Our objective was to examine the role of ethnicity and primary care physician identification of anxiety among older adults.
A cross-sectional survey conducted between 2001–2003.
Primary care offices in the Baltimore, Maryland area.
A sample of 330 adults aged 65 and older from Maryland primary care practices with complete information on psychological status and physician assessments.
Primary care physicians were asked to rate anxiety on a Likert scale. Patient interviews included measures of psychological status and patient use of psychotropic medications.
Older black patients were less likely than older white patients to be identified as anxious (unadjusted Odds Ratio (OR) = 0.34; 95% Confidence Interval (CI) [0.18, 0.64]) and were less likely to be taking psychotropic medications (unadjusted OR = 0.40; 95% CI [0.20, 0.81]). In multivariate models that controlled for potentially influential characteristics including depression and anxiety symptoms, the association of identification (OR = 0.30; 95% CI [0.15, 0.61]) with patient ethnicity remained significantly unchanged.
Older Black Americans were less likely to be identified as anxious compared to white patients by their primary care physicians. An understanding of the role of ethnicity in the identification of anxiety is important for the screening and management of anxiety in the elderly (207 words).
aged; ethnicity; anxiety; diagnosis; primary care
Low health literacy is associated with poor outcomes in asthma and
other diseases but the mechanisms governing this relationship are not
To assess whether literacy is related to subsequent asthma
self-management, measured as adherence to inhaled steroids, and asthma
In a prospective longitudinal cohort study, numeric (Asthma Numeracy
Questionnaire (ANQ)) and print literacy (Short Test of Functional Health
Literacy in Adults (S-TOFHLA)) were assessed at baseline in adults with
moderate or severe asthma for their impact on subsequent electronically
monitored adherence and asthma outcomes (asthma control, asthma-related
quality of life, and FEV1) over 26 weeks, using mixed-effects linear
284 adults participated: 48±14 years, 71% female,
70% African American, 6% Latino, mean FEV1 66%
± 19%, 86 (30%) with hospitalizations and 148
(52%) with ED visits for asthma in the prior year. Mean ANQ score
(range 0–4) was 2.3 ± 1.2; mean S-TOFHLA score 31 ±
8 (range 0–36). In unadjusted analyses numeric and print literacy
were associated with better adherence (p=0.01, p=0.08),
asthma control (p=0.005, p <0.001), and quality of life
(p<0.001, p<0.001). After controlling for age, sex, and
race/ethnicity, the associations diminished and only quality of life
(numeric: p=0.03, print p=0.006) and asthma control (print
p=0.005) remained significantly associated with literacy.
Race/ethnicity, income, and educational attainment were correlated
While the relationship between literacy and health is complex,
interventions which account for and address the literacy needs of patients
may improve asthma outcomes.
Clinical Implications/Key Summary
In adults with moderate or severe asthma, higher health literacy
scores were associated with better subsequent quality of life and asthma
health literacy; numeracy; print literacy; asthma; adherence; adults; inner city asthma; inhaled corticosteroids; asthma-related quality of life; asthma control
Many patients experience difficulty in adhering to medication for both physical and mental health. Our objective was to compare self- reported adherence and electronic monitoring of adherence to oral hypoglycemic agents and antidepressants and to examine the relationship of adherence with clinical outcomes.
Primary care–based longitudinal study.
Adherence was assessed in 180 patients prescribed pharmacotherapy for type 2 diabetes mellitus (T2DM) and depression enrolled in a randomized controlled trial of an integrated intervention for depression and T2DM. Adherence data were collected using self report and electronic monitoring. Glycated hemoglobin (A1C) assays were used to measure glycemic control, and the 9-item Patient Health Questionnaire assessed depression.
At 12 weeks, self-reported adherence and electronic monitoring of adherence showed fair agreement (kappa = 0.213, P = .004 for oral hypoglycemic agents and kappa = 0.380, P <.001 for antidepressants). Patients who achieved ≥80% adherence to oral hypoglycemic agents measured with electronic monitoring were more likely to achieve A1C <7% compared with patients who did not achieve ≥80% adherence at 12 weeks (adjusted odds ratio = 3.52, 95% confidence interval 1.07–11.57). Self-reported adherence to oral hypoglycemic agents was not associated with diabetes outcomes. Measures of adherence for antidepressants were not associated with depression outcomes in models adjusted for potentially influential covariates.
Compared with electronic monitoring of adherence, self-reported adherence tended to overestimate medication adherence. Electronic monitoring of adherence to oral hypoglycemic agents predicted glycemic control, but self-reported adherence did not predict clinical outcomes.
BACKGROUND AND OBJECTIVES
Depression is a risk factor for hypertension, and risk of depression is increased substantially in patients with hypertension. Our objective was to examine whether an intervention carried out by Licensed Practical Nurses (LPNs) integrating depression treatment into care for hypertension improved blood pressure control and depressive symptoms.
In all, 60 patients ages 41 to 92 years with hypertension and depressive symptoms at a large primary care practice in Philadelphia were randomly assigned to an integrated care intervention carried out by LPNs (n=30) or usual care (n=30). Intervention and control groups did not differ statistically on baseline measures. Outcomes assessed at baseline and 12 weeks included standard laboratory procedures to measure blood pressure control and the Patient Health Questionnaire (PHQ-9) to assess depression.
Patients in the integrated care intervention had lower diastolic blood pressure (intervention 74.2 mmHg versus usual care 82.0 mmHg) and fewer depressive symptoms (PHQ-9 mean scores, intervention 2.4 versus usual care 7.1) compared with patients in the usual care group at 12 weeks after adjustment for baseline values. Patients in the integrated care intervention also had lower systolic blood pressure (intervention 130.0 mmHg versus usual care 140.6 mmHg) compared with patients in the usual care group at 12 weeks although the results approached but did not reach conventional levels of statistical significance.
Training existing primary care practice office staff will facilitate implementation in real world practices with limited resources and competing demands.
Staphylococcus aureus is a cause of community- and healthcare-acquired infections and is associated with substantial morbidity, mortality, and costs. Vancomycin minimum inhibitory concentrations (MICs) among S. aureus have increased, and reduced vancomycin susceptibility (RVS) may be associated with treatment failure. We aimed to identify clinical risk factors for RVS in S. aureus bacteremia.
Academic tertiary care medical center and affiliated urban community hospital.
Cases were patients with RVS S. aureus isolates (defined as vancomycin E-test MIC >1.0 μg/mL). Controls were patients with non-RVS S. aureus isolates.
Of 392 subjects, 134 (34.2%) had RVS. Fifty-eight of 202 patients (28.7%) with methicillin-susceptible S. aureus (MSSA) isolates had RVS, and 76 of 190 patients (40.0%) with methicillin-resistant S. aureus (MRSA) isolates had RVS (P =.02). In unadjusted analyses, prior vancomycin use was associated with RVS (odds ratio [OR], 2.08; 95% confidence interval [CI], 1.00–4.32; P =.046). In stratified analyses, there was significant effect modification by methicillin susceptibility on the association between vancomycin use and RVS (P = .04). In multivariable analyses, after hospital of admission and prior levofloxacin use were controlled for, the association between vancomycin use and RVS was significant for patients with MSSA infection (adjusted OR, 4.02; 95% CI, 1.11–14.50) but not MRSA infection (adjusted OR, 0.87; 95% CI, 0.36–2.13).
A substantial proportion of patients with S. aureus bacteremia had RVS. The association between prior vancomycin use and RVS was significant for patients with MSSA infection but not MRSA infection, suggesting a complex relationship between the clinical and molecular epidemiology of RVS in S. aureus.
Early onset baldness has been linked to prostate cancer (CaP), however, little is known about this relationship in African Americans (AA) who are at elevated CaP risk.
We recruited 219 AA controls and 318 AA CaP cases. We determined age-stratified associations of baldness with CaP occurrence and severity defined by high stage (T3/T4) or high grade (Gleason 7+.) Associations of androgen metabolism genotypes (CYP3A4, CYP3A5, CYP3A43, AR-CAG, SRD5A2 A49T, and SRD5A2 V89L), family history, alcohol intake, and smoking were examined by baldness status and age group by using multivariable logistic regression models.
Baldness was associated with odds of CaP (OR=1.69, 95% CI=1.05–2.74). Frontal baldness was associated with high stage (OR=2.61, 95% CI=1.10–6.18) and high grade (OR=2.20, 95% CI=1.05–4.61) tumors. For men diagnosed less than age 60, frontal baldness was associated with high stage (OR=6.51, 95% CI=2.11–20.06) and high grade (OR=4.23, 95% CI=1.47–12.14). We also observed a suggestion of an interaction among smoking, median age and any baldness (p=0.02).
We observed significant associations between early onset baldness and CaP in AA men. Interactions with age and smoking were suggested in these associations. Studies are needed to investigate the mechanisms influencing the relationship between baldness and CaP in AA.
AA men present with unique risk factors including baldness patterns that may contribute to CaP disparities.
Prostate Cancer; African Americans; Baldness; Genotypes; Smoking
Depression is a treatable illness that disproportionately places older adults at increased risk for mortality.
We sought to examine whether there are patterns of course of depression severity among older primary care patients that are associated with increased risk for mortality.
DESIGN AND SETTING
Our study was a secondary analysis of data from a practice-based randomized controlled trial within 20 primary care practices in New York, New York, and Philadelphia and Pittsburgh, Pennsylvania.
The study sample consisted of 599 adults aged 60 years and older recruited from primary care settings. Participants were identified though a two-stage, age-stratified (60-74; 75+) depression screening of randomly sampled patients. Severity of depression was assessed using the 24-item Hamilton Depression Rating Scale (HDRS).
Longitudinal analysis via general curve mixture modeling was carried out to classify patterns of course of depression severity across 12 months. Vital status at 5 years was ascertained via the National Death Index Plus.
Three patterns of change in course of depression severity over 12 months were identified: (1) persistent depressive symptoms, (2) high but declining depressive symptoms, (3) low and declining depressive symptoms. After a median follow-up of 52.0 months, 114 patients had died. Patients with persistent depressive symptoms were more likely to have died compared with patients with a course of high but declining depressive symptoms (adjusted hazard ratio 2.32, 95% confidence interval (CI) [1.15, 4.69]).
Persistent depressive symptoms signaled increased risk of dying in older primary care patients, even after adjustment for potentially influential characteristics such as age, smoking status, and medical comorbidity (244 words).
Aged; Primary health care; Geriatric depression; Mortality
We sought to examine whether there are patterns of evolving depression symptoms among older primary care patients that are related to prognostic factors and long-term clinical outcomes.
Primary care practices were randomly assigned to Usual Care or to an intervention consisting of a depression care manager offering algorithm-based depression care. In all, 599 adults 60 years and older meeting criteria for major depression or clinically-significant minor depression were randomly selected. Longitudinal analysis via growth curve mixture modeling was carried out to classify patients according to the patterns of depression symptoms across 12 months. Depression diagnosis determined after a structured interview at 24 months was the long-term clinical outcome.
Three patterns of change in depression symptoms over 12 months were identified: high persistent course (19.1% of the sample), high declining course (14.4% of the sample), low declining course (66.5% of the sample). Being in the intervention condition was more likely to be associated with a course of high and declining depression symptoms than high and persistent depression symptoms (OR = 2.53, 95% CI [1.01, 6.37]). Patients with a course of high and persistent depression symptoms were much more likely to have a diagnosis of major depression at 24 months compared with patients with a course of low and declining depression symptoms (adjusted OR = 16.46, 95% CI [7.75, 34.95]).
Identification of patients at particularly high risk of persistent depression symptoms and poor long-term clinical outcomes is important for the development and delivery of interventions.
clinicaltrials.gov registration number: NCT00000367.
Aged; Primary health care; Geriatric depression
Concern has been raised over the practice of unnecessary double anaerobic coverage therapy (DACT) in the hospital setting. However, the incidence of and risk factors for unnecessary DACT are not well studied. On 8 September 2008, the antimicrobial stewardship programme (ASP) at our institution was modified such that several antibiotics, including ampicillin/sulbactam and metronidazole, no longer required pre-approval. We anticipated that this change would increase both unnecessary DACT and target antibiotic consumption.
A nested case–control study was conducted to determine the cumulative incidence of and risk factors for unnecessary DACT. Cases were subjects who received unnecessary DACT while controls were subjects who did not receive DACT or who received necessary DACT. Segmented regression analysis was subsequently performed to evaluate the impact of ASP changes on unnecessary DACT and consumption of target antibiotics.
From October 2007 to September 2009, the cumulative incidence of unnecessary DACT was 2.3% [95% confidence interval (CI) 1.7–3.1]. Independent risk factors for unnecessary DACT [adjusted odds ratio (95% CI); P value] included hospitalization on a surgical ward [3.51 (1.03–12.02); P = 0.002], hospitalization on an obstetrics and gynaecology ward [9.07 (2.54–32.40); P = 0.002] and underlying metastatic malignancy [3.18 (1.38–7.09); P = 0.006]. The ASP change was associated with an increase in ampicillin/sulbactam and metronidazole consumption. However, there was no significant impact on unnecessary DACT prescribing.
Although uncommon, unnecessary DACT is more prevalent in specific services. Future qualitative studies focusing on these specific subgroups would be useful in elucidating this problem more clearly. The ASP changes were not associated with increases in unnecessary DACT.
ampicillin/sulbactam; metronidazole; antibiotic stewardship programme
Primary care offices are critical access points for obesity treatment, but evidence for approaches that can be implemented within these settings is limited. The Think Health! (¡Vive Saludable!) Study was designed to assess the feasibility and effectiveness of a behavioral weight loss program, adapted from the Diabetes Prevention Program, for implementation in routine primary care. Recruitment of clinical sites targeted primary care practices serving African American and Hispanic adults. The randomized design compares (a) a moderate-intensity treatment consisting of primary care provider counseling plus additional counseling by an auxiliary staff member (i.e., lifestyle coach), with (b) a low-intensity, control treatment involving primary care provider counseling only. Treatment and follow up duration are 1 to 2 years. The primary outcome is weight change from baseline at 1 and 2 years post-randomization. Between November 2006 and January 2008, 14 primary care providers (13 physicians; 1 physician assistant) were recruited at five clinical sites. Patients were recruited between October 2007 and November 2008. A total of 412 patients were pre-screened, of whom 284 (68.9%) had baseline assessments and 261 were randomized, with the following characteristics: 65% African American; 16% Hispanic American; 84% female; mean (SD) age of 47.2 (11.7) years; mean (SD) BMI of 37.2(6.4) kg/m2; 43.7% with high blood pressure; and 18.4% with diabetes. This study will provide insights into the potential utility of moderate-intensity lifestyle counseling delivered by motivated primary care clinicians and their staff. The study will have particular relevance to African Americans and women.
Obesity; Counseling; Female; Ethnic Groups; Office Visits; Patient Education
The impact of reduced fluconazole susceptibility on clinical and economic outcomes in patients with Candida glabrata bloodstream infections (BSI) is unknown.
A retrospective cohort study was conducted to evaluate 30-day inpatient mortality and postculture hospital charges in patients with C glabrata BSI with decreased fluconazole susceptibility (minimum inhibitory concentration [MIC] ≥ 16 μg/mL) versus fluconazole-susceptible C glabrata BSI (MIC ≤ 8 μg/mL). These analyses were adjusted for demographics, comorbidities, and time at risk. Secondary analyses limited the C glabrata group with decreased fluconazole susceptibility to MIC ≥ 64 μg/mL.
There were 45 (31%) deaths among 144 enrolled patients: 19 deaths (25%) among 76 patients with C glabrata BSI with decreased fluconazole susceptibility and 26 deaths (38%) among 68 patients with fluconazole-susceptible C glabrata BSI. Decreased fluconazole susceptibility was not independently associated with increased 30-day inpatient mortality (adjusted odds ratio, .60; 95% confidence interval (CI): .26-1.35; P = 0.22) or hospital charges (multiplicative change in hospital charges, .93; 95% CI: .60-1.43; P = 0.73). Older age was associated with increased mortality and increased time at risk was associated with increased hospital charges.
Crude mortality rates remain high in patients with C glabrata BSI. However, decreased fluconazole susceptibility was not associated with increased mortality or hospital charges.
Candida glabrata; bloodstream infections; mortality; hospital charges
This study examined how county-level resources are associated with the identification of children with autism spectrum disorders (ASD) in Medicaid. Medicaid claims from 2004 were combined with county-level data. There were 61,891 children diagnosed with ASD in the Medicaid system in 2004. Counties with lower per-student education expenditures, more students, a greater proportion of students in special education, higher per capita number of pediatricians and pediatric specialists, and a greater proportion of Medicaid enrollees and white residents had higher Medicaid prevalence. Within states, counties differ in how they implement Medicaid policies. The results suggest the substitution of education and Medicaid-reimbursed services. Our findings highlight the need for geographically targeted outreach to minority groups and clinicians to improve recognition of ASD.
Autism spectrum disorders; Medicaid; Geographic variation; Prevalence
Prior-approval antimicrobial stewardship programs (ASPs) improve patient outcomes and decrease antimicrobial resistance. These benefits would be limited if physicians circumvent ASP efforts. Our objectives were: 1) to determine if there is an increase in the proportion of orders for restricted (vs. non-restricted) antimicrobials in the first hour when prior-approval is not required compared with the remainder of the day, and 2) to determine if restricted antimicrobials ordered in the first hour when prior-approval is not required are less likely to be continued when the ASP resumes than antimicrobials ordered in the preceding hour.
A cross-sectional study design and a retrospective cohort study design, respectively.
The study was set in a tertiary care academic medical center with a prior-approval ASP operational from 8 a.m.–10 p.m.
Inpatients with antimicrobial orders during the study period.
Compared with other hours, a greater proportion of orders during 10–10:59 p.m. were for restricted agents (57.0% vs. 49.9%, p=0.02). Surgical patients with orders placed between 10–10:59 p.m. (vs. 9–9:59 p.m.) were less likely to have the ordered antimicrobial continued (60.0% vs. 98.1%, p<0.001). Non-surgical patients with orders placed between 10–10:59 p.m. (vs. 9 – 9:59 p.m.) were also less likely to have the ordered antimicrobial continued (70.8% vs. 84.2%, p=0.01).
Physicians avoid prior-approval by waiting until restrictions are no longer in place to order restricted antimicrobials. These antimicrobials are less often continued when the ASP becomes operational again, suggesting that they are more likely to be off-guideline or unnecessary.
Antimicrobial Stewardship; Patient Safety; Communication
We examined the impact of the wish-to-die on mortality over a 5-year period, stratified by baseline depressive status (i.e., major, minor, no depression diagnosis). We also examined whether a depression care management intervention would minimize these relationships.
Longitudinal analyses of the practice-randomized Prevention of Suicide in Primary Care Elderly: Collaborative Trial (PROSPECT).
20 primary care practices from New York City, Philadelphia, and Pittsburgh.
1202 participants were identified via two-stage, age-stratified (60–74; 75+) depression screening of randomly sampled participants.
Practices randomized to Care Management Intervention or Usual Care conditions.
Vital status at 5 years using the National Death Index.
Rates of the wish-to-die were 29% (major depression), 11% (minor depression), and 7% (no depression). In Usual Care, the wish-to-die was associated with an increased risk of 5-year mortality across depressive status (adjusted hazard ratios ranging from 1.62 to 1.71). In Intervention practices, this association was greater among the no depression (adjusted hazard ratio 1.64) compared to major depression group (adjusted hazard ratio 0.68).
The wish-to-die was associated with mortality in the usual care of elderly primary care patients, suggesting that the wish-to-die has clinical significance and may be worth assessing even in patients without other evidence of depression. This association was not observed among depressed patients located in primary care practices that implemented the PROSPECT intervention, suggesting potential long-term benefits of treatment and management of depression.
suicidal ideation; wish-to-die; mortality; primary care; geriatrics
This study examined child- and county-level factors associated with age of diagnosis of autism among Medicaid-enrolled children and the change in age of diagnosis over time.
National Medicaid claims from 2002 to 2004 were used to identify age of diagnosis and characteristics of children younger than ten years old with a diagnosis of autism (ICD-9 codes 299, 299.0x, or 299.8x). These data were linked to county-level education and health care variables. Linear regression with random effects for state and county was used to examine associations between these variables and age of diagnosis.
A total of 28,722 Medicaid-enrolled children newly diagnosed with an autism spectrum disorder were identified. Their average age of diagnosis was 64.9 months. Adjusted average age of diagnosis dropped 5.0 months for autistic disorder and 1.8 months for other spectrum disorders during the study period. Asian children were diagnosed earlier than children in other racial or ethnic groups, although these differences were much more pronounced for other spectrum disorders than for autistic disorder. Children eligible for Medicaid through the poverty category were diagnosed earlier, on average, than children who were eligible through disability, foster care, or other reasons, although this difference decreased over time. Children in large urban or rural counties were diagnosed later than children in small urban or suburban counties.
Findings showed that diagnosis of autism occurs much later than it should among Medicaid-enrolled children, although timeliness is improving over time. Analyses suggest that most of the observed variation is accounted for by child-level variables, rather than county-level resources or state policies.
Bloodstream infections (BSIs) caused by Candida glabrata have increased substantially. Candida glabrata is often associated with resistance to fluconazole therapy. However, to our knowledge, risk factors for fluconazole-resistant C glabrata BSIs have not been studied.
A case-case-control study was conducted at 3 hospitals from January 1, 2003, to May 31, 2007. The 2 case groups included patients with fluconazole-resistant C glabrata BSIs (minimum inhibitory concentration ≥16 μg/mL) and patients with fluconazole-susceptible C glabrata BSIs (minimum inhibitory concentration ≤8 μg/mL). Hospitalized patients without C glabrata BSIs were randomly selected for inclusion in the control group and were frequency matched to cases on the basis of time at risk. Two case-control studies were performed using this shared control group. The primary risk factor of interest, previous fluconazole use, was evaluated at multivariate analyses, adjusting for demographic data, comorbid conditions, and antimicrobial exposures.
We included 76 patients with fluconazole-resistant C glabrata BSIs, 68 patients with fluconazole-susceptible C glabrata BSIs, and 512 control patients. Previous fluconazole use (adjusted odds ratio [95% confidence interval], 2.3 [1.3–4.2]) and linezolid use (4.6 [2.2–9.3]) were independent risk factors for fluconazole-resistant C glabrata BSIs; previous cefepime use (2.2 [1.2–3.9]) and metronidazole use (2.0 [1.1–3.5]) were independent risk factors for fluconazole-susceptible C glabrata BSIs.
Previous fluconazole use is a significant risk factor for health care–associated fluconazole-resistant C glabrata BSIs. Future studies will be needed to evaluate the effect of decreasing fluconazole use on rates of fluconazole-resistant C glabrata BSIs.
The objective of this study was to provide national estimates of psychotropic medication use among Medicaid-enrolled children with autism spectrum disorders and to examine child and health system characteristics associated with psychotropic medication use.
This cross-sectional study used Medicaid claims for calendar year 2001 from all 50 states and Washington, DC, to examine 60 641 children with an autism spectrum disorder diagnosis. Logistic regression with random effects was used to examine the child, county, and state factors associated with psychotropic medication use.
Of the sample, 56% used at least 1 psychotropic medication, 20% of whom were prescribed ≥3 medications concurrently. Use was common even in children aged 0 to 2 years (18%) and 3 to 5 years (32%). Neuroleptic drugs were the most common psychotropic class (31%), followed by antidepressants (25%) and stimulants (22%). In adjusted analyses, male, older, and white children; those who were in foster care or in the Medicaid disability category; those who received additional psychiatric diagnoses; and those who used more autism spectrum disorder services were more likely to have used psychotropic drugs. Children who had a diagnosis of autistic disorder or who lived in counties with a lower percentage of white residents or greater urban density were less likely to use such medications.
Psychotropic medication use is common among even very young children with autism spectrum disorders. Factors unrelated to clinical presentation seem highly associated with prescribing practices. Given the limited evidence base, there is an urgent need to assess the risks, benefits, and costs of medication use and understand the local and national policies that affect medication use.
autistic disorder; Asperger disorder; psychotropic drugs; pharmacoepidemiology; physician practice patterns; Medicaid
Possessing the ε4 allele of apolipoprotein E (APOE-ε4) genotype is associated with cognitive impairment in non-demented older adults. We hypothesized that we might find a subtype of depression related to impaired cognitive performance associated with the APOE-ε4 allele.
A survey conducted between 2001-2003 with APOE genotyping.
Primary care offices in the Baltimore, Maryland area.
The study sample consisted of 305 adults aged 65 or older with complete information on APOE genotyping and covariates.
We used the latent class model to classify respondents according to symptom criteria of the American Psychiatric Association's Diagnostic and Statistical Manual as assessed in the Composite International Diagnostic Interview and the following four measures of cognitive function: the Mini-Mental State Exam, Hopkins Verbal Learning Test, Controlled Oral Word Association Test, and the Brief Test of Attention. We examined the relationship between class membership and APOE genotype.
The latent class model yielded three classes: a non-depressed class, a class with depressive symptoms and average cognitive functioning, and a class with depressive symptoms (particularly thoughts of death and suicide) and impaired cognitive functioning. Possessing at least one APOE-ε4 allele was not predictive of class membership.
A subgroup of elderly patients with depressive symptoms, cognitive impairment, and a high likelihood of experiencing thoughts of death or suicide may exist that may not be related to APOE-ε4. Subgroups of older patients with depressive symptoms may be important to identify because of the association with thoughts of death or suicide and cognitive impairment (249 words).
aged; depressive symptoms; cognition; genetic testing; apolipoprotein E; primary care
Our purpose was to determine the personal characteristics associated with different patterns of adherence to the antidepressant citalopram in a primary care trial of depression management.
The study sample consisted of 228 adults aged 60 years and older recruited from primary care settings and who participated in a depression intervention. The intervention consisted of services of trained care managers, who offered recommendations to physicians following a clinical algorithm and helped patients with treatment adherence. Adherence to the antidepressant citalopram was measured using pill counts. We employed the latent class model to classify patients according to the pattern of adherence to citalopram over time. We examined the association of sociodemographic characteristics, depression status, cognitive status, and medical comorbidity with the resulting classes of adherence.
The latent class model generated three classes of adherence: known to be adherent, unknown adherence, and known to be nonadherent. Participants who were white were more likely to be in the known to be adherent class than in the known to be nonadherent class (odds ratio (OR) = 10.38, 95% confidence interval (CI) [3.47, 31.12]). Married participants were less likely to be in the unknown adherence class than the known to be nonadherent class (OR = 0.28, 95% CI [0.09, 0.85]). No associations between age, gender, education level, depression status, cognitive status, or medical comorbidity and classes of adherence were found.
We found stronger relationships between ethnicity and marital status with patterns of adherence to citalopram than we did other personal characteristics. Identification of a subgroup of patients at particularly high risk of nonadherence is important for the development of adherence interventions.
aged; primary health care; patient compliance; adherence; compliance interventions
Black Americans are more likely to obtain mental health care from primary care than from a mental health specialist. Our objective was to investigate the association of ethnicity with the identification and active management of depression among older patients.
Cross-sectional survey 355 older adults with and without significant depressive symptoms. At the index visit, doctor's ratings of depression and reports of active management were obtained on 341 of the 355 patients who completed in-home interviews.
Older black patients were less likely to be identified as depressed than were older whites (unadjusted odds ratio (OR) = 0.40, 95% confidence interval (CI) [0.25, 0.63]) and less likely to be actively managed for depression in the 6 months prior to interview (unadjusted OR = 0.63, 95% CI [0.19, 2.16]). In multivariate models that controlled for potentially influential characteristics such as patient age, gender, marital status, level of education, functional status, physical health, severity of depressive symptoms, severity of anxiety symptoms, attitudes about depression, number of office visits in the last 6 months, and the doctor’s rating of how well they knew the patient, the associations of identification (OR = 0.25, 95% CI [0.17, 0.39]) and management (OR = 0.57, 95% CI [0.19, 1.77]) with patient ethnicity remained substantially unchanged.
Our study calls attention to the role ethnicity may play in the identification and active management of depression among older primary care patients.
African-Americans; aged; depression; mental health services; primary health care
Few studies have tested the effects of a depression intervention on the risk for death associated with depression.
To test whether an intervention to improve depression care can modify the risk for death.
Practice-based, randomized, controlled trial.
20 primary care practices in New York, New York, and Philadelphia and Pittsburgh, Pennsylvania.
1226 randomly sampled patients identified through a 2-stage, age-stratified (60 to 74 years and ≥75 years) depression screening.
Depression care manager working with primary care physicians to provide algorithm-based care.
Depression status based on clinical interview and vital status at 5 years by using the National Death Index.
At baseline, 396 patients met criteria for major depression and 203 patients met criteria for clinically significant minor depression. After a median follow-up of 52.8 months, 223 patients died. Patients with depression in intervention practices were less likely to have died than those in usual care practices (adjusted hazard ratio, 0.67 [95% CI, 0.44 to 1.00]). Risk for death was reduced in patients with major depression (adjusted hazard ratio, 0.55 [CI, 0.36 to 0.84]) but not in patients with clinically significant minor depression (adjusted hazard ratio, 0.97 [CI, 0.49 to 1.92]). The benefit seemed to be almost entirely attributable to a reduction in deaths due to cancer.
The mechanism for an effect on deaths due to cancer is unclear. Depression status, cause of death, and vital status might have been misclassified.
Older primary care patients with major depression in practices that implemented depression care management were less likely to die over a 5-year period than were patients with major depression in usual care practices. The effect seemed to be limited to deaths due to cancer. The mechanism for such an effect is unclear and warrants further investigation.
Our a priori hypothesis was that depressed patients with diabetes in practices implementing a depression management program would have a decreased risk of mortality compared to depressed patients with diabetes in usual care practices.
RESEARCH DESIGN AND METHODS
Multi-site practice-randomized controlled trial PROSPECT (Prevention of Suicide in Primary Care Elderly: Collaborative Trial) with patient recruitment from 5/99-8/01 and supplemented with a search of the National Death Index. Twenty primary care practices participated from New York City, Philadelphia, and Pittsburgh. In all, 584 participants who were identified though a two-stage, age-stratified (60-74; 75+) depression screening of randomly sampled patients and were classified as depressed with complete information on diabetes status are included in these analyses. Of all the 584 participants, 123 (21.2%) reported a history of diabetes. A depression care manager worked with primary care physicians to provide algorithm-based care. Vital status was assessed at 5 years.
After a median follow-up of 52.0 months, 110 depressed patients had died. Depressed patients with diabetes in the Intervention Condition were less likely to have died during the 5-year follow-up interval than were depressed persons with diabetes in Usual Care after accounting for baseline differences among patients (adjusted hazard ratio 0.49, 95% CI [0.24, 0.98]).
Older depressed primary care patients with diabetes in practices implementing depression care management were less likely to die over the course of a 5-year interval than were depressed patients with diabetes in usual care practices.
aged; depression; diabetes; mortality; primary health care
Depression is a major contributor to death and disability, but few follow-up studies of depression have been carried out in the primary care setting. We sought to assess whether depression in older patients is associated with increased mortality after a 2-year follow-up interval and to estimate the population attributable fraction (PAF) of depression on mortality in older primary care patients.
Longitudinal cohort analysis carried out in 20 primary care practices. Participants were identified though a two-stage, age-stratified (60–74; 75+) depression screening of randomly sampled patients; enrollment included patients who screened positive and a random sample of screened negative patients. In all, 1226 persons were assessed at baseline. Vital status at 2 years was the outcome of interest.
Of 1226 persons in the sample, 598 were classified as depressed. After 2 years, 64 persons had died. Persons with depression at baseline were more likely to die at the end of the 2-year follow-up interval than were persons without depression (relative odds 1.81, 95% confidence interval [1.07, 3.05]; Wald χ2 = 4.96, df = 1, p = 0.03), even after accounting for potentially influential covariates such as whether the participant reported a history of myocardial infarction (MI) or diabetes. We estimated the PAF due to depression on mortality to be 13%. By comparison, the PAF on mortality due to baseline report of MI was 11%; diabetes 9%; and any cardiovascular disease 18%.
Among older primary care patients over the course of a 2-year follow-up interval, depression contributed as much to mortality as did MI or diabetes.
aged; depressive disorder; mortality; prospective studies; risk factors
Preferences for life-sustaining treatment elicited in one state of health may not reflect preferences in another state of health.
We estimated the stability of preferences for end-of-life treatment over 3 years and whether decline in physical functioning and mental health were associated with change in preferences for end-of-life treatment.
Mailed survey of older physicians.
Longitudinal cohort study of medical students in the graduating classes from 1948 to 1964 at Johns Hopkins University.
818 physicians who completed the life-sustaining treatment questionnaire in 1999 and 2002 (mean age 69 years at baseline).
Preferences for life-sustaining treatment, assessed using a checklist questionnaire in response to a standard vignette.
While the prevalence of the three clusters of life sustaining treatment preferences remained stable over the 3-year follow-up interval, certain physicians changed their preferences over time. The probability that physicians were in the same cluster at follow-up as at baseline was 0.41 for “most aggressive,” 0.50 for “intermediate care,” and 0.80 for “least aggressive.” Physicians without an advance directive were more likely to transition to the “most aggressive” than to the “least aggressive” cluster over the course of the 3-year follow-up (odds ratio 1.96, 95% confidence interval [1.11, 3.45]). Age at baseline and decline in physical and mental health were not associated with transitions between 1999 and 2002.
The preferences we elicited might not accurately predict treatment decisions during actual illness.
Our findings suggest that periodic re-assessment of preferences are most critical for patients who desire aggressive end of life care or do not have advance directives. (261 words)
To determine the frequency and correlates of impulse control disorders (ICDs) in Parkinson’s disease (PD).
An unstructured screening interview for ICDs (compulsive gambling, buying, and sexual behavior) followed by a telephone-administered structured interview for screen-positive patients.
Two university-affiliated movement disorders centers.
A convenience sample of 272 patients with idiopathic PD who were screened for psychiatric complications.
Main Outcome Measures
Presence of compulsive gambling, buying, or sexual behavior as assessed by the Minnesota Impulsive Disorders Interview.
Eighteen (6.6%) PD patients met criteria for an ICD at some point during the course of PD, including 11 (4.0%) with an active ICD. Compulsive gambling and compulsive sexual behavior were equally common. In a multivariate model, treatment with a dopamine agonist (P = .01) and a history of ICD symptomatology prior to PD onset (P = .02) predicted current ICD. There were no differences between the dopamine agonists in their association with ICDs (P = .21), and daily doses of dopamine agonists were higher in patients with an ICD than in dopamine agonist-treated patients without an ICD (P < .001).
PD patients treated with a dopamine agonist should be made aware of the risk of developing an ICD and monitored clinically. As dopamine agonists are increasing being used for other indications, future research should assess the dopamine agonist-associated risk for ICDs in other populations.