Integrating PROMIS Measures in a Treat-to-Target Approach to Standardize Patient-Centered Treatment of Rheumatoid Arthritis.

OBJECTIVE: To evaluate the effect of a patient-centered rheumatoid arthritis (RA) treat-to-target (T2T) disease management approach on patient outcomes and patient satisfaction with care. METHODS: In this longitudinal, observational pilot study, rheumatologists implemented a modified T2T approach that integrated Patient Reported Outcomes Measurement Information System (PROMIS) measures for depression, fatigue, pain interference, physical function, and social function into RA care. Study participants selected 1 PROMIS domain to target treatment and completed quarterly follow-up assessments. Participants were classified as improved if their Clinical Disease Activity Index (CDAI) changed by > 5 points. Change in PROMIS t scores was examined for the group with improved CDAI, and then compared to those with unchanged or worsened CDAI. Satisfaction with care was assessed using multiple measures, including the Functional Assessment of Chronic Illness Therapy-Treatment Satisfaction-Patient Satisfaction Scale. RESULTS: The analytical sample (n = 119, median age 57 years, 90.8% female) was split between those with CDAI > 10 (n = 63) and CDAI ≤ 10 (n = 53). At 1 year, there was improvement in CDAI by > 5 points in 66% and 13% of individuals with baseline CDAI > 10 and baseline CDAI ≤ 10, respectively. Across all participants, improvement in CDAI by > 5 points correlated with improvements in the 5 PROMIS domains. Satisfaction with RA treatment also increased. CONCLUSION: The integration of PROMIS measures into the T2T approach for RA care was associated with improvements in disease activity, and improvement in disease activity was associated with improvements in PROMIS measures.

A Process Evaluation of Developing Older Adult Research Advisory Boards in Long-term Care Settings.

BACKGROUND: Enhancing the capacity of researchers, providers and older adults to collaborate in research is critical for promoting relevant, useful research findings. OBJECTIVES: The Sages in Every Setting project aimed to disseminate a flexible model for developing research advisory boards (RABs) comprised of older adults receiving long-term services and supports (LTSS) via partnerships between academic researchers and LTSS providers. METHODS: Process evaluation assessed the feasibility of using resources to develop RABs. Partners sought regular feedback from facilitators and RAB members, which was shared with the evaluator. The evaluator conducted regular debriefings with academic partners and observed some RAB meetings. LESSONS LEARNED: The development of RABs was impacted by pre-existing collaborations, characteristics of providers, flexible use of the resources, facilitator capacity, member capacity, and researcher capacity. CONCLUSIONS: Developing RABs was feasible. Long-term partnerships between research institutions and LTSS providers that serve diverse populations could improve successful dissemination of this model.

The Bureau of Sages: Incorporating Older Adult Voice into Meaningful Research.

BACKGROUND: Older adults receiving long-term care are often excluded from the design, development, and implementation of health-related research. The project aimed to create, implement and evaluate a sustainable research advisory board consisting of researchers, clinicians, and older adults living at home or in a skilled nursing facility (SNF). METHODS: To initiate Bureau development, 15 older adults, researchers, and clinicians came together to engage in research. In meetings and retreats, stakeholders mutually developed group procedures, roles, and values. Process evaluation focused on stakeholder experiences, development of the Bureau, and its impact. RESULTS: Trained Sages were able to offer meaningful input to researchers and present their own proposal at a conference. Lessons learned centered around continuously seeking feedback from participants, emphasizing co-learning, adapting to virtual engagement, and remaining flexible in structure and content of meetings. CONCLUSIONS: Results can inform future development of research advisory boards of older adult populations.

Smartwatches Can Detect Walker and Cane Use in Older Adults.

BACKGROUND AND OBJECTIVES: Clinicians commonly prescribe assistive devices such as walkers or canes to reduce older adults' fall risk. However, older adults may not consistently use their assistive device, and measuring adherence can be challenging due to self-report bias or cognitive deficits. Because walking patterns can change while using an assistive device, we hypothesized that smartphones and smartwatches, combined with machine-learning algorithms, could detect whether an older adult was walking with an assistive device. RESEARCH DESIGN AND METHODS: Older adults at an Adult Day Center (n = 14) wore an Android smartphone and Actigraph smartwatch while completing the six-minute walk, 10-meter walk, and Timed Up and Go tests with and without their assistive device on five separate days. We used accelerometer data from the devices to build machine-learning algorithms to detect whether the participant was walking with or without their assistive device. We tested our algorithms using cross-validation. RESULTS: Smartwatch classifiers could accurately detect assistive device use, but smartphone classifiers performed poorly. Customized smartwatch classifiers, which were created specifically for one participant, had greater than 95% classification accuracy for all participants. Noncustomized smartwatch classifiers (ie, an "off-the-shelf" system) had greater than 90% accuracy for 10 of the 14 participants. A noncustomized system performed better for walker users than cane users. DISCUSSION AND IMPLICATIONS: Our approach can leverage data from existing commercial devices to provide a deeper understanding of walker or cane use. This work can inform scalable public health monitoring tools to quantify assistive device adherence and enable proactive fall interventions.

A Community-Partnered Approach to Inform a Culturally Relevant Health Promotion Intervention for Stroke.

BACKGROUND: The purpose of this study was to generate information from multiethnic, high-risk communities to inform the creation of culturally relevant health promotion intervention for increasing early hospital arrival after stroke. METHODS: The study employed a qualitative design, using focus groups with African American, Caucasian, and Hispanic adults in two Chicago community areas. The study relied heavily on stakeholder input in creating the focus group guide, recruiting participants, and interpreting the analysis. RESULTS: Six focus groups gained information from 51 participants, including insights and perspective on participants' stroke experience and knowledge as well as on facilitators and barriers to calling 9-1-1. Qualitative analysis uncovered themes relating to risk factors, symptoms, knowledge of stroke mechanisms, experience of acute stroke, help seeking, stroke education, recovery, treatment, and emotions. Communities were closely aligned in their knowledge of stroke, but had differing ideas around stroke education and dissemination of education. DISCUSSION: This study identified nuances in real-world barriers to receiving acute stroke services in minority and disadvantaged communities in Chicago neighborhoods. Our findings indicated significant amount of variation by race/ethnicity and, in particular, a lack of similarities based on race/ethnic groups in different communities. These findings underscore the importance of working with communities to fully understand the community-level dynamics that occur.

Non-Emergency Medical Transportation Needs of Middle-Aged and Older Adults: A Rural-Urban Comparison in Delaware, USA.

Background: Older adults in rural areas have unique transportation barriers to accessing medical care, which include a lack of mass transit options and considerable distances to health-related services. This study contrasts non-emergency medical transportation (NEMT) service utilization patterns and associated costs for Medicaid middle-aged and older adults in rural versus urban areas. Methods: Data were analyzed from 39,194 NEMT users of LogistiCare-brokered services in Delaware residing in rural (68.3%) and urban (30.9%) areas. Multivariable logistic analyses compared trip characteristics by rurality designation. Results: Rural (37.2%) and urban (41.2%) participants used services more frequently for dialysis than for any other medical concern. Older age and personal accompaniment were more common and wheel chair use was less common for rural trips. The mean cost per trip was greater for rural users (difference of $2910 per trip), which was attributed to the greater distance per trip in rural areas. Conclusions: Among a sample who were eligible for subsidized NEMT and who utilized this service, rural trips tended to be longer and, therefore, higher in cost. Over 50% of trips were made for dialysis highlighting the need to address prevention and, potentially, health service improvements for rural dialysis patients.

Translating Strong for Life Into the Community Care Program: Lessons Learned.

We used a randomized controlled trial to test the implementation of Strong for Life (SFL), a resistance exercise intervention, using 32 home care aides (HCAs) as exercise leaders with their 42 homebound older adult clients enrolled in the Community Care Program, a Medicaid 1915(c) waiver program. Mixed-methods were used to analyze outcomes of program satisfaction rates, training session evaluations, program fidelity, and job descriptive index scores. Results indicate that it is feasible for HCAs to implement SFL safely with clients. Participants viewed SFL as highly satisfactory and HCAs were able to adapt SFL for their clients. HCAs have high job satisfaction, and leading SFL enhances work achievement and pride. Our results show it is possible to train HCAs to implement SFL with their clients in addition to providing usual care services, participation positively affects both care partners, and this is a feasible and practical delivery model to provide exercise for adults receiving home- and community-based services.

Nurses' Pain Management for Hospitalized Elderly Patients With Postoperative Pain.

Using the theory of planned behavior, the study aim was to determine the relationships among nurses' beliefs, attitudes, perceived norms, perceived behavioral control, intentions, and behavior regarding pain management for hospitalized elderly patients with postoperative pain. A cross-sectional design was used with a convenience sample of 140 nurses working in adult surgical units at three hospitals. Based on path analyses, nurses' behavioral, normative, and control beliefs, respectively, had direct effects on their attitudes, perceived norms, and perceived behavioral control regarding pain management. Nurses' attitudes and perceived norms had direct effects on their pain management intentions. However, nurses' intentions had no direct effect on their behavior (measured by responses to questions about case study vignettes). This study highlights the need for education that enhances nurses' perceptions of pain management benefits, the influence of normative referents, and their ability to assess pain and administer pro re nata (PRN) opioid analgesics.

Performance measures, hours of caregiving assistance, and risk of adverse care outcomes among older adult users of Medicaid home and community-based services.

OBJECTIVES: This study used validated physical performance measures to examine function, risk of adverse health outcomes, and the relationship with allocated hours of weekly caregiving assistance among older adults receiving home and community-based services through a Medicaid waiver program. METHODS: Older adults (n = 42) completed physical performance measures including grip strength, 30-s chair rise, Timed Up and Go, and gait speed. Demographic information including age, gender, and allocated hours of weekly caregiving assistance were also collected. RESULTS: A majority, 72% of females and 86% of males, had weak grip strength, 57% met criteria for fall risk based on their Timed Up and Go score, 83% had lower extremity strength impairments, and 98% were unable to ambulate more than 1.0 m/s. Frailty was prevalent in the sample with 72% of clients meeting Fried's frailty criteria. The most significant predictors of allocated hours of weekly caregiving assistance approved for clients were race and gait speed. CONCLUSION: Based on scores on physical performance measures, clients are at risk of falls, hospitalization, and mortality, and scores indicate an urgent need to assess performance in addition to self-reported activities of daily living limitations for this population. Performance measures associated with quantifiable risk of adverse outcomes can be critical indicators for referrals and services needed to enhance the safety and improve care outcomes for homebound older adults.

The BRIGHTEN program: implementation and evaluation of a program to bridge resources of an interdisciplinary geriatric health team via electronic networking.

PURPOSE: To demonstrate the feasibility of the BRIGHTEN Program (Bridging Resources of an Interdisciplinary Geriatric Health Team via Electronic Networking), an interdisciplinary team intervention for assessing and treating older adults for depression in outpatient primary and specialty medical clinics. The BRIGHTEN team collaborates "virtually" to review patient assessment results, develop a treatment plan, and refer to appropriate team members for follow-up care. DESIGN AND METHODS: Older adults in 9 academic medical center clinics and 2 community-based clinics completed screening forms for symptoms of depression and anxiety. Those with positive screens engaged in comprehensive assessment with the BRIGHTEN Program Coordinator; the BRIGHTEN virtual team provided treatment recommendations based on the results of assessment. A collaborative treatment plan was developed with each participant, who was then connected to appropriate services. RESULTS: Two thousand four hundred twenty-two older adults were screened in participating clinics over a 40-month period. Eight hundred fifty-nine older adults screened positive, and 150 elected to enroll in BRIGHTEN. From baseline to 6 months, significant improvements were found in depression symptoms (Geriatric Depression Scale, p < .01) and general mental health (SF-12 Mental Component, p < .01). IMPLICATIONS: The BRIGHTEN Program demonstrated that an interdisciplinary virtual team linked with outpatient medical clinics can be an effective, nonthreatening, and seamless approach to enable older adults to access treatment for depression.

Environmental correlates of overweight and obesity in community residing older adults.

OBJECTIVE: This study examines the role of environmental correlates of overweight and obesity among older adults independent of walking activity and lower body function. METHODS: In-person interviews were conducted with 789 adults aged 65 and older, residing in four areas in the U.S. Demographic information, general health, lower body function, walking behavior, and awareness of environmental infrastructure features using the modified Neighborhood Environment Walking Survey (NEWS) were obtained. Regression analyses examined the association between Body Mass Index (BMI) and environmental infrastructure features, adjusting for demographics and lower body function. RESULTS: Older adults who perceived their neighborhood as less safe from crime and had reduced access to services were more likely to have higher BMI. Controlling for demographic and functional characteristics, access to services remained significant. This association remained significant for those with lower functional status. DISCUSSION: This research suggests that neighborhood environment may have an influence on BMI above and beyond walking activity.

Role of technology in supporting quality control and treatment fidelity in a family caregiver clinical trial.

This article describes how a family caregiver lifestyle physical activity clinical trial uses research technology to enhance quality control and treatment fidelity. This trial uses a range of Internet, Blaise(®) Windows-based software and Echo Server technologies to support quality control issues, such as data collection, data entry, and study management advocated by the clinical trials literature, and to ensure treatment fidelity concerning intervention implementation (i.e., design, training, delivery, receipt, and enactment) as proposed by the National Institutes of Health Behavior Change Consortium. All research staff are trained to use these technologies. Strengths of this technological approach to support quality control and treatment fidelity include the comprehensive plan, involvement of all staff, and ability to maintain accurate and timely data. Limitations include the upfront time and costs for developing and testing these technological methods, and having support staff readily available to address technological issues if they occur.

Meta-analysis provides evidence-based effect sizes for a cancer-specific quality-of-life questionnaire, the FACT-G.

OBJECTIVE: To compare Cohen's guidelines for small (0.2), medium (0.5), and large (0.8) effect sizes with empirical estimates for a cancer-specific health-related quality-of-life questionnaire (HRQOL), the Functional Assessment of Cancer Therapy - General (FACT-G). METHODS: Seventy-one papers satisfied inclusion criteria for meta-analysis. Blinded to the HRQOL results, three "experts" (with expertise in interpreting the FACT-G questionnaire and managing cancer patients), predicted the relative magnitude of HRQOL mean differences. Size classes (small, medium, large) were defined in terms of relevance to clinical decision making. The experts worked independently and based their predictions on patient characteristics and clinical circumstances. Their judgments were linked with FACT-G results and inverse-variance-weighted mean effect sizes calculated for each size class. RESULTS: At least two experts were perfectly concordant and up to one was discordant by at most one size category for 833 of the mean differences; for these, weighted kappas were generally in the "substantial" range (0.60-0.79). Of these mean differences, 617 were cross-sectional; small, medium, and large mean effect sizes were physical well-being 0.42, 0.87, 1.6; functional well-being 0.37, 0.71, 1.6; emotional well-being 0.32, 0.40, no large differences; and social well-being 0.14, 0.23, no large differences. Two hundred and sixteen longitudinal mean differences yielded small and medium effect sizes: physical well-being 0.26, 0.34; functional well-being 0.14, 0.28; emotional well-being 0.27, 0.23; and social well-being 0.08, 0.01. There was virtually no evidence for large longitudinal effects. CONCLUSION: These results provide specific, evidence-based alternatives to Cohen's generic guidelines, for use in sample-size calculations for the FACT-G and interpretation of the clinical significance of effects measured with FACT-G.

Walking and the preservation of cognitive function in older populations.

PURPOSE: This cross-sectional study takes a unique look at the association between patterns of walking and cognitive functioning by examining whether older adults with mild cognitive impairment differ in terms of the community settings where they walk and the frequency, intensity, or duration of walking. DESIGN AND METHODS: The sample was based on interviews with 884 adults aged 65 years and older, residing in 4 locations across the United States: Alameda County, California; Cook County, Illinois; Allegheny County, Pennsylvania; and Durham/Wake Counties, North Carolina. Cognitive function was assessed using a modified Mini-Mental State Examination (MMSE) and the Mental Alternation Test (MAT). Multiple linear regressions were conducted between self-reported walking activities and cognitive measures, controlling for psychosocial, demographic, health status, functional performance, and neighborhood characteristics. RESULTS: The community setting where people walk and the intensity of walking in their neighborhood were significantly associated with cognitive status. After controlling for individual and neighborhood characteristics, better MAT scores were significantly associated with brisk walking and walking fewer times per week. Compared with the MMSE, the MAT was more likely to be associated with patterns of walking among older adults. Older adults with lower MAT scores were more likely to walk in indoor shopping malls and less in parks, whereas those with higher cognitive function scores on the MMSE were less likely to walk in indoor gyms. IMPLICATIONS: This investigation provides insight into the extent to which walking is associated with preservation of cognitive health, setting the stage for future longitudinal studies and community-based interventions.

Elder abuse and neglect: an overview.

The dramatic growth of the American elderly population has great implications for our health care system. The "demographic imperative" that has fueled the awareness of the needs of older adults has a major impact on issues related to social welfare, justice, and economics. There are 45 million people over the age of 60 and 3 million over the age of 85. Those over age 85 represent the fastest growing segment of the elderly population. With this trend comes a segment of the population that is at risk for abuse, neglect, or self-neglect. We are challenged to be aware of the many faces of elder mistreatment and to understand it in the broader context of domestic violence. All health care professionals working with older adults need to become familiar with the recognition, treatment, and prevention of elder abuse and neglect.

Quality of life in lung cancer: the validity and cross-cultural applicability of the Functional Assessment Of Cancer Therapy-Lung scale.

This article discusses quality of life in lung cancer: the validity and cross-cultural applicability of the Functional Assessment of Cancer Therapy-Lung scale.