Patient activation and medication adherence in adults.

BACKGROUND: Patients' level of medication adherence provides conflicting results in its relationship to patient activation. Multiple factors may be contributing to these mixed results. OBJECTIVES: The primary purpose was to assess the association of patient activation to medication adherence in adults with chronic health conditions and low health literacy (HL). Secondary objectives were to determine whether age, education, gender, and race were associated with activation. METHODS: Participants completed self-report questionnaires regarding chronic disease self-management. Patient activation was measured using Hibbard's Patient Activation Measure (PAM). Self-report of medication adherence was determined using the Gonzalez-Lu adherence questionnaire. Block regressions first assessed the relation of demographic variables and education to adherence and then the added relation of patient activation in a second model. RESULTS: The analyses included 301 participants (mean age 58 years; 53% female; mean chronic conditions of 6.6). Some of the most common chronic conditions included hypertension (60%), arthritis (51%), depression (49%), and hyperlipidemia (43%). The relation of older age to greater medication adherence was significant (P < 0.05) in both models. The addition of PAM was significantly related to better adherence (P < 0.001) and also increased the R squared value from 0.04 to 0.09. This change resulted in a moderate effect size (d = 0.50). CONCLUSION: Evaluating patient activation at baseline may predict those more likely to be medication adherent in patients with low HL.

Cognitive function and impact on driving after SARS-COV-2 infection in a man with long-standing HIV infection: a case report.

A substantial number of individuals who experience COVID-19 infection experience prolonged physical and mental symptoms after resolution of their initial infection, and among them, many individuals experience cognitive difficulties including memory lapses and executive function difficulties, often referred to as "brain fog." The possible impact of COVID-19 infection on cognition in persons with HIV-related cognitive disorders is unknown. In this report, we describe post-COVID-19 cognitive and driving function in a 62-year-old man with HIV infection since the early 1990s.

Durable viral suppression among persons with HIV in the deep south: an observational study.

This study assessed predictors of stable HIV viral suppression in a racially diverse sample of persons living with HIV (PWH) in the southern US. A total of 700 PWH were recruited from one of four HIV clinics in Metro Atlanta, GA. Data were collected from September 2012 to July 2017, and HIV viral loads were retrieved from EMR for 18 months. The baseline visits and EMR data were used for current analyses. Durable viral suppression was categorized as 1. Remain suppressed, 2. Remain unsuppressed, and 3. Unstable suppression. The number of antiretroviral medications and age were significantly associated with durable viral suppression. Older age, fewer ART medications and availability of social support were positively associated with durable viral suppression over the 18-month observation period. Findings suggest that regimen complexity is potentially a better predictor of viral suppression than self-reported medication adherence. The need for consensus on the definition of durable viral suppression is also urged.

Association Between Cognitive Tests and Antiretroviral Medication Adherence in Older Adults With HIV.

BACKGROUND: One of the fastest growing populations living with HIV is older adults especially those 65 years of age or older. Current antiretroviral therapy (ART) has prolonged life expectancy of persons with HIV. However, for therapy to be effective, patients need to be adherent. Over time, older persons with HIV may experience HIV-associated neurocognitive disorders or other factors that could affect ART adherence. The use of expedient cognitive tests that help measure medication adherence may be useful for the optimal care of these patients. OBJECTIVE: To investigate the association between cognitive tests and ART adherence. METHODS: This was a prospective study evaluating patients 65 years of age or older with HIV. Cognitive tests used included the Executive Clock-Drawing Task (CLOX) 1 and 2, Trail Making Test parts A and B, and Grooved Pegboard Test (GPB). The medication event monitoring system cap over 1 month was used as the primary measure for adherence. RESULTS: CLOX 1 and GPB were significantly related to adherence ( P < 0.05). Comparison of the magnitude of each measure's relation to adherence suggests that the GPB is a better indicator of ability to adhere ( R = 0.514 vs R = 0.381). Conclusion and Relevance: CLOX 1 and GPB demonstrated an association with adherence in patients 65 years of age or older with HIV. Although the use of these tests to measure adherence in older persons with HIV seems promising, more research is needed to ascertain their ultimate utility.

Evaluation of practice effect on neuropsychological measures among persons with and without HIV infection in northern India.

An evaluation of the effects of HIV infection on neurocognition over time is important for understanding disease progression. Changes in cognitive function can be evaluated longitudinally by using neuropsychological testing at repeated intervals. The assessment of change over time, however, is complicated by the potentially confounding influence of learning on repeated test administrations, often referred to as practice effect. In this study, we present data on testing of persons with or without HIV infection on a battery administered at study baseline and repeated 1 year later. Results suggest that practice effects may be diminished in persons with HIV infection compared to without it. This appears to be true even among those with relatively intact immune functioning as measured by CD4 count.

Cognitive and Performance Enhancing Medication Use to Improve Performance in Poker.

Use of neuroenhancers has been studied in groups ranging from students to surgeons; however, use of cognitive and performance enhancing medications (CPEMs) to improve performance in poker has remained largely overlooked. To assess the use of CPEMs to improve poker performance, a survey of poker players was conducted. Participants were recruited via Internet poker forums; 198 completed the online survey. Approximately 28 % of respondents used prescription CPEMs, with the most commonly used including: amphetamine/dextroamphetamine (62 %), benzodiazepines (20 %), and methylphenidate (20 %). CPEMs were used in poker to focus (73 %), calm nerves (11 %), and stay awake (11 %). Caffeine (71 %), as well as conventionally counter-intuitive substances like marijuana (35 %) and alcohol (30 %) were also reported to enhance poker performance. Non-users of CPEMs were dissuaded from use due to not knowing where to get them (29 %), apprehension about trying them (26 %), and legal or ethical concerns (16 %). Respondents most frequently acquired CPEMs via friends/fellow poker players (52 %), or prescription from physician (38 %). Additionally, greater use of CPEMs was associated with living outside the United States (p = 0.042), prior use of prescription medications for improving non-poker related performance (p < 0.001), and amateur and semi-professional player status (p = 0.035). Unmonitored use of pharmacologically active agents and their methods of acquisition highlight safety concerns in this cohort of poker players, especially among non-professional players. The current state of guidance from national organizations on CPEM use in healthy individuals could impact prescribing patterns.

Neuropsychological test performance among healthy persons in northern India: development of normative data.

Accurate identification of neurocognitive impairment associated with HIV infection (and other CNS-involved conditions) is dependent upon utilization of appropriate normative neuropsychological test performance data from healthy individuals with a similar background, culture, and characteristics of the target individual or group to be tested. In India, regional differences in language, culture, and availability of resources can significantly affect performance on neuropsychological testing. This study developed age- and education-adjusted normative data for commonly used neuropsychological test scores for use in northern India.

Changes in neurocognition and adherence over six months in HIV-infected individuals with cocaine or heroin dependence.

We sought to examine the course of adherence and cognition in HIV-infected individuals with either cocaine or heroin dependence and investigate independent predictors of cognition change. A prospective study over six months was undertaken in which adherence was measured by monthly electronic pill cap monitoring (Medication Event Monitoring System), while a comprehensive neuropsychological battery resulting in a composite score (NPZ8) was performed at baseline and six months. Multivariable regression models were performed in order to determine independent associations with change in cognition. There were 101 subjects at baseline, of whom 62% were male and 83% were non-Hispanic black. 46.6% of subjects at baseline had completed high school, 36.6% reported active cocaine use during the course of the study, and 0% reported active heroin use during the course of the study. 66 subjects completed the final cognitive assessment at six months. Subjects had markedly impaired cognitive function at baseline (NPZ8 -1.49) which persisted at six months (NPZ8 -1.47) in the group of study completers. There was an average monthly decrease in adherence of -2.91% overall (p = 0.008). In the multivariable model, each of the following variables: baseline cognition (R(2) change = 0.121, p = 0.006), cocaine use during the study (R(2) change = 0.059, p = 0.046), and monthly adherence change (R(2) change = 0.078, p = 0.018) independently contributed to NPZ8 change with an overall R(2) change = 0.219 (p = 0.001). This study shows an overall decrease in adherence over time in this population of subjects with a history of drug dependence. Active cocaine use, baseline cognition, and temporal adherence changes independently contributed to changes in cognition. Further study on enhancing adherence, cognition, and limiting drug abuse are warranted in this subgroup of HIV-infected individuals.

Subtypes of sleep problems in patients with Alzheimer disease.

OBJECTIVE: Sleep disturbances are common in patients with Alzheimer disease (AD) and can contribute to cognitive dysfunction and a negative impact on patients' and caregivers' quality of life. The purpose of this study was to evaluate whether subtypes of sleep disturbance could be identified in patients with AD and to assess the relation of these subtypes to patient characteristics and caregiver mood. METHODS: As part of routine clinical assessment, primary caregivers of 344 patients with AD completed a questionnaire that included five items about the patients' sleep. Patients' cognitive and functional status and their mood were assessed as was caregivers' mood. Latent class analysis was used to define subgroups of patients based on their sleep patterns. After identification of groups of sleep disturbance, the relation of group membership to patient and caregiver characteristics was also evaluated. RESULTS: Analyses revealed groups with moderate and severe sleep problems as well as a group without problems. Patients with more severe sleep disturbance were older, less well educated, and had poorer cognitive and functional status. Caregiver and patient depression was related to membership in the severe group, suggesting that both may contribute to caregivers' ratings of more severe sleep disturbance, whereas only patient depression was related to membership in the moderate group. CONCLUSION: Sleep problems in patients with AD are related to poorer cognitive and functional status and patient and caregiver depression. Caregiver depression was most closely related to more severe patient sleep disturbance.

Risk and protective factors for retention in HIV care.

Retention in care for HIV is essential for effective disease management; however, factors that may confer risk or protection for adherence to regular HIV care are less well understood. This study tested whether HIV-associated cognitive impairment (CI) and low health literacy reduced adherence to routine HIV medical and phlebotomy visits and if social support and patient-provider relationship conferred a protective effect. Participants were 210 HIV-infected patients enrolled in outpatient care and followed for 28-weeks. Results showed that those attending >75 % of phlebotomy visits were more likely to be virally suppressed. Health literacy was unassociated with adherence to medical or phlebotomy visits. CI was not directly related to medical or phlebotomy visit adherence; however those with CI and greater use of social support were less likely to miss medical visits. Utilizing social support may be an effective means of managing visit adherence, especially among patients with CI.

Development of a culturally appropriate computer-delivered tailored Internet-based health literacy intervention for Spanish-dominant Hispanics living with HIV.

BACKGROUND: Low health literacy is associated with poor medication adherence in persons with human immunodeficiency virus (HIV), which can lead to poor health outcomes. As linguistic minorities, Spanish-dominant Hispanics (SDH) face challenges such as difficulties in obtaining and understanding accurate information about HIV and its treatment. Traditional health educational methods (e.g., pamphlets, talking) may not be as effective as delivering through alternate venues. Technology-based health information interventions have the potential for being readily available on desktop computers or over the Internet. The purpose of this research was to adapt a theoretically-based computer application (initially developed for English-speaking HIV-positive persons) that will provide linguistically and culturally appropriate tailored health education to Spanish-dominant Hispanics with HIV (HIV + SDH). METHODS: A mixed methods approach using quantitative and qualitative interviews with 25 HIV + SDH and 5 key informants guided by the Information-Motivation-Behavioral (IMB) Skills model was used to investigate cultural factors influencing medication adherence in HIV + SDH. We used a triangulation approach to identify major themes within cultural contexts relevant to understanding factors related to motivation to adhere to treatment. From this data we adapted an automated computer-based health literacy intervention to be delivered in Spanish. RESULTS: Culture-specific motivational factors for treatment adherence in HIV + SDH persons that emerged from the data were stigma, familismo (family), mood, and social support. Using this data, we developed a culturally and linguistically adapted a tailored intervention that provides information about HIV infection, treatment, and medication related problem solving skills (proven effective in English-speaking populations) that can be delivered using touch-screen computers, tablets, and smartphones to be tested in a future study. CONCLUSION: Using a theoretically-grounded Internet-based eHealth education intervention that builds on knowledge and also targets core cultural determinants of adherence may prove a highly effective approach to improve health literacy and medication decision-making in this group.

Disease-Modifying Treatments and Their Future in Alzheimer's Disease Management.

Alzheimer's disease (AD) is a progressive neurodegenerative disorder characterized by memory impairment, a loss of cholinergic neurons, and cognitive decline that insidiously progresses to dementia. The pathoetiology of AD is complex, as genetic predisposition, age, inflammation, oxidative stress, and dysregulated proteostasis all contribute to its development and progression. The histological hallmarks of AD are the formation and accumulation of amyloid-ß plaques and interfibrillar tau tangles within the central nervous system. These histological hallmarks trigger neuroinflammation and disrupt the physiological structure and functioning of neurons, leading to cognitive dysfunction. Most treatments currently available for AD focus only on symptomatic relief. Disease-modifying treatments (DMTs) that target the biology of the disease in hopes of slowing or reversing disease progression are desperately needed. This narrative review investigates novel DMTs and their therapeutic targets that are either in phase three of development or have been recently approved by the U.S. Food and Drug Administration (FDA). The target areas of some of these novel DMTs consist of combatting amyloid or tau accumulation, oxidative stress, neuroinflammation, and dysregulated proteostasis, metabolism, or circadian rhythm. Neuroprotection and neuroplasticity promotion were also key target areas. DMT therapeutic target diversity may permit improved therapeutic responses in certain subpopulations of AD, particularly if the therapeutic target of the DMT being administered aligns with the subpopulation's most prominent pathological findings. Clinicians should be cognizant of how these novel drugs differ in therapeutic targets, as this knowledge may potentially enhance the level of care they can provide to AD patients in the future.

Impact of Mental Health Treatment on Outcomes in Patients With Heart Failure and Ischemic Heart Disease.

BACKGROUND: There is conflicting evidence as to the impact of mental health treatment on outcomes in patients with heart disease. The aim of this study was to examine whether individuals who received mental health treatment for anxiety or depression after being hospitalized for ischemic disorders or heart failure had a reduced frequency of rehospitalizations, emergency department visits, or mortality compared with those who did not receive treatment. METHODS AND RESULTS: A population-based, retrospective, cohort design was used to examine the association between psychotherapy or antidepressant medication prescription and health service utilization and mortality in patients with coronary artery disease or heart failure and comorbid anxiety or depression. Those receiving versus not receiving mental health treatment were compared based on the frequency of rehospitalization, emergency department visits, and mortality. The study sample included 1563 patients who had a mean age of 50.1 years. Individuals who received both forms of mental health treatment for anxiety or depression were 75% less likely to be rehospitalized, 74% less likely to have an emergency department visit, and 66% less likely to die from any cause. CONCLUSIONS: Mental health treatment for anxiety or depression has a significant impact on outcomes in patients with cardiovascular disease consisting of reduced hospitalizations, emergency department visits, and in some conditions improved survival.

A mobile app providing individually-tailored psychoeducation about sleep for older adults with chronic health conditions and low health literacy.

Objective: This paper reports on a study of a mobile app that provides tailored information about sleep to individuals aged 40 and older who have chronic health conditions and low health literacy. Methods: The sleep module was a part of a multitopic app focused on chronic disease self-management. Participants were randomly assigned to receive sleep psychoeducation at reading levels equivalent to 3rd, 6th or 8th grade. The primary outcome measure was the Pittsburgh Sleep Quality Index (PSQI), which was completed at baseline, after the intervention, and again three months later. Outcomes were assessed using repeated measures mixed effects models. Results: Most participants were Black, Indigenous, or Other Persons of Color (BIPOC; 87%); they had average reading level at the 7th grade. Health literacy, socioeconomic status, and number of health conditions were related to the PSQI. The PSQI score decreased over the course of the three study visits for all groups, consistent with a small to medium effect size (d = 0.40). No effect of treatment group was observed. Participants were positive about the usefulness and helpfulness of the app. Conclusion: Results suggest that a brief tailored information intervention may be beneficial for individuals aged 40 and older who have low health literacy and chronic health conditions. Further development of the intervention may enhance its clinical effectiveness.

Health literacy: impact on the health of HIV-infected individuals.

Health literacy is known to affect vulnerable communities such as persons living with HIV/AIDS. The purpose of this review was to provide a current summary of research on the impact of health literacy on the health of persons living with HIV/AIDS and to address future areas of need. Contemporary studies focused on expanding the reach of health literacy in HIV/AIDS to retention in HIV care, use of technology for assessing and intervening to improve health literacy, and health literacy across the globe, for example. A number of studies did not find health literacy to explain health behaviors whereas other studies supported such a relationship. Future issues relevant to health literacy in HIV/AIDS include the aging of the HIV population and associated comorbidities, studies to understand the role of health literacy in specific populations affected by HIV/AIDS, and the continued need to refine the definition and measurement of health literacy.

Development and validation of a brief computer-administered HIV-Related Health Literacy Scale (HIV-HL).

Health literacy is related to a number of health status variables and has been associated with medication adherence in persons treated for HIV infection. Currently-available measures of health literacy require lengthy administration or have content or format limitations. In this paper we report the preliminary development and validation of a brief computer-administered health literacy test that includes content focused on medication adherence as well as questions based on a video simulation of an HIV-related clinical encounter. The measure shows significant relations with other measures of health literacy, HIV-related knowledge, and electronically-measured medication adherence. We also present receiver operating characteristic analyses that provide estimates of various scores' sensitivities and specificities so that the HIV-Related Health Literacy Scale can be used as a screening measure.

Cost effectiveness of a computer-delivered intervention to improve HIV medication adherence.

BACKGROUND: High levels of adherence to medications for HIV infection are essential for optimal clinical outcomes and to reduce viral transmission, but many patients do not achieve required levels. Clinician-delivered interventions can improve patients' adherence, but usually require substantial effort by trained individuals and may not be widely available. Computer-delivered interventions can address this problem by reducing required staff time for delivery and by making the interventions widely available via the Internet. We previously developed a computer-delivered intervention designed to improve patients' level of health literacy as a strategy to improve their HIV medication adherence. The intervention was shown to increase patients' adherence, but it was not clear that the benefits resulting from the increase in adherence could justify the costs of developing and deploying the intervention. The purpose of this study was to evaluate the relation of development and deployment costs to the effectiveness of the intervention. METHODS: Costs of intervention development were drawn from accounting reports for the grant under which its development was supported, adjusted for costs primarily resulting from the project's research purpose. Effectiveness of the intervention was drawn from results of the parent study. The relation of the intervention's effects to changes in health status, expressed as utilities, was also evaluated in order to assess the net cost of the intervention in terms of quality adjusted life years (QALYs). Sensitivity analyses evaluated ranges of possible intervention effectiveness and durations of its effects, and costs were evaluated over several deployment scenarios. RESULTS: The intervention's cost effectiveness depends largely on the number of persons using it and the duration of its effectiveness. Even with modest effects for a small number of patients the intervention was associated with net cost savings in some scenarios and for durations greater than three months and longer it was usually associated with a favorable cost per QALY. For intermediate and larger assumed effects and longer durations of intervention effectiveness, the intervention was associated with net cost savings. CONCLUSIONS: Computer-delivered adherence interventions may be a cost-effective strategy to improve adherence in persons treated for HIV. TRIAL REGISTRATION: Clinicaltrials.gov identifier NCT01304186.

Cogstim: A Shared Decision-making Model to Support Older Adults' Brain Health.

The lack of effective treatments for cognitive decline in older adults has led to an interest in the possibility that lifestyle interventions can help to prevent changes in mental functioning and reduce the risk for dementia. Multiple lifestyle factors have been related to risk for decline, and multicomponent intervention studies suggest that changing older adults' behaviors can have a positive impact on their cognition. How to translate these findings into a practical model for clinical use with older adults, however, is not clear. In this Commentary, we propose a shared decision-making model to support clinicians' efforts to promote brain health in older persons. The model organizes risk and protective factors into three broad groups based on their mechanism of action and provides older persons with basic information to allow them to make evidence- and preference-based choices in choosing goals for effective brain health programs. A final component includes basic instruction in behavior change strategies such as goal setting, self-monitoring, and problem-solving. The implementation of the model will support older persons' efforts to develop a personally relevant and effective brainhealthy lifestyle that may help to reduce their risk for cognitive decline.

An Online Shared Decision-making Intervention for Dementia Prevention: A Parallel-group Randomized Pilot Study.

OBJECTIVES: Evaluate the acceptability and efficacy of an online dementia prevention intervention based on a cognitive behavioral shared decision-making model. MATERIALS AND METHODS: This was an unblinded pilot study in which participants were randomly assigned to one of two treatment groups. This study was carried out remotely via telephone, video conferencing, and online data collection. Eighteen English-speaking persons 40 years of age and older interested in developing more brain-healthy lifestyles. Both groups received 12 weekly sessions on lifestyle factors related to cognitive decline. The treatment-as-usual (TAU) group received the information and was encouraged to make lifestyle changes. The cognitive behavioral shared decision- making model (CBSDM) group received structured weekly sessions with support for evidence- informed personal goal choices and behavior change strategies. Primary outcome measures were the Alzheimer's Disease Risk Inventory and the Memory Self-Efficacy and Dementia Knowledge Assessment Scales. Participants reported brain health activities during the first, sixth, and 12th weeks of the study. RESULTS: No significant between-group changes were seen in the three primary outcome measures. The intervention was viewed positively by participants, who all said they would participate in it again. Participants in the CBSDM group showed increases in knowledge of dementia risk factors and exercise. Other outcomes were consistent with moderate to large effect sizes for both groups. CONCLUSION: An online intervention providing psychoeducation and behavior change support was viewed positively by older adults. Results provide preliminary support for the CBSDM intervention's efficacy in promoting brain health in older adults. CLINICAL TRIAL REGISTRATION NUMBER: NCT04822129.

Creating a Tailored Info App to Promote Self-Management Skills in Persons with Chronic Health Conditions: Development Strategies and User Experience.

Persons with chronic health conditions, such as heart disease, diabetes, hypertension, and others, often experience self-management problems that are not disease specific. These include disrupted sleep, pain, memory issues, and challenges in working with healthcare providers. These patients may benefit from information and skill development for these problems, but simply providing them information in brief sessions during clinical appointments or in handouts or pamphlets may not have a substantial impact on their behavior. Providing information tailored to persons' needs and individual characteristics has a greater impact on patients' behavior and may increase these persons' abilities to manage their health. Creating tailored information for each person, however, is labor intensive, making it difficult to use in everyday clinical practice. Computer-based tailoring is an alternative, allowing automated tailoring of information presented to patients based on their interactions with a computer app. The purpose of this article is to describe our process in developing a series of modules for chronic disease self-management for persons 40 years of age or older with one or more chronic health conditions.