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1.  Development of an Instrument to Measure Staff-Reported Resident-to-Resident Elder Mistreatment (R-REM) Using Item Response Theory and Other Latent Variable Models 
The Gerontologist  2013;54(3):460-472.
Objectives: Although numerous studies have measured behaviors among individuals in congregate settings, few have focused on resident-to-resident elder mistreatment (R-REM). To our knowledge, there is no psychometrically developed measure of R-REM extant. The quantitative development of a measure of staff-reported R-REM is described. Methods: The design was a prevalent cohort study of residents of 5 long-term care facilities. The primary certified nursing assistant was interviewed about R-REM. Advanced measurement methods were used to develop a measure of R-REM. Results: The loadings on the general factor for the final 11-item scale were greater than those on the group factor except for the item “other physical behavior” (0.63 vs. 0.74), suggesting essential unidimensionality. Although the bifactor model fit was slightly better than that of the unidimensional model, the difference was trivial (bifactor comparative fit index [CFI] = 0.997, root mean square error of approximation [RMSEA] = 0.013, unidimensional CFI = 0.979, and RMSEA = 0.030). However, modest support was provided for use of verbal and physical subscales. The explained common variance statistics were 0.76 for the bifactor model compared with 0.63 for the unidimensional model. Discussion: The development of this R-REM measure will help to advance the measurement and ultimately evaluation of interventions associated with this important and under recognized problem facing residents in long-term care settings.
PMCID: PMC4013722  PMID: 23448960
Elder abuse; Mistreatment; Congregate care; Item response theory; Latent variable models; Scale development
2.  Psychiatric assessment and screening for the elderly in primary care: design, implementation, and preliminary results 
Journal of geriatrics  2015;2015:792043.
We describe the design and implementation of a psychiatric collaborative care model in a University-based geriatric primary care practice. Initial results of screening for anxiety and depression are reported.
Methods and Materials
Screens for anxiety and depression were administered to practice patients. A mental health team, consisting of a psychiatrist, mental health nurse practitioner and social worker, identified patients who on review of screening and chart data warranted evaluation or treatment. Referrals for mental health interventions were directed to members of the mental health team, primary care physicians at the practice, or community providers.
Subjects (N=1505) comprised 38.2% of the 3940 unique patients seen at the practice during the 4-year study period. 37.1% (N=555) screened positive for depression, 26.9 % (N=405) for anxiety, and 322 (21.4%) screened positive for both. Any positive score was associated with age (p<0.033), female gender (p<0.006), and a non-significant trend toward living alone (p<0.095). 8.87% had suicidal thoughts.
Screening captured the most affectively symptomatic patients, including those with suicidal ideation, for intervention. The partnering of mental health professionals and primary care physicians offers a workable model for addressing the scarcity of expertise in geriatric psychiatry.
PMCID: PMC4420197  PMID: 25954771
Screening; Anxiety; Depression
3.  Quality of life impacts on 16-year survival of an older ethnically diverse cohort 
The objective of this study is to examine the prediction of mortality, over 16 years, by the domains and domain elements underlying generic measures of quality of life (QoL).
The method used was an analysis of mortality in an older (65 + years) representative sample (N = 2130) of a multicultural community in North Manhattan. Five conventional QoL domains were measured by in-home, rater-administered, and computer-assisted questionnaire: depressed mood, pain, self-perceived health, and function and social relationships.
Some domain scales that qualitatively express distress, such as depressed mood and widespread pain, significantly predicted lower mortality (were protective) and felt isolation trended in that direction, whereas domains indicating quantitative limitations such as impairment of functioning in daily tasks, stair climbing, as well as social disengagements and lack of support network significantly predicted higher mortality. Domain elements also mattered; contrary to their domain predictions, increased mortality was predicted by the domain elements of somatic symptoms of depression. Self-perceived poor health reflected the predictive (higher mortality) direction of the limitations cluster.
The internal complexity of QoL is underscored by differential impacts of domains and elements on mortality. Clinical implications include setting distress domains as important clinical goals, whereas strengthening limiting domains could result in lengthening life and secondarily relieving distress. The relative weighting of these goals could be derived from patient preferences and clinical efficacy. Fundamental implications lie in the interaction between the person’s qualitative evaluations of choices and the quantitative building of desired choices for a better QoL.
PMCID: PMC4372056  PMID: 24167085
quality of life domains; multicultural older community; 16-year mortality; fundamental and clinical implications
4.  Tailored approaches to stroke health education (TASHE): study protocol for a randomized controlled trial 
Trials  2015;16:176.
Stroke is a leading cause of adult disability and mortality. Intravenous thrombolysis can minimize disability when patients present to the emergency department for treatment within the 3 − 4½ h of symptom onset. Blacks and Hispanics are more likely to die and suffer disability from stroke than whites, due in part to delayed hospital arrival and ineligibility for intravenous thrombolysis for acute stroke. Low stroke literacy (poor knowledge of stroke symptoms and when to call 911) among Blacks and Hispanics compared to whites may contribute to disparities in acute stroke treatment and outcomes. Improving stroke literacy may be a critical step along the pathway to reducing stroke disparities. The aim of the current study is to test a novel intervention to increase stroke literacy in minority populations in New York City.
Design and Methods
In a two-arm cluster randomized trial, we will evaluate the effectiveness of two culturally tailored stroke education films – one in English and one in Spanish – on changing behavioral intent to call 911 for suspected stroke, compared to usual care. These films will target knowledge of stroke symptoms, the range of severity of symptoms and the therapeutic benefit of calling 911, as well as address barriers to timely presentation to the hospital. Given the success of previous church-based programs targeting behavior change in minority populations, this trial will be conducted with 250 congregants across 14 churches (125 intervention; 125 control). Our proposed outcomes are (1) recognition of stroke symptoms and (2) behavioral intent to call 911 for suspected stroke, measured using the Stroke Action Test at the 6-month and 1-year follow-up.
This is the first randomized trial of a church-placed narrative intervention to improve stroke outcomes in urban Black and Hispanic populations. A film intervention has the potential to make a significant public health impact, as film is a highly scalable and disseminable medium. Since there is at least one church in almost every neighborhood in the USA, churches have the ability and reach to play an important role in the dissemination and translation of stroke prevention programs in minority communities.
Trial registration
NCT01909271; July 22, 2013
PMCID: PMC4417303  PMID: 25927452
Stroke; Community-based research; Narrative persuasion; Health disparities; Randomized trial; Stroke health education; Stroke action test
5.  Results of the Northern Manhattan Diabetes Community Outreach Project: A Randomized Trial Studying a Community Health Worker Intervention to Improve Diabetes Care in Hispanic Adults 
Diabetes Care  2014;37(4):963-969.
The Northern Manhattan Diabetes Community Outreach Project evaluated whether a community health worker (CHW) intervention improved clinically relevant markers of diabetes care in adult Hispanics.
Participants were adult Hispanics, ages 35–70 years, with recent hemoglobin A1c (A1C) ≥8% (≥64 mmol/mol), from a university-affiliated network of primary care practices in northern Manhattan (New York City, NY). They were randomized to a 12-month CHW intervention (n = 181), or enhanced usual care (educational materials mailed at 4-month intervals, preceded by phone calls, n = 179). The primary outcome was A1C at 12 months; the secondary outcomes were systolic blood pressure (SBP), diastolic blood pressure, and LDL-cholesterol levels.
There was a nonsignificant trend toward improvement in A1C levels in the intervention group (from unadjusted mean A1C of 8.77 to 8.40%), as compared with usual care (from 8.58 to 8.53%) (P = 0.131). There was also a nonsignificant trend toward an increase in SBP and LDL cholesterol in the intervention arm. Intervention fidelity, measured as the number of contacts in the intervention arm (visits, phone contacts, group support, and nutritional education), showed a borderline association with greater A1C reduction (P = 0.054). When assessed separately, phone contacts were associated with greater A1C reduction (P = 0.04).
The trend toward A1C reduction with the CHW intervention failed to achieve statistical significance. Greater intervention fidelity may achieve better glycemic control, and more accessible treatment models, such as phone-based interventions, may be more efficacious in socioeconomically disadvantaged populations.
PMCID: PMC3964489  PMID: 24496805
6.  Comparative effectiveness of home blood pressure telemonitoring (HBPTM) plus nurse case management versus HBPTM alone among Black and Hispanic stroke survivors: study protocol for a randomized controlled trial 
Trials  2015;16:97.
Black and Hispanic stroke survivors experience higher rates of recurrent stroke than whites. This disparity is partly explained by disproportionately higher rates of uncontrolled hypertension in these populations. Home blood pressure telemonitoring (HBPTM) and nurse case management (NCM) have proven efficacy in addressing the multilevel barriers to blood pressure (BP) control and reducing BP. However, the effectiveness of these interventions has not been evaluated in stroke patients. This study is designed to evaluate the comparative effectiveness, cost-effectiveness and sustainability of these two telehealth interventions in reducing BP and recurrent stroke among high-risk Black and Hispanic stroke survivors with uncontrolled hypertension.
A total of 450 Black and Hispanic patients with recent nondisabling stroke and uncontrolled hypertension are randomly assigned to one of two 12-month interventions: 1) HBPTM with wireless feedback to primary care providers or 2) HBPTM plus individualized, culturally-tailored, telephone-based NCM. Patients are recruited from stroke centers and primary care practices within the Health and Hospital Corporations (HHC) Network in New York City. Study visits occur at baseline, 6, 12 and 24 months. The primary outcomes are within-patient change in systolic BP at 12 months, and the rate of stroke recurrence at 24 months. The secondary outcome is the comparative cost-effectiveness of the interventions at 12 and 24 months; and exploratory outcomes include changes in stroke risk factors, health behaviors and treatment intensification. Recruitment for the stroke telemonitoring hypertension trial is currently ongoing.
The combination of two established and effective interventions along with the utilization of health information technology supports the sustainability of the HBPTM + NCM intervention and feasibility of its widespread implementation. Results of this trial will provide strong empirical evidence to inform clinical guidelines for management of stroke in minority stroke survivors with uncontrolled hypertension. If effective among Black and Hispanic stroke survivors, these interventions have the potential to substantially mitigate racial and ethnic disparities in stroke recurrence.
Trial registration NCT02011685. Registered 10 December 2013.
PMCID: PMC4365522  PMID: 25873044
stroke; hypertension; blood pressure; disparities; telehealth; comparative effectiveness research
7.  Performance of the Family Satisfaction with the End-of-Life Care (FAMCARE) measure in an ethnically diverse cohort: Psychometric analyses using item response theory 
The Family Satisfaction with End-of-Life Care (FAMCARE) has been used widely among caregivers to individuals with cancer. The aim of this study was to evaluate the psychometric properties of this measure using item response theory (IRT).
The analytic sample was comprised of caregivers to 1983 patients with advanced cancer. Among the patients, 56% were female, with mean age 59.9 (s.d. = 11.8); 20% were non-Hispanic Black. The majority were family members either living with (44%) or not living with (35%) the patient.
Factor analyses and IRT were used to examine the dimensionality, information and reliability of the FAMCARE.
Although a bi-factor model fit the data slightly better than did a unidimensional model, the loadings on the group factors were very low. Thus, a unidimensional model appears to provide adequate representation for the item set. The reliability estimates, calculated along the satisfaction (theta) continuum were adequate (>0.80) for all levels of theta for which subjects had scores.
Examination of the category response functions from IRT showed overlap in the lower categories with little unique information provided; moreover the categories were not observed to be interval. Based on these analyses, a three response category format was recommended: very satisfied, satisfied and not satisfied. Most information was provided in the range indicative of either dissatisfaction or high satisfaction.
These analyses support the use of fewer response categories, and provide item parameters that form a basis for developing shorter-form scales. Such a revision has the potential to reduce respondent burden.
PMCID: PMC4151612  PMID: 24091717
FAMCARE; patient; caregiver; satisfaction; item response theory; psychometric properties
8.  Depression is not associated with diabetes control in minority elderly 
We investigated the longitudinal association of depression, with and without cognitive dysfunction, with hemoglobin A1c (HbA1c), systolic blood pressure (SBP), and low-density lipoprotein (LDL) in a predominantly minority cohort.
There were 613 participants. Presence of depression was defined by a score ≥ 7 on the Short-CARE depression scale. We tested participants for executive dysfunction using the Color Trails Test (CTT), part 2, and for memory dysfunction using the total recall task of the Selective Reminding Test (TR-SRT). We classified performance in these tests as abnormal based on standardized score cutoffs (<16th percentile and one standard deviation below the sample mean). Random effects models were used to compare repeated measures of the diabetes control measures between those with depression versus those without depression and ever versus never cognitively impaired.
Baseline depression was present in 36% of participants. Over a median follow-up of 2 years, depression was not related to worse HbA1c, SBP, or LDL. The presence of (1) abnormal performance on a test of executive function and depression (n = 57) or (2) abnormal performance on a test of verbal recall and depression (n = 43) was also not associated with clinically significant worse change in diabetes control.
Depression, with or without low performance in tests of executive function and memory, may not affect clinically significant measures of diabetes control in the elderly.
PMCID: PMC4310458  PMID: 25156987
Diabetes; Depression; Diabetes control; Cognitive dysfunction; Older adults
9.  Center for stroke disparities solutions community- based care transition interventions: study protocol of a randomized controlled trial 
Trials  2015;16:32.
Racial and ethnic disparities persist in stroke occurrence, recurrence, morbidity and mortality. Uncontrolled hypertension (HTN) is the most important modifiable risk factor for stroke risk. Home health care organizations care for many patients with uncontrolled HTN and history of stroke; however, recurrent stroke prevention has not been a home care priority. We are conducting a randomized controlled trial (RCT) to compare the effectiveness, relative to usual home care (UHC), of two Community Transitions Interventions (CTIs). The CTIs aim to reduce recurrent stroke risk among post-stroke patients via home-based transitional care focused on better HTN management.
This 3-arm trial will randomly assign 495 black and Hispanic post-stroke home care patients with uncontrolled systolic blood pressure (SBP) to one of three arms: UHC, UHC complemented by nurse practitioner-delivered transitional care (UHC + NP) or UHC complemented by an NP plus health coach (UHC + NP + HC). Both intervention arms emphasize: 1) linking patients to continuous, responsive preventive and primary care, 2) increasing patients’/caregivers’ ability to manage a culturally and individually tailored BP reduction plan, and 3) facilitating the patient’s reintegration into the community after home health care discharge. The primary hypothesis is that both NP-only and NP + HC transitional care will be more effective than UHC alone in achieving a SBP reduction. The primary outcome is change in SPB at 3 and 12 months. The study also will examine cost-effectiveness, quality of life and moderators (for example, race/ethnicity) and mediators (for example, changes in health behaviors) that may affect treatment outcomes. All outcome data are collected by staff blinded to group assignment.
This study targets care gaps affecting a particularly vulnerable black/Hispanic population characterized by persistent stroke disparities. It focuses on care transitions, a juncture when patients are particularly susceptible to adverse events. The CTI is innovative in adapting for stroke patients an established transitional care model shown to be effective for HF patients, pairing the professional NP with a HC, implementing a culturally tailored intervention, and placing primary emphasis on longer-term risk factor reduction and community reintegration rather than shorter-term transitional care outcomes.
Trial registration NCT01918891; Registered 5 August 2013.
PMCID: PMC4322449  PMID: 25622823
Care transitions; Home health; Stroke; Hypertension; Blood pressure; Health disparities; Trial design
10.  Mild Cognitive Dysfunction Does Not Affect Diabetes Mellitus Control in Minority Elderly Adults 
To determine whether older adults with type 2 diabetes mellitus and cognitive dysfunction have poorer metabolic control of glycosylated hemoglobin, systolic blood pressure, and low-density lipoprotein cholesterol than those without cognitive dysfunction.
Prospective cohort study.
A minority cohort in New York City previously recruited for a trial of telemedicine.
Persons aged 73.0 ± 3.0 (N = 613; 69.5% female; 82.5% Hispanic, 15.5% non-Hispanic black).
Participants were classified with executive or memory dysfunction based on standardized score cutoffs (<16th percentile) for the Color Trails Test and Selective Reminding Test. Linear mixed models were used to compare repeated measures of the metabolic measures and evaluate the rates of change in individuals with and without dysfunction.
Of the 613 participants, 331 (54%) had executive dysfunction, 202 (33%) had memory dysfunction, and 96 (16%) had both. Over a median of 2 years, participants with executive or memory dysfunction did not exhibit significantly poorer metabolic control than those without executive function or memory type cognitive dysfunction.
Cognitive dysfunction in the mild range did not seem to affect diabetes mellitus control parameters in this multiethnic cohort of older adults with diabetes mellitus, although it cannot be excluded that cognitive impairment was overcome through assistance from formal or informal caregivers. It is possible that more-severe cognitive dysfunction could affect control.
PMCID: PMC4288580  PMID: 25439094
cognition; diabetes mellitus; control; elderly
11.  Disparities in Symptom Burden and Renal Transplant Eligibility: A Pilot Study 
Journal of Palliative Medicine  2013;16(11):1459-1465.
Patients with end-stage renal disease (ESRD) on hemodialysis (HD) suffer from a high symptom burden. However, there is significant heterogeneity within the HD population; certain subgroups, such as the elderly, may experience disproportionate symptom burden.
The study's objective was to propose a category of HD patients at elevated risk for symptom burden (those patients who are not transplant candidates) and to compare symptomatology among transplant ineligible versus eligible HD patients.
This was a cross-sectional study.
English-speaking, cognitively intact patients receiving HD and who were either transplant eligible (n=25) or ineligible (n=32) were recruited from two urban HD units serving patients in the greater New York City region.
In-person interviews were conducted to ascertain participants' symptom burden using the Dialysis Symptom Index (DSI), perceived symptom bother and attribution (whether the symptom was perceived to be related to HD treatment), and quality of life using the SF-36. Participants' medical records were reviewed to collect demographic and clinical data.
Transplant ineligible (versus eligible) patients reported an average of 13.9±4.6 symptoms versus 9.2±4.4 symptoms (p<0.01); these differences persisted after adjustment for multiple factors. A greater proportion of transplant ineligible (versus eligible) patients attributed their symptoms to HD and were more likely to report greater bother on account of the symptoms. Quality of life was also significantly lower in the transplant ineligible group.
Among HD patients, transplant eligibility is associated with symptom burden. Our pilot data suggest that consideration be given to employing transplant status as a method of identifying HD patients at risk for greater symptom burden and targeting them for palliative interventions.
PMCID: PMC3822373  PMID: 24111782
12.  Using Qualitative Methods to Develop a Measure of Resident-to-Resident Elder Mistreatment in Nursing Homes 
International psychogeriatrics / IPA  2013;25(8):1245-1256.
Despite expansion of research on elder mistreatment, limited attention has been paid to the development of improved measurement instruments. This gap is particularly notable regarding measurement of mistreatment in long-term care facilities. This article demonstrates the value of qualitative methods used in item development of a Resident-to-Resident Elder Mistreatment (R-REM) measure for use in nursing homes and other care facilities. It describes the development strategy and the modification and refinement of items using a variety of qualitative methods.
A combination of qualitative methods was used to develop close-ended items to measure R-REM, including review by a panel of experts, focus groups, and in-depth cognitive interviews.
Information gathered from the multiple methods aided in flagging problematic items, helped to highlight the nature of the problems in measures, and provided suggestions for item modification and improvement.
The method employed is potentially useful for future attempts to develop better measures of elder mistreatment. The employment of previously established measurement items drawn from related fields, modified through an intensive qualitative research strategy, is an effective strategy to improve elder mistreatment measurement.
PMCID: PMC4178930  PMID: 23506835
qualitative methods; measure development; resident-to-resident elder mistreatment; long-term care
13.  Managing resident to resident elder mistreatment (R-REM) in nursing homes: the SEARCH approach 
This article describes an educational program to inform nursing and care staff in the management of resident-to-resident elder mistreatment (R-REM) in nursing homes, using the SEARCH approach. Although relatively little research has been conducted on this form of abuse, there is mounting interest in R-REM, as such aggression has been found to be extensive and can have both physical and psychological consequences for residents and staff. The aim of the SEARCH approach is to support staff in the identification and recognition of R-REM, and suggesting recommendations for management. The education program and the SEARCH approach are described. Three case studies from the research project are presented, illustrating how the SEARCH approach can be used by nurses and care staff to manage R-REM in nursing homes. Resident- and staff safety and well-being can be enhanced by the use of the evidence-based SEARCH approach.
PMCID: PMC4178932  PMID: 24548656
14.  Modifying Measures Based on Differential Item Functioning (DIF) Impact Analyses 
Journal of aging and health  2012;24(6):1044-1076.
Measure modification can impact comparability of scores across groups and settings. Changes in items can affect the percent admitting to a symptom.
Using item response theory (IRT) methods, well-calibrated items can be used interchangeably, and the exact same item does not have to be administered to each respondent, theoretically permitting wider latitude in terms of modification.
Recommendations regarding modifications vary, depending on the use of the measure. In the context of research, adjustments can be made at the analytic level by freeing and fixing parameters based on findings of differential item functioning (DIF). The consequences of DIF for clinical decision making depend on whether or not the patient’s performance level approaches the scale decision cutpoint. High-stakes testing may require item removal or separate calibrations to ensure accurate assessment.
Guidelines for modification based on DIF analyses and illustrations of the impact of adjustments are presented.
PMCID: PMC4030595  PMID: 22422759
differential item functioning; DIF; factorial invariance; impact of DIF; ethnicity; measure modification
16.  Verbal and Physical Aggression Directed at Nursing Home Staff by Residents 
Little research has been conducted on aggression directed at staff by nursing home residents.
To estimate the prevalence of resident-to-staff aggression (RSA) over a 2-week period.
Prevalent cohort study.
Large urban nursing homes.
Population-based sample of 1,552 residents (80 % of eligible residents) and 282 certified nursing assistants.
Main Outcome Measures
Measures of resident characteristics and staff reports of physical, verbal, or sexual behaviors directed at staff by residents.
The staff response rate was 89 %. Staff reported that 15.6 % of residents directed aggressive behaviors toward them (2.8 % physical, 7.5 % verbal, 0.5 % sexual, and 4.8 % both verbal and physical). The most commonly reported type was verbal (12.4 %), particularly screaming at the certified nursing assistant (9.0 % of residents). Overall, physical aggression toward staff was reported for 7.6 % of residents, the most common being hitting (3.9 % of residents). Aggressive behaviors occurred most commonly in resident rooms (77.2 %) and in the morning (84.3 %), typically during the provision of morning care. In a logistic regression model, three clinical factors were significantly associated with resident-to-staff aggression: greater disordered behavior (OR = 6.48, 95 % CI: 4.55, 9.21), affective disturbance (OR = 2.29, 95 % CI: 1.68, 3.13), and need for activities of daily living morning assistance (OR = 2.16, 95 % CI: 1.53, 3.05). Hispanic (as contrasted with White) residents were less likely to be identified as aggressors toward staff (OR = 0.57, 95 % CI: 0.36, 0.91).
Resident-to-staff aggression in nursing homes is common, particularly during morning care. A variety of demographic and clinical factors was associated with resident-to-staff aggression; this could serve as the basis for evidence-based interventions. Because RSA may negatively affect the quality of care, resident and staff safety, and staff job satisfaction and turnover, further research is needed to understand its causes and consequences and to develop interventions to mitigate its potential impact.
PMCID: PMC3631060  PMID: 23225256
nursing home; dementia-related behaviors; elder abuse; staff mistreatment
In 2004 NIH awarded contracts to initiate the development of high quality psychological and neuropsychological outcome measures for improved assessment of health-related outcomes. The workshop introduced these measurement development initiatives, the measures created, and the NIH supported resource (Assessment Center) for internet or tablet-based test administration and scoring. Presentation covered: (a) item response theory (IRT) and assessment of test bias, (b) construction of item banks and computerized adaptive testing, and (c) the different ways in which qualitative analyses contribute to the definition of construct domains and the refinement of outcome constructs. The panel discussion included questions about representativeness of samples, and assessment of cultural bias.
PMCID: PMC4004066  PMID: 23570428
18.  Telemedicine Home Blood Pressure Measurements Predict Progression of Albuminuria in Elderly People with Diabetes 
Hypertension  2008;51(5):10.1161/HYPERTENSIONAHA.107.108589.
We assessed whether home blood pressure monitoring improved the prediction of progression of albuminuria when added to office measurements, and compared it to ambulatory blood pressure monitoring in a multiethnic cohort of older people (n=392) with diabetes mellitus, without macroalbuminuria, participating in the telemedicine arm of the Informatics for Diabetes Education and Telemedicine (IDEATel) study. Albuminuria was assessed by measuring the spot urine albumin-to-creatinine ratio at baseline and annually for three years. Ambulatory sleep/wake systolic blood pressure ratio was categorized as dipping (ratio≤0.9), non-dipping (ratio>0.9 -1), and nocturnal rise (ratio>1). In a repeated measures mixed linear model, after adjustment that included office pulse pressure, home pulse pressure was independently associated with higher follow-up albumin-to-creatinine ratio (p=0.001). That association persisted (p=0.01) after adjusting for 24-hour pulse pressure, and nocturnal rise, which were also independent predictors (p=0.02 and p=0.03, respectively). Cox proportional hazards models examined progression of albuminuria (n=74) as defined by cutoff values used by clinicians. After adjustment for office pulse pressure the hazards ratio (95% CI) per 10 mmHg increment of home pulse pressure was 1.34 (1.1-1.7), p=0.01. Home pulse pressure was not an independent predictor in the model including ambulatory monitoring data—a nocturnal rise was the only independent predictor (p=0.035). However, Cox models built separately for home pulse pressure and ambulatory monitoring exhibited similar calibration and discrimination. In conclusion, home blood pressure adds to office measurements and may substitute for ambulatory monitoring to predict worsening of albuminuria in elderly people with diabetes.
PMCID: PMC3855674  PMID: 18378859
Albuminuria; Diabetes mellitus; Home Blood Pressure; Ambulatory Blood Pressure
19.  The Counseling Older Adults to Control Hypertension (COACH) Trial: design and methodology of a group-based lifestyle intervention for hypertensive minority older adults 
Contemporary clinical trials  2013;35(1):70-79.
The disproportionately high prevalence of hypertension and its associated mortality and morbidity in minority older adults is a major public health concern in the United States. Despite compelling evidence supporting the beneficial effects of therapeutic lifestyle changes on blood pressure reduction, these approaches remain largely untested among minority elders in community-based settings. The Counseling Older Adults to Control Hypertension trial is a two-arm randomized controlled trial of 250 African-American and Latino seniors, 60 years and older with uncontrolled hypertension, who attend senior centers. The goal of the trial is to evaluate the effect of a therapeutic lifestyle intervention delivered via group classes and individual motivational interviewing sessions versus health education, on blood pressure reduction. The primary outcome is change in systolic and diastolic blood pressure from baseline to 12 months. The secondary outcomes are blood pressure control at 12 months; changes in levels of physical activity; body weight; and number of daily servings of fruits and vegetables from baseline to 12 months. The intervention group will receive 12 weekly group classes followed by individual motivational interviewing sessions. The health education group will receive an individual counseling session on healthy lifestyle changes and standard hypertension education materials. Findings from this study will provide needed information on the effectiveness of lifestyle interventions delivered in senior centers. Such information is crucial in order to develop implementation strategies for translation of evidence-based lifestyle interventions to senior centers, where many minority elders spend their time, making the centers a salient point of dissemination.
PMCID: PMC3805359  PMID: 23462343
Hypertension; Minority Elders; Senior Centers; Therapeutic Lifestyle Changes
20.  Adiponectin and All-Cause Mortality in Elderly People With Type 2 Diabetes 
Diabetes Care  2012;35(9):1858-1863.
To assess the association between serum adiponectin level and all-cause mortality in people with type 2 diabetes. Because of the insulin-sensitizing, anti-inflammatory, and antiatherogenic effects of adiponectin, we hypothesized that higher adiponectin level would be associated with lower all-cause mortality.
A total of 609 men and women aged 72 ± 6.3 years with type 2 diabetes and information on total and high molecular weight adiponectin were followed for a median of 5 years. The longitudinal association between adiponectin and all-cause mortality was analyzed with Cox proportional hazards models with time from adiponectin measurement to death as the time-to-event variable. Analyses were adjusted for demographic variables and significant diabetes parameters, significant cardiovascular parameters, and significant diabetes medications.
Total and high molecular weight adiponectin were highly correlated. The highest adiponectin quartile was strongly associated with higher all-cause mortality compared with the lowest quartile (hazard ratio = 4.0 [95% CI: 1.7–9.2]) in the fully adjusted model. These results did not change in analyses stratified by sex and thiazolidinedione use, after exclusion of people who died within one year of adiponectin measurement, or when change in weight before adiponectin measurement was considered.
Contrary to our hypothesis, higher adiponectin level was related to higher all-cause mortality. This association was not explained by confounding by other characteristics, including medications or preceding weight loss.
PMCID: PMC3424994  PMID: 22773703
21.  Effects of Electronic Health Information Technology Implementation on Nursing Home Resident Outcomes 
Journal of aging and health  2011;24(1):92-112.
To examine the effects of electronic health information technology (HIT) on nursing home residents.
The study evaluated the impact of implementing a comprehensive HIT system on resident clinical, functional, and quality of care outcome indicators, as well as measures of resident awareness of and satisfaction with the technology. The study used a prospective, quasi-experimental design, directly assessing 761 nursing home residents in 10 urban and suburban nursing homes in the greater New York City area.
No statistically significant impact of the introduction of HIT on residents was found on any outcomes, with the exception of a significant negative effect on behavioral symptoms. Residents' subjective assessment of the HIT intervention were generally positive.
The absence of effects on most indicators is encouraging for the future development of HIT in nursing homes. The single negative finding suggests that further investigation is needed on possible impact on resident behavior.
PMCID: PMC3677697  PMID: 21646551
Long-Term Care; Technology; Quality of Care
22.  A staff intervention targeting resident-to-resident elder mistreatment (R-REM) in long-term care increased staff knowledge, recognition and reporting: Results from a cluster randomized trial 
Elder abuse in long term care has received considerable attention; however, resident-to-resident elder mistreatment (R-REM) has not been well researched. Preliminary findings from studies of R-REM suggest that it is sufficiently widespread to merit concern, and is likely to have serious detrimental outcomes for residents. However, no evidence-based training, intervention and implementation strategies exist that address this issue.
The objective was to evaluate the impact of a newly developed R-REM training intervention for nursing staff on knowledge, recognition and reporting of R-REM.
The design was a prospective cluster randomized trial with randomization at the unit level.
A sample of 1405 residents (685 in the control and 720 in the intervention group) from 47 New York City nursing home units (23 experimental and 24 control) in 5 nursing homes was assessed. Data were collected at three waves: baseline, 6 and 12 months. Staff on the experimental units received the training and implementation protocols, while those on the comparison units did not. Evaluation of outcomes was conducted on an intent-to-treat basis using mixed (random and fixed effects) models for continuous knowledge variables and Poisson regressions for longitudinal count data measuring recognition and reporting.
There was a significant increase in knowledge post-training, controlling for pre-training levels for the intervention group (p<0.001), significantly increased recognition of R-REM (p<0.001), and longitudinal reporting in the intervention as contrasted with the control group (p=0.0058).
A longitudinal evaluation demonstrated that the training intervention was effective in enhancing knowledge, recognition and reporting of R-REM. It is recommended that this training program be implemented in long term care facilities.
PMCID: PMC3677710  PMID: 23159018
Resident-to-resident elder mistreatment (R-REM); nursing homes; long term care; older people; elder abuse; staff education; staff training
23.  A comparison of item response theory-based methods for examining differential item functioning in object naming test by language of assessment among older Latinos 
Object naming tests are commonly included in neuropsychological test batteries. Differential item functioning (DIF) in these tests due to cultural and language differences may compromise the validity of cognitive measures in diverse populations. We evaluated 26 object naming items for DIF due to Spanish and English language translations among Latinos (n=1,159), mean age of 70.5 years old (Standard Deviation (SD)±7.2), using the following four item response theory-based approaches: Mplus/Multiple Indicator, Multiple Causes (Mplus/MIMIC; Muthén & Muthén, 1998–2011), Item Response Theory Likelihood Ratio Differential Item Functioning (IRTLRDIF/MULTILOG; Thissen, 1991, 2001), difwithpar/Parscale (Crane, Gibbons, Jolley, & van Belle, 2006; Muraki & Bock, 2003), and Differential Functioning of Items and Tests/MULTILOG (DFIT/MULTILOG; Flowers, Oshima, & Raju, 1999; Thissen, 1991). Overall, there was moderate to near perfect agreement across methods. Fourteen items were found to exhibit DIF and 5 items observed consistently across all methods, which were more likely to be answered correctly by individuals tested in Spanish after controlling for overall ability.
PMCID: PMC3588164  PMID: 23471423
Item response theory; differential item functioning; object naming test; Hispanic/Latinos; Spanish
24.  Resident-to-Resident Aggression in Nursing Homes: Results from a Qualitative Event Reconstruction Study 
The Gerontologist  2011;52(1):24-33.
Despite its prevalence and negative consequences, research on elder abuse has rarely considered resident-to-resident aggression (RRA) in nursing homes. This study employed a qualitative event reconstruction methodology to identify the major forms of RRA that occur in nursing homes.
Design and methods:
Events of RRA were identified within a 2-week period in all units (n = 53) in nursing homes located in New York City. Narrative reconstructions were created for each event based on information from residents and staff who were involved as well as other sources. The event reconstructions were analyzed using qualitative methods to identify common features of RRA events.
Analysis of the 122 event reconstructions identified 13 major forms of RRA, grouped under five themes. The resulting framework demonstrated the heterogeneity of types of RRA, the importance of considering personal, environmental, and triggering factors, and the potential emotional and physical harm to residents.
These results suggest the need for person-centered and environmental interventions to reduce RRA, as well as for further research on the topic.
PMCID: PMC3265555  PMID: 22048811
Abuse/neglect; Behavior; Long-term care; Aggression
25.  Are Clinical Diagnoses of Alzheimer’s Disease and Other Dementias Affected by Education and Self-Reported Race? 
Psychological assessment  2012;24(3):531-544.
A randomized controlled trial examined whether the diagnostic process for Alzheimer’s disease and other dementias may be influenced by knowledge of the patient’s education and/or self-reported race. Four conditions were implemented: diagnostic team knows (a) race and education, (b) education only, (c) race only, or (d) neither. Diagnosis and clinical staging was established at baseline, at Wave 2, and for a random sample of Wave 3 respondents by a consensus panel. At study end, a longitudinal, “gold standard” diagnosis was made for patients with follow-up data (71%). Group differences in Diagnostic and Statistical Manual of Mental Disorders (4th ed.; American Psychiatric Association, 1994) diagnosis were estimated using logistic regression and generalized estimating equations. Sensitivity and specificity were examined for baseline diagnosis in relation to the gold standard, longitudinal diagnosis. Despite equivalent status on all measured variables across waves, members of the “knows race only” group were less likely than those of other groups to receive a diagnosis of dementia. At final diagnosis, 19% of the “knows race only” group was diagnosed with dementia versus 38% to 40% in the other 3 conditions (p = .038). Examination of sensitivities and specificities of baseline diagnosis in relation to the gold standard diagnosis showed a nonsignificant trend for lower sensitivities in the knowing race conditions (0.3846), as contrasted with knowing education only (0.480) or neither (0.600). The finding that knowledge of race may influence the diagnostic process in some unknown way is timely, given the recent State-of-the-Science conference on Alzheimer’s disease prevention, the authors of which called for information about and standardization of the diagnostic process.
PMCID: PMC3518032  PMID: 22309001
Alzheimer’s disease; clinical diagnosis; bias; self-reported race; education

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