Factors leading to the resurgence include an aging society, improved technology, an increased emphasis on home and community services, higher fee-for-service payments, and health care reform that rewards value over volume. The cost savings come principally from reduced institutional care in hospitals and skilled nursing facilities. HBPC targets the most complex and costliest patients in society. An interdisciplinary team best serves this high-need population. This remarkable care model provides immense provider satisfaction. HBPC models differ based on their mission, target population, geography, and revenue structure. Different missions include improved care, reduced costs, reduced readmissions, and teaching. Various payment structures include fee-for-service and value-based contracts such as Medicare Shared Savings Programs, Medicare capitation programs, or at-risk contracts. Future directions include home-based services such as hospital at home and the expansion of the home-based workforce. HBPC is an area that will continue to expand. In conclusion, HBPC has been shown to improve the quality of life of home-limited patients and their caregivers while reducing health care costs.

Magnetic nanotubes for magnetic-field-assisted bioseparation, biointeraction, and drug delivery.

Tubular structure of nanoparticles is highly attractive due to their structural attributes, such as the distinctive inner and outer surfaces, over conventional spherical nanoparticles. Inner voids can be used for capturing, concentrating, and releasing species ranging in size from large proteins to small molecules. Distinctive outer surfaces can be differentially functionalized with environment-friendly and/or probe molecules to a specific target. Magnetic particles have been extensively studied in the field of biomedical and biotechnological applications, including drug delivery, biosensors, chemical and biochemical separation and concentration of trace amounts of specific targets, and contrast enhancement in magnetic resonance imaging (MRI). Therefore, by combining the attractive tubular structure with magnetic property, the magnetic nanotube (MNT) can be an ideal candidate for the multifunctional nanomaterial toward biomedical applications, such as targeting drug delivery with MRI capability. Here, we successfully synthesized magnetic silica-iron oxide composite nanotubes and demonstrated the magnetic-field-assisted chemical and biochemical separations, immunobinding, and drug delivery.