Dementia and co-occurring chronic conditions: a systematic literature review to identify what is known and where are the gaps in the evidence?

OBJECTIVE: The challenges posed by people living with multiple chronic conditions are unique for people with dementia and other significant cognitive impairment. There have been recent calls to action to review the existing literature on co-occurring chronic conditions and dementia in order to better understand the effect of cognitive impairment on disease management, mobility, and mortality. METHODS: This systematic literature review searched PubMed databases through 2011 (updated in 2016) using key constructs of older adults, moderate-to-severe cognitive impairment (both diagnosed and undiagnosed dementia), and chronic conditions. Reviewers assessed papers for eligibility and extracted key data from each included manuscript. An independent expert panel rated the strength and quality of evidence and prioritized gaps for future study. RESULTS: Four thousand thirty-three articles were identified, of which 147 met criteria for review. We found that moderate-to-severe cognitive impairment increased risks of mortality, was associated with prolonged institutional stays, and decreased function in persons with multiple chronic conditions. There was no relationship between significant cognitive impairment and use of cardiovascular or hypertensive medications for persons with these comorbidities. Prioritized areas for future research include hospitalizations, disease-specific outcomes, diabetes, chronic pain, cardiovascular disease, depression, falls, stroke, and multiple chronic conditions. CONCLUSIONS: This review summarizes that living with significant cognitive impairment or dementia negatively impacts mortality, institutionalization, and functional outcomes for people living with multiple chronic conditions. Our findings suggest that chronic-disease management interventions will need to address co-occurring cognitive impairment. Copyright © 2017 John Wiley & Sons, Ltd.

Using Social Network Analysis to Assess Mentorship and Collaboration in a Public Health Network.

INTRODUCTION: Addressing chronic disease burden requires the creation of collaborative networks to promote systemic changes and engage stakeholders. Although many such networks exist, they are rarely assessed with tools that account for their complexity. This study examined the structure of mentorship and collaboration relationships among members of the Healthy Aging Research Network (HAN) using social network analysis (SNA). METHODS: We invited 97 HAN members and partners to complete an online social network survey that included closed-ended questions about HAN-specific mentorship and collaboration during the previous 12 months. Collaboration was measured by examining the activity of the network on 6 types of products: published articles, in-progress manuscripts, grant applications, tools, research projects, and presentations. We computed network-level measures such as density, number of components, and centralization to assess the cohesiveness of the network. RESULTS: Sixty-three respondents completed the survey (response rate, 65%). Responses, which included information about collaboration with nonrespondents, suggested that 74% of HAN members were connected through mentorship ties and that all 97 members were connected through at least one form of collaboration. Mentorship and collaboration ties were present both within and across boundaries of HAN member organizations. CONCLUSION: SNA of public health collaborative networks provides understanding about the structure of relationships that are formed as a result of participation in network activities. This approach may offer members and funders a way to assess the impact of such networks that goes beyond simply measuring products and participation at the individual level.

How an Intergenerational Book Club Can Prevent Cognitive Decline in Older Adults: A Pilot Study.

Older adults are at higher risk for social isolation because of widowhood, loss of friends, retirement, physical limitations, geographic relocation, and caregiving demands. Behavioral interventions aimed at increasing social contact may help to maintain cognition and prevent cognitive decline. The purpose of this pilot study was to examine a novel intervention for social isolation with an intergenerational book club that had weekly in-person and virtual meetings of college students and older adults. We wanted to know whether the study was feasible and if our methods would be likely to generate meaningful results should it be expanded to a larger number of participants. We predicted that wellbeing and cognition would improve following participation in the book club. Results found that while measures of quality of life and affect were not statistically different before and after participation in a book club, scores on a measure of cognition (the Montreal Cognitive Assessment) were statistically significant between groups (intervention and control) showing greater improvement among book club participants.

Social Determinants of Health and Depression among African American Adults: A Scoping Review of Current Research.

Depression in the United States (US) is increasing across all races and ethnicities and is attributed to multiple social determinants of health (SDOH). For members of historically marginalized races and ethnicities, depression is often underreported and undertreated, and can present as more severe. Limited research explores multiple SDOH and depression among African American adults in the US. Guided by Healthy People (HP) 2030, and using cross-disciplinary mental health terminology, we conducted a comprehensive search to capture studies specific to African American adults in the US published after 2016. We applied known scoping review methodology and followed Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) guidelines. From 12,315 initial results, 60 studies were included in our final sample. Most studies explored the HP 2030 Social and Community Context domain, with a heavy focus on discrimination and social support; no studies examined Health Care Access and Quality. Researchers typically utilized cross-sectional, secondary datasets; no qualitative studies were included. We recommend research that comprehensively examines mental health risk and protective factors over the life course within, not just between, populations to inform tailored health promotion and public policy interventions for improving SDOH and reducing racial and ethnic health disparities.

An Evaluation of Dementia Dialogues®: A Program for Informal and Formal Caregivers in North and South Carolina.

In 2019, the University of South Carolina's Office for the Study of Aging (OSA) remodeled the curriculum for the nationally registered Dementia Dialogues® program that delivers high-quality education to formal and informal caregivers of persons who exhibit signs and symptoms of Alzheimer's disease and related dementias (ADRD). This study evaluated new knowledge acquired and program satisfaction by North and South Carolina program participants (N = 235) after completing updated modules. Pre/post module survey data were analyzed using means and percentiles, McNemar's test, and paired t tests. Results demonstrated significant positive increases in caregiver knowledge attainment, with differences in overall knowledge change in specific modules among caregivers and noncaregivers (p < .0001-<.05). Dementia Dialogues® may serve as a useful tool in providing important information that increases caregiver knowledge of persons living with ADRD. Further research is recommended to examine how knowledge improvement translates into caregiving practices.

Mentorship and Training to Increase Diversity of Researchers and Practitioners in the Field of Aging and Alzheimer's Disease: A Scoping Review of Program Characteristics.

Objectives: Diversity is needed within the aging and Alzheimer's disease and related dementias (ADRD) research and practice workforce to comprehensively address health inequities faced by underrepresented minority (URM) older adults. We conducted a scoping review of training programs designed to diversify the pool of researchers and practitioners in the field of aging and ADRD. Methods: Online database searches yielded 3976 articles published from 1999 to 2019. Fourteen studies met the inclusion criteria. Results: All programs were from the United States and included URM populations. Nine programs included students, one targeted university faculty, and four targeted clinical staff. Only five programs were guided by theory. Discussion: Our review identified URMs' desire for culturally diverse and representative mentorship, the need for career development support at various training stages, and the importance of incorporating theory to program design. It also identified key characteristics for future program development, creation of systematic evaluation standards, and opportunities for promotion.

Genetic Risk Factors for Alzheimer's Disease in Racial/Ethnic Minority Populations in the U.S.: A Scoping Review.

Objectives: As the United States (U.S.) population rapidly ages, the incidence of Alzheimer's Disease and Related Dementias (ADRDs) is rising, with racial/ethnic minorities affected at disproportionate rates. Much research has been undertaken to test, sequence, and analyze genetic risk factors for ADRDs in Caucasian populations, but comparatively little has been done with racial/ethnic minority populations. We conducted a scoping review to examine the nature and extent of the research that has been published about the genetic factors of ADRDs among racial/ethnic minorities in the U.S. Design: Using an established scoping review methodological framework, we searched electronic databases for articles describing peer-reviewed empirical studies or Genome-Wide Association Studies that had been published 2005-2018 and focused on ADRD-related genes or genetic factors among underrepresented racial/ethnic minority population in the U.S. Results: Sixty-six articles met the inclusion criteria for full text review. Well-established ADRD genetic risk factors for Caucasian populations including APOE, APP, PSEN1, and PSEN2 have not been studied to the same degree in minority U.S. populations. Compared to the amount of research that has been conducted with Caucasian populations in the U.S., racial/ethnic minority communities are underrepresented. Conclusion: Given the projected growth of the aging population and incidence of ADRDs, particularly among racial/ethnic minorities, increased focus on this important segment of the population is warranted. Our review can aid researchers in developing fundamental research questions to determine the role that ADRD risk genes play in the heavier burden of ADRDs in racial/ethnic minority populations.

Representative Sequencing: Unbiased Sampling of Solid Tumor Tissue.

Although thousands of solid tumors have been sequenced to date, a fundamental under-sampling bias is inherent in current methodologies. This is caused by a tissue sample input of fixed dimensions (e.g., 6 mm biopsy), which becomes grossly under-powered as tumor volume scales. Here, we demonstrate representative sequencing (Rep-Seq) as a new method to achieve unbiased tumor tissue sampling. Rep-Seq uses fixed residual tumor material, which is homogenized and subjected to next-generation sequencing. Analysis of intratumor tumor mutation burden (TMB) variability shows a high level of misclassification using current single-biopsy methods, with 20% of lung and 52% of bladder tumors having at least one biopsy with high TMB but low clonal TMB overall. Misclassification rates by contrast are reduced to 2% (lung) and 4% (bladder) when a more representative sampling methodology is used. Rep-Seq offers an improved sampling protocol for tumor profiling, with significant potential for improved clinical utility and more accurate deconvolution of clonal structure.

Recommendations for treating depression in community-based older adults.

OBJECTIVE: To present recommendations for community-based treatment of late-life depression to public health and aging networks. METHODS: An expert panel of mental health and public health researchers and community-based practitioners in aging was convened in April 2006 to form consensus-based recommendations. When making recommendations, panelists considered feasibility and appropriateness for community-based delivery, as well as strength of evidence on program effectiveness from a systematic literature review of articles published through 2005. RESULTS: The expert panel strongly recommended depression care management-modeled interventions delivered at home or at primary care clinics. The panel recommended individual cognitive behavioral therapy. Interventions not recommended as primary treatments for late-life depression included education and skills training, comprehensive geriatric health evaluation programs, exercise, and physical rehabilitation/occupational therapy. There was insufficient evidence for making recommendations for several intervention categories, including group psychotherapy and psychotherapies other than cognitive behavioral therapy. CONCLUSIONS: This interdisciplinary expert panel determined that recommended interventions should be disseminated throughout the public health and aging networks, while acknowledging the challenges and obstacles involved. Interventions that were not recommended or had insufficient evidence often did not treat depression primarily and/or did not include a clinically depressed sample while attempting to establish efficacy. These interventions may provide other benefits, but should not be presumed to effectively treat depression by themselves. Panelists also identified primary prevention of depression as a much under-studied area. These findings should aid individual clinicians as well as public health decision makers in the delivery of population-based mental health services in diverse community settings.

Community-based treatment of late life depression an expert panel-informed literature review.

OBJECTIVES: To present findings from an expert panel-informed literature review on community-based treatment of late-life depression. METHODS: A systematic literature review was conducted to appraise publications on community-based interventions for depression in older adults. The search was conducted between March and October 2005. An expert panel of mental health, aging, health services, and epidemiology researchers guided the review and voted on quality and effectiveness of these interventions. RESULTS: A total of 3,543 articles were found with publication dates from 1967 to October 2005; of these, 116 were eligible for inclusion. Adequate data existed to determine effectiveness for the following interventions: depression care management, group and individual psychotherapy for depression, psychotherapy targeting mental health, psychotherapy for caregivers, education and skills training (to manage health problems besides depression; and for caregivers), geriatric health evaluation and management, exercise, and physical rehabilitation and occupational therapy. After reviewing the data, panelists rated the depression care management interventions as effective. Education and skills training, geriatric health evaluation and management, and physical rehabilitation and occupational therapy received ineffective ratings. Other interventions received mixed effectiveness ratings. Insufficient data availability and poor study quality prevented the panelists from rating several reviewed interventions. CONCLUSIONS: While several well-described interventions were found to treat depression effectively in community-dwelling older adults, significant gaps still exist. Interventions that did not target depression specifically may be of benefit to older adults, but they should not be presumed to treat depression by themselves. Treating depressed elders may require a multifaceted approach to ensure effectiveness. More research in this area is needed.

Retracted: Using bald eagles to track spatial (1999-2008) and temporal (1987-1992, 1999-2003, and 2004-2008) trends of contaminants in Michigan's aquatic ecosystems.

Retraction: 'Using bald eagles to track spatial (1999-2008) and temporal (1987-1992, 1999-2003, and 2004-2008) trends of contaminants in Michigan's aquatic ecosystems' by Michael R. Wierda, Katherine F. Leith, Teryl G. Grubb, James G. Sikarskie, David A. Best, and William Bowerman The above article from Environmental Toxicology and Chemistry, published online on 10 February 2015 in Wiley Online Library (wileyonlinelibrary.com), has been retracted by agreement between the authors, the journal Editor in Chief, G.A. Burton, Jr., SETAC and Wiley Periodicals, Inc. The retraction has been agreed since the authors determined that some of the plasma samples run at Clemson University had failed quality assurance/quality control and were retested. The concentrations have since been corrected and validated. Reference Wierda MR, Leith KF, Grubb TG, Sikarskie JG, Best DA, Bowerman W. 2015. Using bald eagles to track spatial (1999-2008) and temporal (1987-1992, 1999-2003, and 2004-2008) trends of contaminants in Michigan's aquatic ecosystems. Environ ToxicolChem doi:10.1002/etc.2859.

Using bald eagles to track spatial (1999-2008) and temporal (1987-1992, 1999-2003, and 2004-2008) trends of contaminants in Michigan's aquatic ecosystems.

The bald eagle (Haliaeetus leucocephalus) is an extensively researched tertiary predator. Studies have delineated information about its life history and the influences of various stressors on its reproduction. Due to the bald eagle's position at the top of the food web, it is susceptible to biomagnification of xenobiotics. The Michigan Department of Environmental Quality implemented a program in 1999 to monitor persistent chemicals including polychlorinated biphenols (PCBs) and dichlorodiphenyltrichloroethane (DDE). The objectives of the present study were to evaluate spatial and temporal trends of PCBs and organochlorine pesticides in nestling bald eagles of Michigan. The authors' study found that concentrations of PCBs and DDE were higher in Great Lakes areas with Lakes Michigan and Lake Huron having the highest concentrations of DDE and Lake Erie having the highest concentrations of PCBs. Temporally (1987-1992, 1999-2003, and 2004-2008) the present study found declines in PCB and DDE concentrations with a few exceptions. Continued monitoring of Michigan bald eagle populations is suggested for a couple of reasons. First, nestling blood contaminant levels are an appropriate method to monitor ecosystem contaminant levels. Second, from 1999 to 2008 PCB and DDE concentrations for 30% and 40%, respectively, of the nestling eagles sampled were above the no observable adverse effect level (NOAEL) for bald eagles. Lastly, with the continued development and deployment of new chemistries a continuous long term monitoring program is an invaluable resource. Environ Toxicol Chem 2016;35:1995-2002. © 2016 SETAC.

Girdin (GIV) Expression as a Prognostic Marker of Recurrence in Mismatch Repair-Proficient Stage II Colon Cancer.

PURPOSE: Prognostic markers that identify patients with stage II colon cancers who are at the risk of recurrence are essential to personalize therapy. We evaluated the potential of GIV/Girdin as a predictor of recurrence risk in such patients. EXPERIMENTAL DESIGN: Expression of full-length GIV was evaluated by IHC using a newly developed mAb together with a mismatch repair (MMR)-specific antibody panel in three stage II colon cancer patient cohorts, that is, a training (n = 192), test (n = 317), and validation (n = 181) cohort, with clinical follow-up data. Recurrence risk stratification models were established in the training cohort of T3, proficient MMR (pMMR) patients without chemotherapy and subsequently validated. RESULTS: For T3 pMMR tumors, GIV expression and the presence of lymphovascular invasion (LVI) were the only factors predicting recurrence in both training (GIV: HR, 2.78, P = 0.013; LVI: HR, 2.54, P = 0.025) and combined test and validation (pooled) cohorts (GIV: HR, 1.85, P = 0.019; LVI: HR, 2.52, P = 0.0004). A risk model based on GIV expression and LVI status classified patients into high- or low-risk groups; 3-year recurrence-free survival was significantly lower in the high-risk versus low-risk group across all cohorts [Training: 52.3% vs. 84.8%; HR, 3.74, 95% confidence interval (CI), 1.50-9.32; Test: 85.9% vs. 97.9%, HR, 7.83, 95% CI, 1.03-59.54; validation: 59.4% vs. 84.4%, HR, 3.71, 95% CI, 1.24-11.12]. CONCLUSIONS: GIV expression status predicts recurrence risk in patients with T3 pMMR stage II colon cancer. A risk model combining GIV expression and LVI status information further enhances prediction of recurrence. Further validation studies are warranted before GIV status can be routinely included in patient management algorithms. Clin Cancer Res; 22(14); 3488-98. ©2016 AACR.

Recruitment and retention of emergency medical technicians: a qualitative study.

Emergency medical technicians (EMTs) are critical to out-of-hospital care, but maintaining staff can be difficult. The study objective was to identify factors that contribute to recruitment and retention of EMTs and paramedics. Information was drawn from three focus groups of EMT-Basic, EMT-Intermediate, and EMT-Paramedic personnel recruited from participants at an annual conference. Thoughts and feelings of EMTs and paramedics were investigated using eight questions designed to explore entry into emergency medical services, what it is like to be an EMT or paramedic, and the EMT educational process. Data were analyzed at the group level for common themes using NVivo. For a majority of respondents, emergency medical services was not a primary career path. Most respondents entered the industry as an alternate or replacement for a nursing career or as a second career following military medic service. The majority of respondents believed the job was stressful yet rewarding, and although it negatively affected their personal lives, the occupation gave them a sense of accomplishment and belonging. Respondents expressed a preference for EMT education resulting in college credit or licensure versus professional certification. Job-related stress produced by numerous factors appears to be a likely contributor to low employee retention. Recruitment and retention efforts should address study findings, incorporating key findings into educational, evaluation, and job enhancement programs.

The steps to health randomized trial for arthritis: a self-directed exercise versus nutrition control program.

BACKGROUND: Despite the established benefits of exercise for adults with arthritis, participation is low. Safe, evidence-based, self-directed programs, which have the potential for high reach at a low cost, are needed. PURPOSE: To test a 12-week, self-directed, multicomponent exercise program for adults with arthritis. DESIGN: Randomized controlled trial. Data were collected from 2010 to 2012. Data were analyzed in 2013 and 2014. SETTING/PARTICIPANTS: Adults with arthritis (N=401, aged 56.3 [10.7] years, 85.8% women, 63.8% white, 35.2% African American, BMI of 33.0 [8.2]) completed measures at a university research center and participated in a self-directed exercise intervention (First Step to Active Health(®)) or nutrition control program (Steps to Healthy Eating). INTERVENTION: Intervention participants received a self-directed multicomponent exercise program and returned self-monitoring logs for 12 weeks. MAIN OUTCOME MEASURES: Self-reported physical activity, functional performance measures, and disease-specific outcomes (arthritis symptoms and self-efficacy) assessed at baseline, 12 weeks, and 9 months. RESULTS: Participants in the exercise condition showed greater increases in physical activity than those in the nutrition control group (p=0.01). Significant improvements, irrespective of condition, were seen in lower body strength, functional exercise capacity, lower body flexibility, pain, fatigue, stiffness, and arthritis management self-efficacy (p values<0.0001). More adverse events occurred in the exercise than nutrition control condition, but only one was severe and most were expected with increased physical activity. CONCLUSIONS: The exercise program improves physical activity, and both programs improve functional and psychosocial outcomes. Potential reasons for improvements in the nutrition control condition are discussed. These interventions have the potential for large-scale dissemination. This study is registered at Clinicaltrials.gov NCT01172327.

Developing a framework and priorities to promote mobility among older adults.

Mobility, broadly defined as movement in all of its forms from ambulation to transportation, is critical to supporting optimal aging. This article describes two projects to develop a framework and a set of priority actions designed to promote mobility among community-dwelling older adults. Project 1 involved a concept-mapping process to solicit and organize action items into domains from a broad group of stakeholders to create the framework. Concept mapping uses qualitative group processes with multivariate statistical analysis to represent the ideas visually through maps. A snowball technique was used to identify stakeholders (n = 211). A 12-member steering committee developed a focus prompt, "One specific action that can lead to positive change in mobility for older adults in the United States is..." Project 2 included a Delphi technique (n = 43) with three iterations to prioritize four to six items using results from the concept mapping rating process. Project 1 resulted in 102 items across nine domains (Research to Practice, Independence and Engagement, Built Environment and Safety, Transportation, Policy, Housing and Accessibility, Community Supports, Training, and Coordinated Action). The number of items ranged from 6 to 18 per domain. Project 2 resulted in agreement on four items that reflect the importance of promoting environmental strategies through collaborative initiatives aimed at planning and best practices focusing on environmental enhancements or transit, training of professionals, and integration of mobility into state and local public health plans. These findings can be applied to support coordinated, multidisciplinary research and practice to promote mobility among older adults.

Effect of physical activity, social support, and skills training on late-life emotional health: a systematic literature review and implications for public health research.

PURPOSE: Given that emotional health is a critical component of healthy aging, we undertook a systematic literature review to assess whether current interventions can positively affect older adults' emotional health. METHODS: A national panel of health services and mental health researchers guided the review. Eligibility criteria included community-dwelling older adult (aged ≥ 50 years) samples, reproducible interventions, and emotional health outcomes, which included multiple domains and both positive (well-being) and illness-related (anxiety) dimensions. This review focused on three types of interventions - physical activity, social support, and skills training - given their public health significance and large number of studies identified. Panel members evaluated the strength of evidence (quality and effectiveness). RESULTS: In all, 292 articles met inclusion criteria. These included 83 exercise/physical activity, 25 social support, and 40 skills training interventions. For evidence rating, these 148 interventions were categorized into 64 pairings by intervention type and emotional health outcome, e.g., strength training targeting loneliness or social support to address mood. 83% of these pairings were rated at least fair quality. Expert panelists found sufficient evidence of effectiveness only for skills training interventions with health outcomes of decreasing anxiety and improving quality of life and self-efficacy. Due to limitations in reviewed studies, many intervention-outcome pairings yielded insufficient evidence. CONCLUSION: Skills training interventions improved several aspects of emotional health in community-dwelling older adults, while the effects for other outcomes and interventions lacked clear evidence. We discuss the implications and challenges in moving forward in this important area.

The healthy aging research network: resources for building capacity for public health and aging practice.

There is an urgent need to translate science into practice and help enhance the capacity of professionals to deliver evidence-based programming. We describe contributions of the Healthy Aging Research Network in building professional capacity through online modules, issue briefs, monographs, and tools focused on health promotion practice, physical activity, mental health, and environment and policy. We also describe practice partnerships and research activities that helped inform product development and ways these products have been incorporated into real-world practice to illustrate possibilities for future applications. Our work aims to bridge the research-to-practice gap to meet the demands of an aging population.

Physical activity and older adults: expert consensus for a new research agenda.

PURPOSE: This study sought to advance the state of knowledge regarding physical activity and aging by identifying areas of agreement among experts regarding topics that are well understood versus those that are in urgent need of continued research efforts. DESIGN AND METHODS: We used a web-based survey with snowball sampling to identify 348 experts who were invited to complete a brief web-based survey. Responses were received from 38% of invited respondents. RESULTS: Respondents reported that the efficacy and effectiveness of several types of physical activity were well understood but the dose-response relationship required for a health benefit was not. In general, more research is needed examining the effectiveness of programs on cognitive health outcomes and the impact of multiple risk factor programs. With respect to translation, more research is needed on how to maintain older adults in evidence-based programs and how to adapt programs for special populations. Researchers agreed that racial/ethnic minorities; persons with low socioeconomic status; and those with physical, intellectual, or mental health disability were substantially understudied. Finally, research on maintenance, implementation, and reach with respect to these populations was judged to be more urgently needed than research on efficacy and effectiveness. IMPLICATIONS: A substantial amount of consensus was found across a national group of experts. These findings should be instrumental in forging a new research agenda in the area of aging and physical activity.