Publications

Delirium and dementia are common causes of cognitive impairment in older adults. They are distinct but interrelated. Delirium, an acute confusional state, has been linked to the chronic and progressive loss of cognitive ability seen in dementia. Individuals with dementia are at higher risk for delirium, and delirium itself is a risk factor for incident dementia. Additionally, delirium in individuals with dementia can hasten underlying cognitive decline. In this review, we summarize recent literature linking these conditions, including epidemiological, clinicopathological, neuroimaging, biomarker, and experimental evidence supporting the intersection between these conditions. Strategies for evaluation and diagnosis that focus on distinguishing delirium from dementia in clinical settings and recommendations for delirium prevention interventions for patients with dementia are presented. We also discuss studies that provide evidence that delirium may be a modifiable risk factor for dementia and consider the impact of delirium prevention interventions on long-term outcomes.

BACKGROUND: Guidelines advise automated office blood pressure (AOBP) with an initial 5-minute delay and multiple measurements at least 60 seconds apart. Recent studies suggest that AOBP may be accurate with shorter delays or intervals, but evidence in clinical settings is limited.

METHODS: Patients referred to one hypertension (HTN) center underwent 24-hour ambulatory blood pressure monitoring (ABPM) and one of four non-randomized, unattended AOBP protocols: a 3- or 5-minute delay with a 30 or 60-second interval, i.e., 3 min/30 sec/30 sec, 3/60/60, 5/30/30 and 5/60/60 protocols. HTN was defined as systolic blood pressure ≥140 or diastolic blood pressure ≥90 mmHg.

RESULTS: We compared differences in mean blood pressure and HTN classification between average AOBP and awake-time ABPM by t-tests and Fisher's exact test. Among 212 participants (mean 58.9 years, 61% women, 25% Black), there was substantial overlap in the probability distributions of awake-time ABPM and each of the three AOBP measures. Systolic blood pressure means were similar between the 5/60/60 and 3/30/30 protocols and 5/30/30 and 3/60/60 protocols. The 5/30/30 was associated with a higher proportion of systolic HTN, while the 3/60/60 protocol was associated with a higher proportion of diastolic HTN. There were no significant differences in systolic or diastolic HTN between 5/60/60 and 3/30/30 protocols with respect to awake-time ABPM.

CONCLUSIONS: In this quality improvement study, the shortest AOBP protocol did not differ significantly from the longest protocol. The time savings of shorter protocols may improve AOBP adoption in clinical practice without meaningfully compromising accuracy.

BACKGROUND: Following acute coronary syndrome (ACS), up to 40% of patients report elevated depressive symptoms which is associated with a two-fold increase in mortality risk due to behavioral and biological mechanisms. Mindfulness-Based Cognitive Therapy (MBCT) delivered via synchronous group videoconferencing could help reduce depressive symptoms.

OBJECTIVE: To guide MBCT adaptation for ACS patients for a future clinical trial, this qualitative study aimed to explore ACS patients' (1) symptoms after ACS, (2) needs for behavioral health treatment, (3) perspectives on mindfulness intervention and group videoconference delivery, and (4) willingness to self-collect dried blood spots in a research study.

METHODS: We compared ACS patients with and without depressive symptoms to highlight particularly relevant treatment topics for patients developing depression following ACS experience. From 2/2019-11/2019, we conducted semi-structured individual telephone interviews with N = 23 patients after ACS (N = 13 with and N = 10 without elevated depressive symptoms; 63.4 (SD = 8.5) years, 87% male, 96% non-Hispanic white, 7.1 (SD = 7.5) years since ACS). In qualitative content analyses, four independent coders coded each interview.

RESULTS: Participants with depressive symptoms experienced emotional, physical, social, and health behavior problems, while those without depressive symptoms made positive health behavior changes and struggled with anxiety symptoms. Both groups were interested in a behavioral health treatment for emotional and social support. Most were willing to participate in a mindfulness group via videoconferencing; some preferred in-person, but accessibility and convenience outweighed these cons. Almost all were willing to self-collect dried blood spots and some were already familiar with this technique.

CONCLUSION: ACS patients, especially those with depressive symptoms, need help managing a multitude of quality of life concerns that can be targeted with an adapted MBCT approach. A videoconference-delivered MBCT approach is of interest. Suggestions for adapting MBCT to target the needs of ACS patients are discussed.

Orthostatic hypotension (orthostatic hypotension) is a highly prevalent medical condition that is an independent risk factor for falls and mortality. It reflects a condition in which autonomic reflexes are impaired or intravascular volume is depleted, causing a significant reduction in blood pressure upon standing. This disorder is frequently unrecognized until later in its clinical course. Symptoms like orthostatic dizziness do not reliably identify patients with orthostatic hypotension, who are often asymptomatic, lending further to the difficulty of this diagnosis. We summarize 7 clinically important misconceptions about orthostatic hypotension.

BACKGROUND: Patients, families, and clinicians increasingly communicate through patient portals. Due to potential for multiple authors, clinicians need to know who is communicating with them. OurNotes is a portal-based pre-visit agenda setting questionnaire. This study adapted OurNotes to include a self-identification question to help clinicians interpret information authored by nonpatients.

OBJECTIVES: To describe adapted OurNotes use and clinician feedback to inform broader implementation.

DESIGN: Evaluation of adapted OurNotes in a geriatric practice.

PARTICIPANTS: Older adults with a portal account and a clinic visit; eight clinicians were interviewed.

INTERVENTION: OurNotes adaptation to clarify whether the author is the patient, the patient with help, or a nonpatient.

APPROACH: Cross-sectional chart review of OurNotes completion, patient characteristics, and visit topics by author type. Clinician interviews explored experiences with OurNotes.

RESULTS: Out of 503 visits, 134 (26%) OurNotes questionnaires were completed. Most respondents (n = 92; 69%) identified as the patient, 18 (14%) identified as the patient with help, and 24 (17%) identified as someone other than the patient. On average, patients who authored their own OurNotes were younger (80.9 years) compared to patients who received assistance (85.8 years), or patients for whom someone else authored OurNotes (87.8 years) (p < 0.001). A diagnosis of cognitive impairment was present among 20% of patients who self-authored OurNotes vs. 79% of patients where someone else authored OurNotes (p < 0.001). Topics differed when OurNotes was authored by patients vs. nonpatients. Symptoms (52% patient vs. 83% nonpatient, p = 0.004), community resources (6% vs. 42%, p < 0.001), dementia (5% vs. 21%, p = 0.009), and care partner concerns (1% vs. 12%, p = 0.002) were more often mentioned by nonpatients. Clinicians valued the self-identification question for increasing transparency about who provided information.

CONCLUSIONS: A self-identification question can identify nonpatient authors of OurNotes. Future steps include evaluating whether transparency improves care quality, especially when care partners are involved.

Leptin is an adipokine associated with obesity and with hypertension in animal models. Whether leptin is associated with hypertension independent of obesity is unclear. Relative to White adults, Black adults have higher circulating leptin concentration. As such, leptin may mediate some of the excess burden of incident hypertension among Black adults. REGARDS enrolled 30,239 adults aged ≥45 years from 48 US states in 2003-07. Baseline leptin was measured in a sex- and race-stratified sample of 4400 participants. Modified Poisson regression estimated relative risk (RR) of incident hypertension (new ≥140/≥90 mmHg threshold or use of antihypertensives) per SD of log-transformed leptin, stratified by obesity (BMI of 30 kg/m2). Inverse odds ratio weighting estimated the % mediation by leptin of the excess hypertension RR among Black relative to White participants. Among the 1821 participants without prevalent hypertension, 35% developed incident hypertension. Obesity modified the relationship between leptin and incident hypertension (P-interaction 0.006) such that higher leptin was associated with greater hypertension risk in the crude model among those with BMI < 30 kg/m2, but not those with BMI ≥ 30 kg/m2. This was fully attenuated when adjusting for anthropometric measures. In the crude model, Black adults had a 52% greater risk of incident hypertension. Leptin did not significantly mediate this disparity. In this national U.S. sample, leptin was associated with incident hypertension among non-obese but not obese adults. Future investigations should focus on the effect of weight modification on incident hypertension among non-obese adults with elevated leptin.

Opioid prescription records in existing electronic health record (EHR) databases are a potentially useful, high-fidelity data source for opioid use-related risk phenotyping in genetic analyses. Prescriptions for codeine derived from EHR records were used as targeting traits by screening 16 million patient-level medication records. Genome-wide association analyses were then conducted to identify genomic loci and candidate genes associated with different count patterns of codeine prescriptions. Both low- and high-prescription counts were captured by developing 8 types of phenotypes with selected ranges of prescription numbers to reflect potentially different levels of opioid risk severity. We identified one significant locus associated with low-count codeine prescriptions (1, 2 or 3 prescriptions), while up to 7 loci were identified for higher counts (≥ 4, ≥ 5, ≥6, or ≥ 7 prescriptions), with a strong overlap across different thresholds. We identified 9 significant genomic loci with all-count phenotype. Further, using the polygenic risk approach, we identified a significant correlation (Tau = 0.67, p = 0.01) between an externally derived polygenic risk score for opioid use disorder and numbers of codeine prescriptions. As a proof-of-concept study, our research provides a novel and generalizable phenotyping pipeline for the genomic study of opioid-related risk traits.

Hypertension is ubiquitous among older adults and leads to major adverse cardiovascular events. Nonpharmacologic lifestyle interventions represent important preventive and adjunct strategies in the treatment of hypertension and have benefits beyond cardiovascular disease in this population characterized by a high prevalence of frailty and comorbid conditions. In this review, the authors examine nonpharmacologic interventions with the strongest evidence to prevent cardiovascular disease with an emphasis on the older adults.

PURPOSE: Exercise offers various clinical benefits to older breast cancer survivors. However, studies report that healthcare providers may not regularly discuss exercise with their patients. We evaluated clinical and sociodemographic determinants of receiving advice about exercise from healthcare providers among older breast cancer survivors (aged ≥65 years).

METHODS: We used data from the Surveillance, Epidemiology, and End Results cancer registries linked to the Medicare Health Outcomes Survey (MHOS) from 2008 to 2015. We included female breast cancer survivors, aged ≥65 years, who completed the MHOS survey ≥2 years after a breast cancer diagnosis in a modified Poisson regression to identify clinical and sociodemographic determinants of reportedly receiving advice about exercise from healthcare providers.

RESULTS: The sample included 1,836 breast cancer survivors. The median age of the sample was 76 years (range: 72-81). Overall, 10.7% of the survivors were non-Hispanic Black, 10.1% were Hispanic, and 69.3% were non-Hispanic White. Only 52.3% reported receiving advice about exercise from a healthcare provider. Higher body mass index (BMI) and comorbid medical history that included diabetes, cardiovascular, or musculoskeletal disease were each associated with a higher likelihood of receiving exercise advice. Lower education levels, lower BMI, and never having been married were each associated with a lower likelihood of receiving exercise advice.

CONCLUSIONS: Nearly half of breast cancer survivors aged ≥65 years did not report receiving exercise advice from a healthcare provider, suggesting interventions are needed to improve exercise counseling between providers and survivors, especially with women with lower educational attainment who have never been married.

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