Depression and Medication Beliefs in African Americans with Diabetes.

Medication non-adherence impacts health significantly in African Americans with diabetes. We performed a retrospective data analysis on 56 patients who presented to the emergency departments of two hospitals in Philadelphia, PA, USA. Demographic data, medical history, and point-of-care hemoglobin A1c were collected at baseline. Using Spearman rank correlations, we examined whether depressive symptoms measured with the Patient Health Questionnaire-9 (PHQ-9) were associated with diabetes health beliefs, which were assessed with the Diabetes Health Belief Scale (DHBS). PHQ-9 scores were significantly correlated with DHBS's Perceived Side Effects scores [r(56) = 0.474, p < 0.01] and Perceived Barriers scores [r(56) = 0.337, p < 0.05]. These findings suggest that negative health beliefs may play a role in the relationship between depression and low medication adherence. Treatment of diabetes in middle-aged and older African American individuals should address both depression and negative health beliefs on side effects and perceived barriers.

Emergency Medicine Clinician Experiences Addressing Uncertainty in First-Trimester Bleeding.

The purpose of this work is to understand Emergency Department (ED) clinicians' experiences in communicating uncertainty about first-trimester bleeding (FTB) and their need for training on this topic. This cross-sectional study surveyed a national sample of attending physicians and advanced practice providers (APPs). The survey included quantitative and qualitative questions about communicating with patients presenting with FTB. These questions assessed clinicians' frequency encountering challenges, comfort, training, prior experience, and interest in training on the topic. Of 402 respondents, 54% reported that they encountered challenges at least sometimes when discussing FTB with patients where the pregnancy outcome is uncertain. While the majority (84%) were at least somewhat prepared for these conversations from their training, which commonly addressed the diagnostic approach to this scenario, 39% strongly or moderately agreed that they could benefit from training on the topic. Because the majority of ED clinicians identified at least sometimes encountering challenges communicating with pregnant patients about FTB, our study indicates a need exists for more training in this skill.

Diabetes Distress, Daily Functioning, and A1C in Older Black Individuals With Diabetes and Mild Cognitive Impairment.

OBJECTIVE: The purpose of the cross-sectional study was to identify associations of diabetes distress, physical functioning, and cognition with A1C in older Black individuals with diabetes and mild cognitive impairment. METHODS: The investigators analyzed previously collected data from 101 older Black individuals with diabetes and mild cognitive impairment. Participants were administered surveys at baseline to assess diabetes distress, physical functioning, and cognitive functioning and had A1C testing. RESULTS: The mean age of participants was 68.4 years, and 62% were women. Participants with higher A1C showed worse self-reported daily functioning (r = -0.28, P <0.01). Three of four diabetes distress factors were positively correlated with A1C: emotional (r = 0.28, P <0.01), regimen-related (r = 0.33, P <0.01), and interpersonal distress (r = 0.27, P <0.01). In a multivariate regression with A1C as the dependent variable, only regimen-related diabetes distress (ß = 0.32, P = 0.008) and self-reported daily functioning (ß = -0.33, P = 0.019) were significant. CONCLUSION: Regimen-related diabetes distress and self-reported daily functioning were found to compromise glycemic control in Black individuals with mild cognitive impairment and diabetes. This finding suggests that diabetes interventions should be multifaceted to improve glycemic control in the high-risk population of Black individuals with diabetes.

Mistrust, Neighborhood Deprivation, and Telehealth Use in African Americans with Diabetes.

This study explored the relationship between trust in physicians and telehealth use during the COVID pandemic in 162 African Americans with diabetes. More than 90% of patients had internet-capable devices and internet service but only 61 patients (39%) had a telehealth visit. Compared to the latter, participants with no telehealth visits had less trust in physicians' ability to diagnose COVID, less trust in physicians' ability to treat via telehealth, and resided in more deprived neighborhoods. There were no differences in age, sex, education, nor literacy. For African Americans with diabetes, health disparities may increase unless fundamental issues such as trust are addressed.

Emergency department visits in African Americans with mild cognitive impairment and diabetes.

AIMS: Dementia, diabetes, and African American race are three factors that are independently associated with emergency department (ED) use. This study tested the hypothesis that ED use is associated with worse cognitive function in African Americans with Mild Cognitive Impairment (MCI) and poorly controlled diabetes. METHODS: This study examined differences in ED use among African Americans with MCI and diabetes in a secondary data analysis of baseline data from a one-year randomized controlled trial (N = 101). RESULTS: Over one year, 49/92 participants (53.3%) had at least one ED visit. At baseline, participants who had an incident ED visit had significantly fewer years of education; lower scores on neuropsychological tests assessing working memory, psychomotor speed, and complex scanning; higher diabetes-related interpersonal distress scores; lower adherence to a diabetes medication; and higher hemoglobin A1c levels compared to participants with no ED visits (p ≤ 0.05 for all comparisons). CONCLUSIONS: This study identified multiple risk factors for ED visits in older African Americans with MCI and diabetes. Targeted interventions may be necessary to reduce the need for ED care in high risk populations.

Prevalence of depressive symptoms and associated factors in an urban, ophthalmic population.

OBJECTIVE: To determine the prevalence of depressive symptoms in an adult ophthalmic patient population and to delineate correlates. DESIGN: Cross-sectional study. PARTICIPANTS: Adult patients (⩾18 years) were approached in general and sub-specialty cornea, retina, and glaucoma ophthalmic clinics. A total of 367 patients from the four clinics were enrolled. METHODS: Depressive symptoms were assessed using the Patient Health Questionnaire-9. A cut-off score of ⩾10 was used to indicate clinically significant depressive symptoms. Patient Health Questionnaire-9 scores were used to evaluate bivariate relationships between depressive symptoms and distance visual acuity, ocular diagnosis, diabetes status, smoking status, demographic information, and medications. RESULTS: The majority of patients were female (52.9%) and Caucasian (48.6%). The mean age was 52.0 years (standard deviation: 16.7). Clinically significant depressive symptoms were present in 19.9% of patients overall; this rate varied slightly by clinic. Patients with low vision and blindness (visual acuity worse than 20/60) were more likely to have depressive symptoms (odds ratio = 2.82; 95% confidence interval: 1.90-4.21). Smoking and diabetes were also associated with depressive symptoms (odds ratio = 3.11 (2.66-3.64) and 3.42 (1.90-6.16), respectively). CONCLUSION: In a sample of urban ophthalmic adult patients, depressive symptoms were highly associated with low vision, smoking, and diabetes. This information can be used to target interventions to those at greatest risk of depressive symptoms.

Improving Glycemic Control in African Americans With Diabetes and Mild Cognitive Impairment.

BACKGROUND/OBJECTIVES: Improving glycemic control in older African Americans with diabetes and mild cognitive impairment (MCI) is important as the population ages and becomes more racially diverse. DESIGN: Randomized controlled trial. SETTING: Recruitment from primary care practices of an urban academic medical center. Community-based treatment delivery. PARTICIPANTS: Older African Americans with MCI, low medication adherence, and poor glycemic control (N = 101). INTERVENTIONS: Occupational therapy (OT) behavioral intervention and diabetes self-management education. MEASUREMENTS: The primary outcome was a reduction in hemoglobin A1c level of at least 0.5% at 6 months, with maintenance effects assessed at 12 months. RESULTS: At 6 months, 25 of 41 (61.0%) OT participants and 22 of 46 (48.2%) diabetes self-management education participants had a reduction in hemoglobin A1c level of at least 0.5%. The model-estimated rates were 58% (95% confidence interval [CI] = 45%-75%) and 48% (95% CI = 36%-64%), respectively (relative risk [RR] = 1.21; 95% CI = 0.84-1.75; P = .31). At 12 months, the respective rates were 21 of 39 (53.8%) OT participants and 24 of 49 (49.0%) diabetes self-management education participants. The model-estimated rates were 50% (95% CI = 37%-68%) and 48% (95% CI = 36%-64%), respectively (RR = 1.05; 95% CI = 0.70-1.57; P = .81). CONCLUSION: Both interventions improved glycemic control in older African Americans with MCI and poor glycemic control. This result reinforces the American Diabetes Association's recommendation to assess cognition in older persons with diabetes and demonstrates the potential to improve glycemic control in this high-risk population. J Am Geriatr Soc 68:1015-1022, 2020.

Trust and Glycemic Control in Black Patients With Diabetic Retinopathy: A Pilot Study.

Diabetic retinopathy (DR) is more prevalent in blacks than whites because, compared to whites, blacks on average have worse glycemic control. Both of these racial disparities reflect differences in sociocultural determinants of health, including physician mistrust. This randomized, controlled 6-month pilot trial compared the efficacy of a culturally tailored behavioral health/ophthalmologic intervention called Collaborative Care for Depression and Diabetic Retinopathy (CC-DDR) to enhanced usual care (EUC) for improving glycemic control in black patients with DR (n = 33). The mean age of participants was 68 years (SD 6.1 years), 76% were women, and the mean A1C was 8.7% (SD 1.5%). At baseline, 14 participants (42%) expressed mistrust about ophthalmologic diagnoses. After 6 months, CC-DDR participants had a clinically meaningful decline in A1C of 0.6% (SD 2.1%), whereas EUC participants had an increase of 0.2% (SD 1.1%) (f[1, 28] = 1.9; P = 0.176). Within CC-DDR, participants with trust had a reduction in A1C (1.4% [SD 2.5%]), whereas participants with mistrust had an increase in A1C (0.44% [SD 0.7%]) (f[1, 11] = 2.11; P = 0.177). EUC participants with trust had a reduction in A1C (0.1% [SD 1.1%]), whereas those with mistrust had an increase in A1C (0.70% [SD 1.1%]) (f[1, 16] = 2.01; P = 0.172). Mistrust adversely affected glycemic control independent of treatment. This finding, coupled with the high rate of mistrust, highlights the need to target mistrust in new interventions to improve glycemic control in black patients with DR.

Memory improvement in African Americans with amnestic mild cognitive impairment.

OBJECTIVE: Amnestic mild cognitive impairment (aMCI) has an uncertain course. Valid methods to evaluate memory change will best identify predictors of course. This issue is especially relevant to older persons in minority groups, who may have encountered life course factors that adversely affect cognition. METHODS/DESIGN: Growth curve mixture models were used to identify trajectories of memory test scores obtained every 6 months over 2 years in 221 African Americans with aMCI. RESULTS: Participants sorted into two classes, with clinically and statistically significant differences in memory scores over time. Class 1 (n = 28 [14.7%]) had sustained improved scores. Class 2 (n = 162 [85.3%]) scores remained low, fluctuated, or declined. Class 1 had better baseline cognition and daily function than class 2. CONCLUSIONS: The observed rate of improved memory is lower than reported reversion rates from aMCI to normal cognition. Evaluating trajectories of memory test scores rather than changes in categorical diagnoses of aMCI, which may depend on recalling (or not recalling) one or two words, may yield a more valid indicator of cognitive change. These approaches require further study in minority groups.

Preventing Cognitive Decline in Black Individuals With Mild Cognitive Impairment: A Randomized Clinical Trial.

Importance: Mild cognitive impairment (MCI) is a transition state between normal cognitive aging and dementia that increases the risk for progressive cognitive decline. Preventing cognitive decline is a public health priority. Objective: To determine whether behavioral activation prevents cognitive and functional decline over 2 years in black individuals with MCI. Design, Setting, and Participants: Single-center, single-masked, attention-controlled randomized clinical trial. Participants were enrolled from June 21, 2011, to October 3, 2014, and follow-up ended December 13, 2016. Community-based recruitment and treatment of black individuals older than 65 years with amnestic MCI. Volunteer sample of 1390 persons with memory complaints were screened. Overall, 536 individuals had baseline assessment, and 315 (58.8%) were ineligible, most often owing to normal cognition (205 of 315 [65%]) or dementia (59 of 315 [18.7%]); 221 fully eligible participants were randomized. Analyses were intention to treat. Interventions: Participants were randomized to behavioral activation, which aimed to increase cognitive, physical, and social activity (111 [50.2%]), or supportive therapy, an attention control treatment (110 [49.8%]). Main Outcomes and Measures: The prespecified primary outcome was a decline of 6 or more recalled words on the total recall score of the Hopkins Verbal Learning Test-Revised assessed at 6, 12, 18, and 24 months. The secondary outcome was functional decline. Results: Of 221 randomized participants (mean [SD] age, 75.8 [7.0] years, 175 women [79%]), 77 behavioral activation participants (69.4%) and 87 supportive therapy participants (79.1%) had 2-year outcome assessments. After baseline, behavioral activation participants engaged in significantly more cognitive activities than supportive therapy participants. The 2-year incidence of memory decline was 1.2% (95% CI, 0.2-6.4) for behavioral activation vs 9.3% (95% CI, 5.30-16.4) for supportive therapy (relative risk, 0.12; 95% CI, 0.02-0.74; P = .02). Behavioral activation was associated with stable everyday function, whereas supportive therapy was associated with decline (difference in slopes, 2.71; 95% CI, 0.12-5.30; P = .04). Rates of serious adverse events for behavioral activation and supportive therapy, respectively, were: falls (14 [13%] vs 28 [25%]), emergency department visits (24 [22%] vs 24 [22%]), hospitalizations (36 [32%] vs 31 [28%]), and deaths (7 [5%] vs 3 [4%]). Conclusions and Relevance: Behavioral activation prevented cognitive and functional decline, but this finding requires further investigation. Black individuals have almost twice the rate of dementia as white individuals; behavioral activation may reduce this health disparity. Trial Registration: ClinicalTrials.gov Identifier: NCT01299766.

Health Beliefs and Medication Adherence in Black Patients with Diabetes and Mild Cognitive Impairment.

OBJECTIVES: To evaluate determinants of medication adherence and glycemic control in black patients with diabetes and mild cognitive impairment (MCI). METHODS: Cross-sectional study of 143 participants with mean age of 68.8 (SD: 6.7) years; 66.4% were women. RESULTS: Eighty-seven participants (60.8%) self-reported medication nonadherence; they had more negative beliefs about medicines, greater diabetes-related distress, and more difficulty with daily living activities and affording medications than adherent participants. There were no group differences in cognition, depressive symptoms, or glycemic control. Glycemic control negatively correlated with regimen distress, emotional burden, interpersonal distress, beliefs that physicians overprescribe medications, and beliefs that medications are harmful. CONCLUSIONS: Beliefs about medications, diabetes-related distress, functional disability, and medication affordability are associated with medication nonadherence in black individuals with diabetes and MCI. Interventions that respect personal health beliefs and compensate for impaired cognition may improve medication adherence and glycemic control in this population.

Functional Outcomes of the Low Vision Depression Prevention Trial in Age-Related Macular Degeneration.

Purpose: To compare the efficacy of behavioral activation (BA) plus low vision rehabilitation with an occupational therapist (OT-LVR) with supportive therapy (ST) on visual function in patients with age-related macular degeneration (AMD). Methods: Single-masked, attention-controlled, randomized clinical trial with AMD patients with subsyndromal depressive symptoms (n = 188). All subjects had two outpatient low vision rehabilitation optometry visits, then were randomized to in-home BA + OT-LVR or ST. Behavioral activation is a structured behavioral treatment aiming to increase adaptive behaviors and achieve valued goals. Supportive therapy is a nondirective, psychological treatment that provides emotional support and controls for attention. Functional vision was assessed with the activity inventory (AI) in which participants rate the difficulty level of goals and corresponding tasks. Participants were assessed at baseline and 4 months. Results: Improvements in functional vision measures were seen in both the BA + OT-LVR and ST groups at the goal level (d = 0.71; d = 0.56 respectively). At the task level, BA + OT-LVR patients showed more improvement in reading, inside-the-home tasks and outside-the-home tasks, when compared to ST patients. The greatest effects were seen in the BA + OT-LVR group in subjects with a visual acuity ≥20/70 (d = 0.360 reading; d = 0.500 inside the home; d = 0.468 outside the home). Conclusions: Based on the trends of the AI data, we suggest that BA + OT-LVR services, provided by an OT in the patient's home following conventional low vision optometry services, are more effective than conventional optometric low vision services alone for those with mild visual impairment. (ClinicalTrials.gov number, NCT00769015.).

A qualitative analysis of interprofessional healthcare team members' perceptions of patient barriers to healthcare engagement.

BACKGROUND: Healthcare systems increasingly engage interprofessional healthcare team members such as case managers, social workers, and community health workers to work directly with patients and improve population health. This study elicited perspectives of interprofessional healthcare team members regarding patient barriers to health and suggestions to address these barriers. METHODS: This is a qualitative study employing focus groups and semi-structured interviews with 39 interprofessional healthcare team members in Philadelphia to elicit perceptions of patients' needs and experiences with the health system, and suggestions for positioning health care systems to better serve patients. Themes were identified using a content analysis approach. RESULTS: Three focus groups and 21 interviews were conducted with 26 hospital-based and 13 ambulatory-based participants. Three domains emerged to characterize barriers to care: social determinants, health system factors, and patient trust in the health system. Social determinants included insurance and financial shortcomings, mental health and substance abuse issues, housing and transportation-related limitations, and unpredictability associated with living in poverty. Suggestions for addressing these barriers included increased financial assistance from the health system, and building a workforce to address these determinants directly. Health care system factors included poor care coordination, inadequate communication of hospital discharge instructions, and difficulty navigating complex systems. Suggestions for addressing these barriers included enhanced communication between care sites, patient-centered scheduling, and improved patient education especially in discharge planning. Finally, factors related to patient trust of the health system emerged. Participants reported that patients are often intimidated by the health system, mistrusting of physicians, and fearful of receiving a serious diagnosis or prognosis. A suggestion for mitigating these issues was increased visibility of the health system within communities to foster trust and help providers gain a better understanding of unique community needs. CONCLUSION: This work explored interprofessional healthcare team members' perceptions of patient barriers to healthcare engagement. Participants identified barriers related to social determinants of health, complex system organization, and patient mistrust of the health system. Participants offered concrete suggestions to address these barriers, with suggestions supporting current healthcare reform efforts that aim at addressing social determinants and improving health system coordination and adding new insight into how systems might work to improve patient and community trust.

Depression in Visual Impairment Trial (DEPVIT): A Randomized Clinical Trial of Depression Treatments in People With Low Vision.

PURPOSE: The purpose of this study was to compare two interventions for depression, problem solving treatment (PST) and referral to the patient's physician, with a waiting-list control group in people with sight loss and depressive symptoms. METHODS: This was an assessor-masked, exploratory, multicenter, randomized clinical trial, with concurrent economic analysis. Of 1008 consecutive attendees at 14 low-vision rehabilitation centers in Britain, 43% (n = 430) screened positive for depressive symptoms on the Geriatric Depression Scale and 85 of these attendees participated in the trial. Eligible participants were randomized in the ratio 1:1:1 to PST, referral to their physician, or a waiting-list control arm. PST is a manualized talking intervention delivered by a trained therapist who teaches people over six to eight sessions to implement a seven-step method for solving their problems. Referral to the physician involved sending a referral letter to the person's physician, encouraging him or her to consider treatment according to the stepped care protocol recommended by the U.K.'s National Institute of Health and Care Excellence. The primary outcome was change in depressive symptoms (6 months after baseline) as determined by the Beck Depression Inventory. RESULTS: At 6 months, Beck Depression Inventory scores reduced by 1.05 (SD 8.85), 2.11 (SD 7.60), and 2.68 (SD 7.93) in the waiting-list control, referral, and PST arms, respectively. The cost per patient of the PST intervention was £1176 in Wales and £1296 in London. CONCLUSIONS: Depressive symptoms improved most in the PST group and least in the control group. However, the change was small and the uncertainty of the measurements relatively large.

Anxiety and depression in patients with advanced macular degeneration: current perspectives.

Age-related macular degeneration (AMD) - despite advances in prevention and medical treatment options - remains prevalent among older adults, often resulting in functional losses that negatively affect the mental health of older adults. In particular, the prevalence of both anxiety and depression in patients with AMD is high. Along with medical treatment options, low vision rehabilitation and AMD-specific behavioral and self-management programs have been developed and have demonstrated effectiveness in improving the mental health of AMD patients. This article reviews the prevalence of anxiety and depression in patients with advanced AMD, discusses potential mechanisms accounting for the development of depression and anxiety in AMD patients, presents the state-of the-art of available interventions for addressing anxiety and depression in AMD patients, and delineates recommendations for eye care professionals regarding how to screen for these two prevalent mental health problems and how to facilitate appropriate treatment for patients with AMD.

Determinants of Activity Levels in African Americans With Mild Cognitive Impairment.

Engaging in cognitive, social, and physical activities may prevent cognitive decline. In a sample of older African Americans with mild cognitive impairment (MCI; N=221), we investigated the cross-sectional relationships between activity levels and participants' demographic, clinical, and neuropsychological characteristics. The average age of participants was 75.4 years (SD, 7.0); 177 (80.1%) were women. Participation in cognitive/social activities was positively associated with education, depression, literacy, mobility, instrumental activities of daily living (IADL), verbal learning, and subcomponents of executive function. A linear regression identified IADLs, education, depression, and verbal learning as independent predictors. Participation in physical activities was positively associated with sex, depression, IADLs, and subcomponents of executive function. An ordinal regression identified executive function and depression as independent correlates. These data suggest that unique characteristics are associated with cognitive/social and physical activities in older African Americans with MCI. These characteristics, coupled with low activity levels, may increase the risk of progression from MCI to dementia. Culturally relevant behavioral interventions to reduce cognitive decline in this high-risk population are needed.