Does neurocognition contribute to age-related deficits in the online navigation of electronic patient health portals?

OBJECTIVE: The internet serves an increasingly critical role in how older adults manage their personal health. Electronic patient portals, for example, provide a centralized platform for older adults to access lab results, manage prescriptions and appointments, and communicate with providers. This study examined whether neurocognition mediates the effect of older age on electronic patient portal navigation. METHOD: Forty-nine younger (18-35 years) and 35 older adults (50-75 years) completed the Test of Online Health Records Navigation (TOHRN), which is an experimenter-controlled website on which participants were asked to log-in, review laboratory results, read provider messages, and schedule an appointment. Participants also completed a neuropsychological battery, self-report questionnaires, and measures of health literacy and functional capacity. RESULTS: Mediation analyses revealed a significant indirect effect of older age on lower TOHRN accuracy, which was fully mediated by the total cognitive composite. CONCLUSIONS: Findings indicate that neurocognition may help explain some of the variance in age-related difficulties navigating electronic patient health portals. Future studies might examine the possible benefits of both structural (e.g., human factors web design enhancement) and individual (e.g., training and compensation) cognitive supports to improve the navigability of electronic patient health portals for older adults.

Older age and online health information search behaviors: The mediating influence of executive functions.

INTRODUCTION: Searching the internet for health-related information is a complex and dynamic goal-oriented process that ostensibly places demands on executive functions, which are higher-order cognitive abilities that can deteriorate with older age. This study examined the effects of older age on electronic health (eHealth) search behavior and the potential mediating influence of executive functions. METHOD: Fifty younger adults (≤ 35 years) and 41 older adults (≥50 years) completed naturalistic eHealth search tasks involving fact-finding (Fact Search) and symptom determination (Symptom Search), a neurocognitive battery, and a series of self-report questionnaires. RESULTS: Multiple regression models controlling for potentially confounding psychiatric symptoms, health conditions, literacy, and demographic variables revealed that older adults were slower and less accurate than younger adults on the eHealth Fact Search task, but not on the eHealth Symptom Search task. Executive functions mediated the relationship between age and Fact and Symptom Search accuracy, independent of basic processing speed and attention. Parallel mediation models showed that episodic memory was not an independent mediator of age and search accuracy for either eHealth task once speed/attention and executive functions were included. CONCLUSIONS: Older adults can experience difficulty searching the internet for some health-related information, which is at least partly attributable to executive dysfunction. Future studies are needed to determine the benefits of training in the organizational and strategic aspects of internet search for older adults and whether these findings are applicable to clinical populations with executive dysfunction.

Enhancing cue salience improves aspects of naturalistic time-based prospective memory in older adults with HIV disease.

OBJECTIVE: Older persons living with HIV (PLWH) disease commonly experience failures of time-based prospective memory (PM) in their daily lives. This study examined the benefits of providing strategic supports at encoding, monitoring, and cue detection for naturalistic time-based PM among older PLWH. METHOD: Participants included 116 older PLWH and 48 seronegatives who completed a baseline neuropsychological evaluation (see Woods et al., 2020), including a laboratory PM experiment that paralleled the design of the current naturalistic study. The naturalistic time-based PM task required participants to press a button on a portable PM response box 4 times per day for 1 month. PLWH were randomly assigned to an unsupported control condition or to an experimental group in which strategic processing was supported at encoding (implementation intentions and visualization), monitoring (content-free cuing), and/or cue detection (auditory alarm). The seronegative participants were all assigned to the unsupported control group. RESULTS: In a model adjusting for age and affective disorders, PLWH who received all three supports in combination demonstrated moderately better naturalistic time-based PM accuracy as compared with PLWH controls. Both the cue detection and combination conditions were associated with markedly more precise response timing on the naturalistic time-based PM task. Supported PM accuracy as measured in the laboratory was positively associated with naturalistic PM accuracy among PLWH in the experimental groups. CONCLUSIONS: Providing strategic supports to enhance the cue salience of naturalistic time-based PM tasks may improve both the accuracy and timing with which older PLWH remember to perform time-based intentions. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Online pharmacy navigation skills are associated with prospective memory in HIV disease.

OBJECTIVE: The increased use of online pharmacy services in the midst of the COVID-19 pandemic provides an important backdrop against which to examine the role of neurocognitive functions in health-related Internet navigation skills among persons with chronic medical conditions, such as HIV disease. Prospective memory (PM) is reliably impaired in HIV disease and is related to laboratory-based measures of medication management capacity in other populations. This study examined whether PM shows veridicality in relationship to online pharmacy navigation skills in persons with HIV disease. METHOD: Participants included 98 persons with HIV disease age 50 and older who completed the Cambridge Prospective Memory Test (CAMPROMPT) and the Medication-Management Test-Revised (MMT-R) as part of a neuropsychological study. Participants also completed the Test of Online Pharmacy Skills (TOPS), which required them to navigate a simulated, experimenter-controlled online pharmacy to perform several naturalistic tasks (e.g., refill an existing prescription). RESULTS: Lower PM had medium associations with poorer MMT-R and TOPS accuracy scores that were not better explained by other neurocognitive functions. The association between PM and TOPS accuracy was driven by errors of omission and did not vary meaningfully based on whether the intention was cued by time or an event. CONCLUSIONS: These data suggest that PM cue detection processes show veridicality with online pharmacy navigation skills. Future studies might examine the benefits of PM-based strategies (e.g., salient prompts) in supporting online health navigation skills in populations that experience clinically impactful PM failures.

A Culturally Adapted SMS Text Messaging Intervention to Promote Antiretroviral Therapy Adherence Among African Americans: Protocol for a Single-Arm Trial.

BACKGROUND: African Americans are disproportionally affected by HIV and have poorer rates of antiretroviral therapy (ART) adherence compared to other racial or ethnic groups in the United States. Factors associated with poor HIV disease outcomes are commonly associated with sociostructural barriers that prevent engagement with and retention in HIV care. SMS text messaging interventions to promote ART adherence among predominantly non-Hispanic White persons with HIV (PWH) have been shown to be efficacious; however, limited research has been devoted to culturally tailoring interventions for underrepresented racial/ethnic groups. Considering African Americans show poorer engagement along the HIV care continuum, we developed an individualized and culturally tailored two-way SMS text messaging intervention to improve ART adherence and associated virologic suppression among African American PWH. OBJECTIVE: In this paper we describe the protocol of a culturally tailored individualized Texting for Adherence Building (iTAB) intervention in a 24- to 48-week, single-arm study. METHODS: We developed a culturally tailored iTAB intervention, which we are implementing in a 24- to 48-week, single-arm study. Participants were recruited from the Family Health Centers of San Diego (FHCSD), a federally qualified health center. Patient inclusion criteria were (1) receiving care at the FHCSD, (2) living with HIV, (3) self-identification as Black, African American, or of African ancestry, (4) English speaking, (5) age 18 or older, (6) currently on ART, and (7) able to provide informed consent. Study enrollment began in November 2017 and closed in July 2019. A total of 90 participants from the FHCSD enrolled in the iTAB intervention, and we anticipate completing data collection in July 2020. Participants were assisted in individualizing and customizing their SMS text message preferences at the baseline study visit. Self-assessment measures are collected at baseline, interim, and final study visits. Problems related to sending/receiving SMS text messages and barriers to ART adherence are assessed at each interim study visit. The FHCSD staff monitors and tracks participants' daily SMS text message responses to ART adherence reminders using a clinical dashboard. RESULTS: We hypothesize that the proportion of individuals achieving HIV virologic suppression (viral load <40 copies/mL) will be greater at the end of the intervention period compared to the proportion prior to study implementation. Additionally, we anticipate that rates of virologic suppression at the end of the intervention among participants receiving iTAB will be comparable to those among the general FHCSD non-African American population who did not receive iTAB. Finally, we anticipate a high response rate to iTAB SMS text messages as well as positive participant feedback at the end of the intervention with regard to the acceptability of, satisfaction with, and perceived efficacy of iTAB. CONCLUSIONS: The iTAB intervention is a novel individualized two-way SMS text messaging intervention that has been culturally tailored for use among African Americans with HIV. We anticipate that iTAB will demonstrate efficacy in future randomized control trials and will be supportive of medication adherence among other populations facing health disparities. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/21592.

Supporting strategic processes can improve time-based prospective memory in the laboratory among older adults with HIV disease.

OBJECTIVE: Older adults with HIV disease demonstrate moderate deficits in time-based prospective memory (PM), which is the strategically demanding ability of remembering to perform a task at a specific time. Using theories from the PM literature, we hypothesized that supporting strategic processes would improve time-based PM in the laboratory among HIV+ older adults. METHOD: One hundred forty-five HIV+ participants were randomly assigned to a control condition or an experimental group in which strategic processing was supported at encoding (i.e., implementation intentions and visualization), monitoring (i.e., content-free cuing), and/or cue detection (i.e., auditory alarm). The HIV+ control group and 58 seronegative participants completed two ongoing language tasks with a time-based PM requirement. The HIV+ experimental groups underwent counterbalanced time-based PM trials under both control and strategically supported conditions. RESULTS: The HIV+ cue-detection group showed a large within-subjects improvement, which was strongly related to lower scores on separate clinical time-based PM measure and was accompanied by a large reduction in clock-checking behavior. Results also revealed a small within-subjects improvement in time-based PM in the encoding condition. CONCLUSIONS: Supporting strategic encoding and cue-detection processes in the laboratory can improve time-based PM deficits in older HIV+ adults, which may inform the development of more naturalistic PM-based interventions to enhance health behaviors. (PsycINFO Database Record (c) 2020 APA, all rights reserved).

Outcomes of Psychoeducation and a Text Messaging Adherence Intervention Among Individuals With Hypertension and Bipolar Disorder.

OBJECTIVE: This study evaluated the feasibility, acceptability, and preliminary efficacy of psychoeducation plus an automated text messaging intervention (Individualized Texting for Adherence Building-Cardiovascular [iTAB-CV]) to improve adherence to antihypertensives and bipolar disorder medication. METHODS: After a psychoeducation program, iTAB-CV was administered for 2 months. In month 1, participants received one educational-motivational and one mood rating text daily. In month 2, medication reminders were added. RESULTS: The sample (N=38) was 74% African American and 53% women, with a mean±SD age of 51.53±9.06. Antihypertensive nonadherence decreased from a mean of 43%±23% to 21%±18% at 12 weeks (χ2=34.6, df=3, p<0.001). Systolic blood pressure decreased from a mean of 144.8±15.5 mmHg to 136.0±17.8 mmHg (χ2=17.6, df=3, p<.001). Retention was 100%. CONCLUSIONS: In this uncontrolled trial, participants were highly engaged and medication adherence and reduced systolic blood pressure were sustained after psychoeducation plus iTAB-CV. Because iTAB-CV is automated and delivered remotely, it has the potential to reach a large and challenging population.

Patient Participation in the Development of a Customized M-Health Intervention to Improve Medication Adherence in Poorly Adherent Individuals with Bipolar Disorder (BD) and Hypertension (HTN).

OBJECTIVE: Individuals living with bipolar disorder (BD) have poorer management of chronic medical conditions such as hypertension (HTN), and worse treatment adherence than the general population. The study objective was to obtain information from patients with both BD and HTN that would inform the development of an m-Health intervention to improve medication adherence for poorly adherent individuals living with both these chronic illnesses. METHODS: Focus group methodology was used to collect information from 13 participants on perceived barriers and facilitators to BD and HTN medication adherence, as well as feedback on the demonstration and use of a bidirectional text messaging system for medication reminders. Focus groups were audiotaped, transcribed verbatim, and analyzed using content analysis with an emphasis on dominant themes. RESULTS: Forgetfulness was the most frequently mentioned barrier to taking antihypertensive medications, and decisions about taking them were often influenced by BD mood fluctuations and the burden of having to take "too many pills" for both chronic illnesses. Participants' feedback about the use of a text-messaging system to help with medication adherence for BD and HTN was very positive, and their suggestions for modification were incorporated into a more customized system for testing in a Phase 2 trial. CONCLUSIONS: Our findings indicate that patient engagement in the development of an m-health intervention has the potential to improve adherence with both BD and HTN medications in individuals with known sub-optimal adherence. Patient engagement in health care is essential if we are to optimize patient outcomes.

Household Everyday Functioning in the Internet Age: Online Shopping and Banking Skills Are Affected in HIV-Associated Neurocognitive Disorders.

OBJECTIVES: The Internet is a fundamental tool for completing many different instrumental activities of daily living (IADL), including shopping and banking. Persons with HIV-associated Neurocognitive Disorders (HAND) are at heightened risk for IADL problems, but the extent to which HAND interferes with the performance of Internet-based household IADLs is not known. METHODS: Ninety-three individuals with HIV disease, 43 of whom were diagnosed with HAND, and 42 HIV- comparison participants completed Internet-based tests of shopping and banking. Participants used mock credentials to log in to an experimenter-controlled Web site and independently performed a series of typical online shopping (e.g., purchasing household goods) and banking (e.g., transferring funds between accounts) tasks. RESULTS: Individuals with HAND were significantly more likely to fail the online shopping task than neurocognitively normal HIV+ and HIV- participants. HAND was also associated with poorer overall performance versus HIV+ normals on the online banking task. In the HAND group, Internet-based task scores were correlated with episodic memory, executive functions, motor skills, and numeracy. In the HIV+ sample as a whole, lower Internet-based task scores were uniquely associated with poorer performance-based functional capacity and self-reported declines in shopping and financial management in daily life, but not with global manifest functional status. CONCLUSIONS: Findings indicate that HAND is associated with difficulties in using the Internet to complete important household everyday functioning tasks. The development and validation of effective Internet training and compensatory strategies may help to improve the household management of persons with HAND. (JINS, 2017, 23, 605-615).

Health-Related Everyday Functioning in the Internet Age: HIV-Associated Neurocognitive Disorders Disrupt Online Pharmacy and Health Chart Navigation Skills.

This study evaluated the effects of HIV-associated Neurocognitive Disorders (HAND) on 2 Internet-based tests of healthcare management. Study participants included 46 individuals with HIV infection, 19 of whom were diagnosed with HAND, and 21 seronegatives. Participants were administered Internet-based tests of online pharmacy and health records navigation skills in which they used mock credentials to log in to an experimenter-controlled website and independently perform a series of typical online health-related behaviors (e.g., refill a prescription, read and interpret an electronic chart note). HAND was associated with significantly lower accuracy on both the online pharmacy and health records navigation tasks. Among the HIV+ participants, poorer performance on the online healthcare navigation tasks was associated with fewer years of education, higher plasma viral load, less frequent Internet use, and lower health literacy. Findings indicate that individuals with HAND may have marked difficulties navigating the Internet to complete important health-related behaviors.

Habitual prospective memory in HIV disease.

OBJECTIVE: HIV-associated neurocognitive disorders (HAND) are associated with deficits in prospective memory (PM). However, most PM research in HIV has used single-event tasks as opposed to habitual PM paradigms, which may be more relevant to clinical populations for whom many health-care behaviors must be performed both frequently and routinely. METHOD: For the current study, we examined habitual PM and its associations with real-world functioning outcomes in 36 HIV+ individuals with HAND (HAND+), 70 HIV+ individuals without HAND (HAND-), and 115 HIV- individuals. The ongoing task consisted of 24 1-min Stroop trial blocks in which the emotive and cognitive load was manipulated. The habitual PM task required participants to press the spacebar once per block, but only after 20 s had elapsed. RESULTS: A series of MANOVAs covarying for relevant clinicodemographic factors revealed a main effect of study group on habitual PM, such that the HAND+ cohort made significantly more repetition errors than the HIV- and HAND- groups, particularly during early trial blocks. There was no main effect of ongoing task demands, nor was there an interaction between HAND group and task demands. Within the entire HIV+ sample, poorer habitual PM was associated with deficits in learning and dysfunction in real-world outcomes, including medication nonadherence and failures on a naturalistic health-care task. CONCLUSION: Findings indicate that HAND may be associated with deficient internal source monitoring or temporal discrimination for habitual PM output that may play a critical role in real-world functioning, including HIV disease management.

HIV-associated distal neuropathic pain is associated with smaller total cerebral cortical gray matter.

Despite modern antiretroviral therapy, HIV-associated sensory neuropathy affects over 50 % of HIV patients. The clinical expression of HIV neuropathy is highly variable: many individuals report few symptoms, but about half report distal neuropathic pain (DNP), making it one of the most prevalent, disabling, and treatment-resistant complications of HIV disease. The presence and intensity of pain is not fully explained by the degree of peripheral nerve damage, making it unclear why some patients do, and others do not, report pain. To better understand central nervous system contributions to HIV DNP, we performed a cross-sectional analysis of structural magnetic resonance imaging volumes in 241 HIV-infected participants from an observational multi-site cohort study at five US sites (CNS HIV Anti-Retroviral Treatment Effects Research Study, CHARTER). The association between DNP and the structural imaging outcomes was investigated using both linear and nonlinear (Gaussian Kernel support vector) multivariable regression, controlling for key demographic and clinical variables. Severity of DNP symptoms was correlated with smaller total cerebral cortical gray matter volume (r = -0.24; p = 0.004). Understanding the mechanisms for this association between smaller total cortical volumes and DNP may provide insight into HIV DNP chronicity and treatment-resistance.

Prospective memory in HIV-associated neurocognitive disorders (HAND): the neuropsychological dynamics of time monitoring.

Strategic monitoring during a delay interval is theorized to be an essential feature of time-based prospective memory (TB PM), the cognitive architecture of which is thought to rely heavily on frontostriatal systems and executive functions. This hypothesis was examined in 55 individuals with HIV-associated neurocognitive disorders (HAND) and 108 seronegative comparison participants who were administered the Memory for Intentions Screening Test (MIST), during which time-monitoring (clock-checking) behavior was measured. Results revealed a significant interaction between HAND group and the frequency of clock checking, in which individuals with HAND checked the clock significantly less often than the comparison group across the TB PM retention intervals of the MIST. Subsequent analyses in the HAND sample revealed that the frequency of clocking checking was positively related to overall TB performance, as well as to standard clinical measures of retrospective memory and verbal fluency. These findings add support to a growing body of research elucidating TB PM's reliance on strategic monitoring processes dependent upon intact frontostriatal systems. HIV-associated TB strategic time-monitoring deficits may manifest in poorer functioning outcomes, including medication nonadherence and dependence in activities of daily living. Future research is needed to further delineate the cognitive mechanisms underlying strategic time monitoring in order to advise rehabilitation strategies for reducing HAND-related TB PM deficits.

An XML model of an enhanced data dictionary to facilitate the exchange of pre-existing clinical research data in international studies.

Pre-existing clinical research data sets exchanged in international epidemiology research often lack the elements needed to assess their suitability for use in multi-region meta-analyses or other clinical studies. While the missing information is generally known to local investigators, it is not contained in the files exchanged between sites. Instead, such content must be solicited by the study coordinating center though a series of lengthy phone and electronic communications: an informal process whose reproducibility and accuracy decays over time. This report describes a set of supplemental information needed to assess whether clinical research data from diverse research sites are truly comparable, and what metadata ("data about the data") should be preserved when a data set is archived for future use. We propose a structured Extensible Markup Language (XML) model that captures this information. The authors hope this model will be a first step towards preserving the metadata associated with clinical research data sets, thereby improving the quality of international data exchange, data archiving, and merged-data research using data collected in many different countries, languages and care settings.