Objective sleep quality as a predictor of mild cognitive impairment in seniors living alone

National Research Foundation (NRF) Singapore - Ministry of Health HealthCare Research Scholarshi

Examining a Fatigue Management Model That Identifies Risk Factors and Consequences of Fatigue in Older Individuals

Fatigue is experienced by 40-74% of older individuals living with a chronic disease. Despite advances in scientific knowledge around risk factors and consequences associated with fatigue, a comprehensive model that can serve as a guide for healthcare providers caring for older individuals with fatigue is lacking. Thus, the purpose of this study was to examine a fatigue model based on the Theory of Unpleasant Symptoms (TUS). The model included psychological, physiological, and situational risk factors of fatigue, as well as fatigue outcomes, such as physical, social, and cognitive performances, perceived health, and quality of life (QOL). This was a secondary data analysis of the “Patient-Reported Outcomes Measurement Information System Profiles – Health Utilities Index” dataset. Multiple regression analysis and path analyses were used to examine the association between fatigue and the above-mentioned variables. Findings suggested that number of comorbidities, pain, sleep, depression, anxiety, education, and sensory impairment (SI) were significant predictors of fatigue. In their turn, higher fatigue scores predicted lower physical, social, and cognitive performance, as well as worse perceived health and QOL. Additionally, fatigue outcomes mediated the relationship between fatigue and QOL. Health care providers of older individuals with fatigue should closely monitor and manage the physiological, psychological, and situational risk factors of fatigue, which would, in turn, improve these individuals’ performance on all three levels, perceived health, as well as their QOL. Future research should be directed towards exploring other risk factors of fatigue, examining feedback loops depicted in the TUS, identifying whether neurodegenerative diseases moderate the relationship between CP and QOL, and identifying variables that mediate the relationship between certain risk factors and fatigue

Music and Dementia: A Caregiver’s Perspective of the Effects of Individualized Music Programming on Quality of Life for Seniors Living in Assisted Living Environments

For senior-care and service providers, the issue of quality of life has moved beyond marketing to, in effect, the measuring of health-related outcomes. Particularly when the challenge of caring for those with Alzheimer’s disease and related dementias is daunting, as it cannot be prevented or cured and treatment possibilities are framed in a broader perspective to include alternative interventions such as music. Through the eyes of the caregivers, this 6-week, longitudinal quantitative study investigated individualized (passive) music programming and its effect on the health-related quality of life of residents in assisted living. The Alzheimer’s Disease Related Quality of Life instrument (ADRQL) was used to assess quality of life, and the importance of music was captured by the Assessment of Personal Music Preference. The data revealed an increase in quality of life from baseline through the final assessment; and when using only the home health aide staff, a series of multivariate repeated-measures analysis of variance found statistically significant improvements in overall quality of life and in all five ADRQL domain subscales (F = 9.54, p = 000, η2 = .52). The data also showed no significant correlation between the importance of music prior to cognitive impairment and quality of improvements (r = –.09, p = .786). The study had limitations, most importantly the small convenience sample (N = 11); therefore, a formal inductive inference concerning the population cannot be made. More rigorous studies increasing the sample size, using a control group, including confounding variables, and qualitative interviews are recommended

Risk assessment during preventive home visits among older people

Background: Preventive home visits (PHV) may contribute to identify risks and needs in older people, and thereby delay the onset of functional decline and illness, otherwise often followed by home care or admission to hospital or nursing homes. There is a need to increase knowledge about which factors are associated with different risk areas among older people, so that the PHV questionnaire focuses on relevant tests and questions to make the PHV more specific and have a clear focus and purpose. Objective: The objective of this study was to examine associations between five kinds of risks: risk of falls, malnutrition, polypharmacy, cognitive impairment, and risk of developing illness and factors related to lifestyle, health, and medical diagnoses among older people living at home. Methods: A cross-sectional study design was applied. PHV were conducted by nurses among 77-year-old people in an urban municipality and among ≥75-year-old people in a rural municipality. A questionnaire including tests and a risk assessment score for developing illness was used. Descriptive and inferential statistics including regression models were analyzed. Results: The total sample included 166 persons. Poor perceived health was associated with increased risk of developing illness and risk of fall, malnutrition, and polypharmacy. Lifestyle and health factors such as lack of social support, sleep problems, and feeling depressed were associated with risk of developing illness. Risk of falls, malnutrition, polypharmacy, and cognitive impairment were also associated with increased risk of developing illness. None of the independent factors related to lifestyle, health, or medical diagnosis were associated with risk of cognitive impairment. Conclusion: Poor perceived health was associated with health-related risks in older persons living at home. Preventive health programs need to focus on social and lifestyle factors and self-reported health assessment to identify older people at risk of developing illnesses.publishedVersio

Evaluation of direct-to-patient educational approaches for reducing inappropriate sedative-hypnotic use in community-dwelling older adults

Cette thèse teste l’hypothèse selon laquelle l’initiation du processus de déprescription des benzodiazépines peut être facilité chez les aînés via l’utilisation de documents éducatifs fondés sur des données probantes, soulignant les risques associés à ces médicaments ainsi que les alternatives non pharmacologiques plus sécuritaires. Cette thèse détaille comment nous avons développé, testé et adapté des outils éducatifs destinés aux consommateurs de benzodiazépines en nous basant sur des éléments de la théorie sociale cognitive et de la théorie constructiviste de l'apprentissage. Notre recherche a révélé l’importance du soutien offert par les professionnels de la santé chez les patients intéressés à déprescrire. Les étapes subséquentes de notre programme de recherche visaient à fournir aux aînés l'information nécessaire pour initier la conversation sur la déprescription, et, de façon simultanée, améliorer le niveau de confiance et outiller les professionnel de la santé, pour leur permettre d’assister les patients motivés à arrêter leurs sédatif-hypnotiques. Nous avons d'abord mené l'essai randomisé par grappes EMPOWER, où nous avons recruté 303 usagers chroniques de benzodiazépines âgés de 65 à 95 ans, dans 30 pharmacies communautaires (15 interventions, n = 148 participants, 15 témoins, n = 155). Une analyse préliminaire de l'effet de l'intervention sur la perception du risque associé aux benzodiazépines chez les participants a révélé que 45,1% de ceux ayant reçu l'intervention EMPOWER avaient signalé une augmentation du risque perçu, ce qui est associé à une meilleure acquisition des connaissances, à un changement des croyances, à une dissonance cognitive, à un sentiment d’auto-efficacité accru et à une plus grande intention d’entamer la conversation sur la cessation du médicament. Après 6 mois, 27% des patients du groupe d'intervention avaient cessé leur benzodiazépine contre 5% des témoins (différence de risque 23%, IC 95% 14-32%, ICC 0,008, NNT = 4). Aucun facteur de risque n’influençait l'effet de l'intervention. Subséquemment, nous avons cherché à mieux comprendre les raisons pour lesquelles l'intervention avait échoué ou réussi chez certains participants, afin de guider la recherche future. Nous avons vérifié si les patients avec un déficit cognitif léger avaient autant bénéficié de l'intervention que les patients avec une cognition normale. Une analyse post hoc de tous les participants ayant complété l'étude EMPOWER (n = i 261) n'a révélé aucune différence significative, l'arrêt des benzodiazépines ayant été noté chez 39 (32,0% [24.4,40.7]) participants avec déficit cognitif léger et chez 53 (38,1% [30.5,46.4]) participants avec une cognition normale (OR ajusté 0,79, IC 95% [0.45-1.38]). Nous avons ensuite mené une évaluation réaliste qui a révélé que l’intervention avait réussi à motiver 167 participants (n = 64%) à déprescrire, cela ayant été démontré par l'amélioration du niveau de connaissances et un sentiment d’inquiétude accru quant à la prise de benzodiazépines. La déprescription était plus souvent vouée à l’échec chez les participants s’il y avait un manque de support offert par un professionnel de la santé, si l’accent était mis sur la qualité de vie à court terme, ou en présence d’intolérance aux symptômes de sevrage ou de perception défavorable de son niveau de santé. En se basant sur les défis observés dans l'essai EMPOWER, nous avons cherché à éliminer certains des obstacles à la déprescription de sédatif-hypnotiques, ciblant spécifiquement la réticence des professionnels de la santé à soutenir les patients dans le processus de déprescription. L'intervention dans l'essai D-PRESCRIBE consistait en une approche éducative en deux volets dirigés par le pharmacien auprès des patients et des médecins, via la distribution de la brochure EMPOWER aux patients et d'une opinion pharmaceutique destinée aux prescripteurs. Nous avons développé un modèle standard d’opinion pharmaceutique fondé sur des données probantes, testé auprès d’un échantillon de 32 médecins et de 61 pharmaciens. Via révision du prototype, un modèle final a été obtenu par consensus. Dans le cadre de l'étude randomisée par grappes D-PRESCRIBE, nous avons recruté 299 utilisateurs chroniques de sédatif-hypnotiques âgés de 66 à 96 ans, provenant de 68 pharmacies communautaires (34 interventions, n = 145 participants, 34 témoins, n = 154). Après 6 mois, 44% des patients du groupe d'intervention avaient cessé leur sédatif-hypnotique, contre 6,5% chez les contrôles (différence de risque 38%, IC 95% 24-48%, ICC 0,012, NNT = 3). Les taux de cessation de D-PRESCRIBE étaient significativement plus élevés que ceux observés dans l'étude EMPOWER. Les résultats suggèrent que l’ajout d’une composante éducative chez les prescripteurs réduit leur réticence à soutenir un patient motivé par le processus de déprescription.This thesis tests the hypothesis that older adults can enable the initiation of benzodiazepine deprescribing when equipped with evidence-based educational material about drug harms and safer non-pharmacological alternatives. The work described in this thesis explains how we developed, tested, refined and adapted educational tools for benzodiazepine consumers, based on elements of social cognitive theory and constructivist learning theory. Our research revealed that health care provider support is required to assist patients in following through on their initial desire to deprescribe. Subsequent steps in my research program aimed to simultaneously equip older adults with the information they need to drive deprescribing conversations, while also boosting health care provider support and self-efficacy for enabling motivated patients to successfully discontinue sedative-hypnotics. We first conducted the EMPOWER cluster randomized trial, where we recruited 303 chronic users of benzodiazepine medication aged 65-95 years, recruited from 30 community pharmacies (15 intervention, n=148 participants; 15 control, n= 155). A preliminary analysis was conducted to evaluate the intervention’s effect on participants risk perception about benzodiazepines through knowledge acquisition and change in beliefs. We showed that 45.1% of participants receiving the EMPOWER intervention reported an increased perceived risk, which was associated with better knowledge acquisition, change in beliefs, occurrence of cognitive dissonance, increased self- efficacy and increased intent to discuss discontinuation. Six-months outcomes from the trial revealed that 27% of the intervention group had discontinued benzodiazepine use compared to 5% of controls (risk difference 23%, 95% CI 14-32%, ICC 0.008, NNT=4) with no risk factor characteristics interacting with the effect of the intervention. We then aimed to gain a better understanding as to why the intervention failed or succeeded for certain participants in order to guide future research. We tested whether patients with mild cognitive impairment (MCI) received the same benefits from the intervention as patients with normal cognition. A post-hoc analysis of all participants iii completing the EMPOWER study (n=261) revealed no significant differences, with benzodiazepine discontinuation occurring in 39 (32.0% [24.4,40.7]) participants with MCI and in 53 (38.1% [30.5,46.4]) with normal cognition (aOR 0.79, 95% CI [0.45– 1.38]). We then conducted a realist evaluation, which showed that the intervention triggered the motivation to deprescribe among 167 (n=64%) participants, demonstrated by improved knowledge and increased concern about taking benzodiazepines. Contexts where the deprescribing mechanisms failed included lack of support from healthcare providers, short-term quality of life focus, intolerance to withdrawal symptoms and perceived poor health. Based on the challenges observed in the EMPOWER trial, we aimed to address some of the observed barriers to sedative-hypnotic deprescribing, specifically targeting healthcare provider reluctance to support patients in the deprescribing process. The intervention in the subsequent D-PRESCRIBE trial consisted of a two-pronged educational approach brokered by the pharmacist to patients and physicians, through distribution of the EMPOWER brochure to patients and a pharmaceutical opinion to prescribers. We developed a standardized template for an evidence-based pharmaceutical opinion, which we tested in a convenience sample of 32 primary care physicians and 61 primary care pharmacists. The content and format of the prototype underwent revisions until a consensus was reached on a final recommended template. We then conducted the D-PRESCRIBE cluster randomized trial, where we recruited 299 chronic sedative-hypnotic medication users aged 66-96 years, from 68 community pharmacies (34 intervention, n=145 participants; 34 control, n= 154). Six-months outcomes yielded a 44% discontinuation rate in the intervention group compared to a 6.5% rate in the controls (risk difference 38%, 95% CI 24-48%, ICC 0.012, NNT=3) with risk profile characteristics interacting with the effect of the intervention. Discontinuation rates in D-PRESCRIBE were significantly higher than those observed in the EMPOWER trial. Process outcomes from the trial suggest that the added value of adding an educational component to prescribers is that it decreases reluctance to support motivated patients to attempt and succeed at deprescribing

Prevention and Management of Frailty

It is important to prevent and manage the frailty of the elderly because their muscle strength and physical activity decrease in old age, making them prone to falling, depression, and social isolation. In the end, they need to be admitted to a hospital or a nursing home. When successful aging fails and motor ability declines due to illness, malnutrition, or reduced activity, frailty eventually occurs. Once frailty occurs, people with frailty do not have the power to exercise or the power to move. The functions of the heart and muscles are deteriorated more rapidly when they are not used. Consequently, frailty goes through a vicious cycle. As one’s physical fitness is deteriorated, the person has less power to exercise, poorer cognitive functions, and inferior nutrition intake. Consequently, the whole body of the person deteriorates. Therefore, in addition to observational studies to identify risk factors for preventing aging, various intervention studies have been conducted to develop exercise programs and apply them to communities, hospitals, and nursing homes for helping the elderly maintain healthy lives. Until now, most aging studies have focused on physical frailty. However, social frailty and cognitive frailty affect senile health negatively just as much as physical frailty. Nevertheless, little is known about social frailty and cognitive frailty. This special issue includes original experimental studies, reviews, systematic reviews, and meta-analysis studies on the prevention of senescence (physical senescence, cognitive senescence, social senescence), high-risk group detection, differentiation, and intervention

The Gray Matter project: modificating lifestyles to prevent dementia

As dementia aetiology is based on different bio-psychosocial factors, prevention strategies for dementia have recently focused on multi-domain interventions of individuals at risk and/or with a normative cognitive level, encouraging the lifestyle change through combined programs of physical activity, cognitive training, nutrition education and social activities (in chapter 1, a narrative review of these studies is presented). Most of the multidomain intervention aimed on the prevention of cognitive disease are carried on with elderly patients with a mild cognitive decline or on at-risk adult categories. 5 Caregivers of patients with dementia are considered as an at-risk category. The majority of them (86%) are represented by family members (prominently women) who are also defined as “informal caregivers”. They fulfil their caringgiving role from 7 to 11 h a day on average, up to 10-15 h when clinical conditions worsen 10. Informal caregivers have to cope with physical, psychological and social stressors that affect their health conditions and quality of life negatively (Eleuteri et al., 2016). The burdens of caregiving include many things that have been shown to increase the risk of cognitive decline, including chronic stress, social isolation, depression, decreased physical activity, and a shift in eating habits toward more fast food and significantly more weight compared with controls (Vitaliano et al., 1996). This could be connected with the important role that sleep plays between stress and metabolic health (Geiker et al., 2018). Being a caregiver has been found to be a factor affecting negatively sleep quality (Brummett et al., 2006). Interventions to promote positive lifestyles are, therefore, important in order to improve the caregivers’ general health and, specifically, to prevent the cognitive decline. In the second chapter, an article recently published specifies the importance of multimodal interventions in ameliorating caregivers’ health, since complex moderation and mediation effects exist between the different areas involved in the AD risk reduction. The third chapter will, finally, describe the results of the Gray Matter Project, a multidomain pilot RCT, firstly carried out done in Cache County, Utah designed to promote positive changes in lifestyle (exercise, nutrition, cognitive stimulation, social engagement, stress management, and sleep quality), specifically for the purpose of reducing AD risk in family caregivers of elderly with dementia

Drug Use and the Risk of Motor Vehicle Collision in Adults 65 Years of Age and Older

Introduction: The population of adults 65 years of age and older is growing at an exponential rate in the United States. The current generation of older adults is more mobile and driving much later in life compared to previous cohorts. While the current generation of older adults is living longer, they are not necessarily healthier. Older adults consume roughly 30% of all written prescriptions, are the largest consumers of over-the-counter medications, and report a higher prevalence of lifetime licit and illicit drug use compared to previous generations. There is concern that many older adults will drive while taking drugs-either illicit or licit-that will interfere with their ability to safely operate a motor vehicle. Licit and illicit drug use is largely understudied in this population of drivers, particularly in the United States.;Methods: This study employed a systematic review to discern which individual licit drugs were associated with increased risk/odds of motor vehicle collision, a cross-sectional analysis of a national traffic fatality database to discern which types of licit and/or illicit drugs and combinations were most prevalent among fatally injured senior drivers compared to middle-aged drivers, and a case-crossover study using electronic medical records to assess the risk that individual licit drugs pose to drivers 65 years of age and older in West Virginia who were admitted to medical treatment following a motor vehicle collision.;Results: Among the 53 specific medications investigated by the 27 studies included in the systematic review, 15 medications (28.3%) were associated with an increased risk of motor vehicle collision. The medications that were associated with an increased risk of collision were: Buprenorphine, Codeine, Dihydrocodeine, Methadone, Tramadol, Levocitirizine, Diazepam, Flunitrazepam, Flurazepam, Lorazepam, Temazepam, Triazolam, Carisoprodol, Zolpidem, and Zopiclone. In the cross-sectional analysis, licit and illicit drug use among senior drivers occurred in 17.8% of those tested. Among drug-positive senior drivers, benzodiazepines and narcotics were frequent. The rates of testing positive for any drug, multiple drugs, combined drug and alcohol, and alcohol use alone among seniors were 47% (Rate ratio, RR=0.53, 95% CI 0.50, 0.57), 57% (RR=0.43, 95% CI 0.39, 0.48), 88% (RR=0.12, 95% CI 0.10, 0.15) and 79% (RR=0.21, 95% CI 0.19, 0.24) less, respectively, compared to middle-aged drivers. In the case-crossover study, few drivers tested positive for drugs. Of those testing positive, benzodiazepines and opiates were the most common. After adjusting for the number of medications a driver was consuming during case and control periods, cases consuming Tramadol (Odds ratio, OR: 11.41; 95% CI 1.27, 102.15), were at a significantly increased risk of motor vehicle collision if they consumed these medications 14 days before the collision compared to control periods. Numerous other medications, including Clopidogrel, Gabapentin, Citalopram, Insulin, Hydrochlorothiazide, Metoprolol, Zolpidem, and Nitroglycerine, were trending towards being associated with motor vehicle collision, but were not found statistically significant.;Conclusions: The findings of this research pose numerous clinical and research implications. As many of the licit drugs included in this analysis are widely prescribed, patients should be informed that their driving ability may be affected. Further exploration into this area is research is necessary as older adults are choosing to maintain their mobility later in life