Health Literacy, Cognitive Impairment, and Medication Adherence in Veterans with Heart Failure

Background: Heart failure (HF) affects 5.8 million people in the United States, costly in terms of patient mortality and morbidity as well as healthcare dollars. One important manifestation of poor HF outcomes is the excessive admission-readmission cycle. Non-adherence to medication is responsible for the majority of HF readmissions. Identification and intervention for key factors contributing to poor medication adherence is critical to improving outcomes. Two such factors prevalent in persons with HF are cognitive impairment (CI) and poor health literacy (HL). There is a paucity of tested interventions designed to improve medication adherence by addressing underlying CI or HL. A recent study tested a pictorial medication sheet to improve medication adherence in veterans with HF and CI, however no information on HL was collected. This new study examines what mediating effects HL may have played in the adherence scores of subjects in the completed study. Study Aims: Aim 1. Describe the level of HL in the study population. Aim 2. Determine the strength and direction of the relationships between reading HL and numeracy HL and selected clinical and demographic variables in the study population. Aim 3. Determine the direct and indirect effects that reading HL and numeracy HL and other key variables (including the intervention) have upon medication adherence in cognitively impaired veteran outpatients with HF based on prior data from an interventional study testing a pictorial medication sheet to improve medication adherence. Study Design A retrospective, correlational, cross-sectional design was employed to analyze HL scores from medical records with data from the completed study using conventional statistics and structural equation modeling. Results: 27 subjects with a mean age of 65.3 years (SD 8.2, range 45-80) had evaluable data. HL was less than adequate in 19% of the sample. HL scores were strongly correlated with cognition. HL did not significantly affect relationships between study covariates (cognition scores, depression, number of medications) and medication adherence. Conclusions and Significance: HL scores were associated with cognitive function scores. More research is needed to evaluate the prevalence and effect of poor HL in veterans with HF upon adherence

Therapy concordance and drug adherence in Parkinson's disease

Chapter 1 gives an overview of the relevance of studying therapy adherence in Parkinson’s disease. Chapter 2 examines drug induced neurological syndromes and considers the validity of patients’ concerns about taking prescribed medications. Chapter 3 compares different methods of assessing therapy adherence. Chapter 4 studies factors associated with sub-optimal medicine usage in 54 patients. Chapter 5 reports a study of patient perceived involvement with management decisions and an assessment of satisfaction with the movement disorder service in 107 patients. Chapter 6 explores patients’ beliefs about antiparkinson medication in 129 patients. Chapter 7 examines the effect on Parkinson’s patients of emerging data about drug side effects, specifically fibrosis due to ergot-based dopamine agonists. Chapter 8 reports on an educational intervention designed to improve Parkinson drug timing compliance. In summary, this thesis provides important new information about medicine taking in Parkinson’s disease. A fifth of PD patients take less than 80% of prescribed antiparkinson medication. Electronic monitoring is the only reliable method of accurately detecting sub-optimal medication usage. Patients who take less than 80% of prescribed medicines are more likely to be younger, have concomitant depression, be prescribed more tablets per day and have poorer quality of life. Patients are more satisfied if they are involved in management decisions and have increased intention to comply with prescribed medication if there is better communication. Poorer quality of life is associated with less intention to comply with prescribed medication. Timing of medication intake is generally irregular but can be improved by informing patients of the continuous dopaminergic theory and providing specific drug timings. Once daily drugs are taken more consistently than drugs with more frequent doses

Implementing Evidence-Based Adult Psychiatric Inpatient Depression Assessment, Treatment, and Post-Hospitalization Referral

Purpose: This project was designed to strengthen the quality of depression assessment with evidence-based depression assessment tools in inpatient psychiatric units. Background: Missed diagnosis and treatment of depressive disorders contribute to the most severe outcome of depression: suicide. A crisis stabilization facility with inpatient psychiatric units had significant opportunities to improve clinical outcomes by screening for depression in adults and to monitor symptoms with evidence-based tools. Methods: The 12-week quality improvement project included implementation of staff education sessions of evidence-based tools to screen, monitor, interpret scores, and detect risk modifiers. The design and build with Information Technology for Personal Health Questionnaire 2 (PHQ-2) daily scores in the electronic health records, adding admission score of depression assessment tool on nursing handoff reports, improved nurse-provider communication, design of PHQ-2 algorithm, design of flowchart impacting nursing workflow, and revision of the patient goals sheet replacing a numeric scale with the PHQ-2 for depression assessment daily and per shift as needed. Results: Achieved 100% participation in staff educational sessions, established new standard in nursing with Personal Health Questionnaire 9 (PHQ-9) built into shift report sheets, patient completion of daily goals sheets with PHQ-2 increased from 0% to 52.3%, identification of risk factors in patients with Major Depressive Disorder (MDD) including 61.5% history of abuse in lifetime and 62.5% history of Post-Traumatic Stress Disorder (PTSD). Increased provider adherence to evidence-based clinical guidelines in the management and treatment of MDD with 61.7% of patients referred to psychotherapy, 56.8% of patients were prescribed clinical guideline’s 1st line of treatment antidepressants selective serotonin reuptake inhibitors, and 56.4% of patients were prescribed with augmentation pharmacotherapy second generation antipsychotics. Descriptive statistics resulted in referrals to outpatient psychotherapy in 53.2% of funded patients and 46.8% of unfunded patients. Conclusions: Expanding knowledge and use of evidence-based depression assessment tools in an inpatient setting assisted with management, treatment, and post-hospitalization referrals. Guiding the project with DNP Essential II: Organizational and Systems Leadership for Quality Improvement and Systems Thinking involved continuous tracking and modifying the project with feedback from different components (e.g., licensed clinical social workers (LCSWs), pharmacists, providers, nursing staff, technicians, administration) using evidence-based clinical guidelines

Conversational affective social robots for ageing and dementia support

Socially assistive robots (SAR) hold significant potential to assist older adults and people with dementia in human engagement and clinical contexts by supporting mental health and independence at home. While SAR research has recently experienced prolific growth, long-term trust, clinical translation and patient benefit remain immature. Affective human-robot interactions are unresolved and the deployment of robots with conversational abilities is fundamental for robustness and humanrobot engagement. In this paper, we review the state of the art within the past two decades, design trends, and current applications of conversational affective SAR for ageing and dementia support. A horizon scanning of AI voice technology for healthcare, including ubiquitous smart speakers, is further introduced to address current gaps inhibiting home use. We discuss the role of user-centred approaches in the design of voice systems, including the capacity to handle communication breakdowns for effective use by target populations. We summarise the state of development in interactions using speech and natural language processing, which forms a baseline for longitudinal health monitoring and cognitive assessment. Drawing from this foundation, we identify open challenges and propose future directions to advance conversational affective social robots for: 1) user engagement, 2) deployment in real-world settings, and 3) clinical translation

Design of the NL-ENIGMA study: Exploring the effect of Souvenaid on cerebral glucose metabolism in early Alzheimer's disease

Alzheimer's disease is associated with early synaptic loss. Specific nutrients are known to be rate limiting for synapse formation. Studies have shown that administering specific nutrients may improve memory function, possibly by increasing synapse formation. This Dutch study explores the Effect of a specific Nutritional Intervention on cerebral Glucose Metabolism in early Alzheimer's disease (NL-ENIGMA, Dutch Trial Register NTR4718, http://www.trialregister.nl/trialreg/admin/rctview.asp?TC=4718). The NL-ENIGMA study is designed to test whether the specific multinutrient combination Fortasyn Connect present in the medical food Souvenaid influences cerebral glucose metabolism as a marker for improved synapse function. Methods This study is a double-blind, randomized controlled parallel-group single-center trial. Forty drug-naive patients with mild cognitive impairment or mild dementia with evidence of amyloid deposition are 1:1 randomized to receive either the multinutrient combination or placebo once daily. Main exploratory outcome parameters include absolute quantitative positron emission tomography with 18F-fluorodeoxyglucose (including arterial sampling) and standard uptake value ratios normalized for the cerebellum or pons after 24 weeks. Discussion We expect the NL-ENIGMA study to provide further insight in the potential of this multinutrient combination to improve synapse function

Inhalation therapy in the next decade : Determinants of adherence to treatment in asthma and COPD

Peer reviewedPublisher PD

Early detection of mild cognitive impairment with in-home sensors to monitor behavior patterns in community-dwelling senior citizens in Singapore: Cross-sectional feasibility study

Singapore Management University; National Medical Research Council’s Healthcare Research Scholarshi

Design of the PACIFIC study: A randomized controlled trial evaluating a novel treatment for adults with overweight and obesity

The majority of adults in the United States have overweight or obesity which is associated with significant health and psychological consequences. Behavioral Weight Loss (BWL) is the current gold-standard weight-loss program for adults but recidivism rates continue to be disturbingly high. Given the health consequences of excess weight and the lack of long-term effectiveness of BWL, it is important to identify novel weight-loss programs. We developed the ROC (Regulation of Cues) program to reduce overeating through improvement in sensitivity to appetitive cues and decreased responsivity to external food cues. This study is a 4-arm randomized control trial designed to evaluate the efficacy of ROC, ROC combined with BWL, BWL alone and an active comparator over 24 months. Study recruitment completed in November 2017. Two hundred and seventy-one participants were randomized (mean age=46.97 years; 82% female, mean BMI=34.59; 20% Hispanic) and assessments were conducted at baseline, mid-treatment (6 months) and post-treatment (12 months). At this time, participants are completing 6- (18 months) and 12-month (24 months) follow-ups. Targeting novel mechanisms is critically important to improve weight-loss programs. Through this trial, we hope to identify treatments for adults with overweight and obesity to facilitate long-term weight loss and improved health

Uncovering undetected hypoglycemic events

Hypoglycemia is the rate-limiting factor that often prevents patients with diabetes from safely and effectively achieving their glycemic goals. Recent studies have reported that severe hypoglycemia is associated with a significant increase in the adjusted risks of major macrovascular events, major microvascular events, and mortality. Minor hypoglycemic episodes can also have serious implications for patient health, psychological well being, and adherence to treatment regimens. Hypoglycemic events can impact the health economics of the patient, their employer, and third-party payers. Insulin treatment is a key predictor of hypoglycemia, with one large population-based study reporting an overall prevalence of 7.1% (type 1 diabetes mellitus) and 7.3% (type 2 diabetes mellitus) in insulin-treated patients, compared with 0.8% in patients with type 2 diabetes treated with an oral sulfonylurea. Patients with type 1 diabetes typically experience symptomatic hypoglycemia on average twice weekly and severe hypoglycemia once annually. The progressive loss of islet cell function in patients with type 2 diabetes results in a higher risk of both symptomatic and unrecognized hypoglycemia over time. Patients with diabetes who become hypoglycemic are also more susceptible to developing defective counter-regulation, also known as hypoglycemia awareness autonomic failure, which is life-threatening and must be aggressively addressed. In patients unable to recognize hypoglycemia symptoms, frequent home monitoring or use of continuous glucose sensors are critical. Primary care physicians play a key role in the prevention and management of hypoglycemia in patients with diabetes, particularly in those requiring intensive insulin therapy, yet physicians are often unaware of the multitude of consequences of hypoglycemia or how to deal with them. Careful monitoring, adherence to guidelines, and use of optimal treatment combinations are all important steps toward improving care in patients with diabetes. The most important goals are for primary care physicians to recognize that every patient treated with antihyperglycemic medications is at risk of iatrogenic hypoglycemia and to ask patients about hypoglycemia at every visit

Assessing type 2 diabetes associated NeuroCognitive impairment using an e-screening tool in a South African population

Background: Type 2 diabetes has been found to be associated with cognitive impairments in planning, problem solving, organization, and working memory and also with an increased risk of dementia. Neurocognitive impairment may impact self-care and other health behaviours increasing the risk of poor health outcomes in this patient population. Detection of neurocognitive impairment in low and middle-income settings is challenging; there is a lack of validated screening tools suitable for local use in primary care and outpatient settings and access to formal neuropsychological testing services is limited. The inability to easily identify people with type 2 diabetes with neurocognitive impairments is constraining the development of context appropriate interventions to improve the care and outcomes in this sub-group of patients. Aim: The aim of the current analysis is to explore associations between neurocognitive function and measures of diabetes control (HbA1c, disease duration, type of blood glucose lowering treatment) at baseline in a population of people with type 2 diabetes participating in a clinical trial of treatment adherence support using SMS-text messages. Materials and Methods: Sms text Adherence suppoRt for type 2 Diabetes (StAR2D) is a randomised clinical trial testing if a system of SMS-text messages to support treatment adherence is more effective than usual care for controlling blood sugar among people with type 2 diabetes in sub-Sahara Africa (ISRCTN70768808). We have embedded neurocognitive assessment sub-studies into the Cape Town trial site. At baseline participants in the StAR2D trial complete a novel mobile-device based cognitive assessment, NeuroScreen, assisted by a field research assistant. The assessment contains 9 variants of tests found in the gold-standard neuropsychological test battery that have been adapted and normed for use in South Africa. It is available in English or isiXhosa. The assessment takes between 20 to 40 minutes depending on participant error rate. This cross-sectional analysis of baseline data uses linear and logistic regression models to explore associations between neurocognitive function and measures of diabetes control. Results: Six hundred participants eligible for enrolment in the StAR2D trial were recruited from the Cape Town trial site; 499 participants completed the baseline neurocognitive screening assessment (20 to 40 minutes to complete); 101 participants did not complete the assessment (commonly due to eyesight, hearing or motor difficulties e.g. hemiplegia due to previous stroke or technical difficulties.) We found differences in the scores in some but not all the neuropsychological tests. Using cut points suggested by an earlier validation study of NeuroScreen tool more than half of study participants would be scored as having at least mild neurocognitive impairment. HbA1c, duration of disease, type of blood glucose lowering treatment were not significantly associated with individual or overall neuropsychological test scores or odds of neurocognitive impairment. Conclusions: The prevalence of neurocognitive impairment may be substantial in this patient population. A novel tablet based neurocognitive screening tool was broadly feasible and acceptable to lay researchers and trial participants. There was no evidence that HbA1c, duration of disease, or type of blood glucose lowering treatment (oral agents alone or insulin containing regimens) was significantly associated with individual or overall neuropsychological test scores or odds of neurocognitive impairment. Validating this tool for this patient population and optimising its role in routine clinical care need further study