• Adult Patients’ Experience Using Patient Portal: The Impact of Perceived Usability on Portal Use Behavior

      Son, Hyojin; Nahm, Eun-Shim (2020)
      Background: Patient portals (PPs) are a robust tool that can engage patients into their care. PPs can be especially helpful for older adults who have complex healthcare conditions. Usability of PPs is a major influencing factor for PP use. PP usability is more important for older adults who tend to be less familiar with technologies and may need additional support for using PPs. Currently, there has been a lack of studies that examined PP usability perceived by patients after PP implementation in healthcare settings. Objectives: The primary aim of the study was to test a modified PP Acceptance Model that explains factors affecting patients’ PP use. The secondary aim was to compare the difference in PP usability, PP self-efficacy, and PP use between older adults recruited from community settings and older adults recruited from hospital settings. Methods: To test the primary aim, an anonymous cross-sectional online survey was conducted with adult patients in an integrated healthcare system. Data from 743 patients who used PPs in the past 12 months were subject to structural equation modeling (SEM). For the secondary aim, a secondary data analysis was performed using descriptive statistics and content analysis (272 community-residing older adults). From this sample, those who used PPs (n=126) were compared with hospital/clinic-based older adults (n=174) by conducting regression analyses. Results: Among 743, about two-thirds were White and female (mean age, 53.1; range, 18-92). Mean PP usability was 36.6 (range, 6-42). The SEM revealed that the final model fit the data: CFI=.983, RMSEA=.059. PP self-efficacy and privacy/security concerns had a direct impact on PP use. PP use was indirectly influenced by PP usefulness, PP ease of use, eHealth literacy, education, and age. The secondary data analysis indicated that older adults recognized PP benefits and were willing to use PPs. However, their PP use was limited due to several challenges. The relationship between PP usability and PP use was stronger in the community sample. Conclusion: Findings suggest a strong potential for using PPs to engage patients in healthcare and strategies to improve patients’ PP use. Further studies need to include more diverse populations in various settings.
    • Creating harmony, creating happiness: Subjective well-being of older Koreans in the United States

      Park-Lee, Eunice Y.; Oktay, Julianne S. (2005)
      The present qualitative study examined life and aging experiences of elderly Korean Americans. More specifically, it explored how diverse experiences of older Koreans were used to create the meaning of "the good life" and to appraise their well-being in old age. In addition to observing elderly individuals in various social settings, a series of in-depth, face-to-face interviews were conducted with 15 theoretically sampled elderly Koreans with intact cognitive ability who resided in the Washington Metropolitan area. Guided by the grounded theory approach of Glaser and Strauss (1967) and Strauss and Corbin (1998), data were collected and analyzed concurrently throughout the course of the study. "The good life," to older Korean immigrants, implied having continuity of the self while living in harmony. Only when their relationships with others were harmonious, could older Korean immigrants truly continue being the person they had always been. Harmonious social relationships could be maintained when they had comfort in both mind and body and, subsequently, had the freedom to do what they wanted. Employing their own definition of "the good life," each of the elderly evaluated his or her life circumstances. Upon identifying discrepancies between their actual life and their ideal life, they made behavioral and cognitive efforts to reduce and/or accept them. When their attempts were successful, the elderly could preserve harmony in their relationships with others and create happiness for themselves. Such efforts were continuously required since both aging and immigration/acculturation continually brought about changes in their environment. Hardy/resilient individuals thus were more effective in sustaining their efforts in coping with the discrepancies and creating as well as maintaining a positive sense of well-being. Consistent with Korean culture, "the good life" was not seen as an outcome of an individual's hard work. Instead it was viewed as a collaborative task to which both the elderly individual and the environment contributed. This collaborative orientation towards "the good life," therefore, should be taken into consideration when developing services and policy for well-being of older Korean immigrants. Limitations of the study and the study findings are discussed in relation to existing research.
    • Depressive Symptoms, Non-Adherence to Discharge Instructions, and 30-Day Unplanned Hospital Readmission among Community-Dwelling Elders

      Albrecht, Jennifer S.; Furuno, Jon P.; Gruber-Baldini, Ann L. (2012)
      Background: Hospital readmissions are costly to the healthcare system. Understanding patient factors associated with hospital readmission will facilitate targeting of interventions designed to reduce readmissions. Depressive symptoms are associated with poor patient outcomes and may impact hospital readmission. Objective: To investigate the association between depressive symptoms and 30-day unplanned hospital readmission. Non-adherence to discharge instructions was examined as a potential mediator of this association. Methods: We conducted a prospective cohort study of hospitalized patients ages 65 and older. Depressive symptoms were measured within 72 hours of admission to the University of Maryland Medical Center and defined as a score of greater than or equal to 6 on the Geriatric Depression Scale-15. Patients were then contacted three times post-hospital discharge to ascertain incident deaths, unplanned hospital readmissions, and adherence to discharge instructions. Results: 750 patients were enrolled in the study. Depressive symptoms were not associated with 30-day unplanned hospital readmission (RR 1.20; 95% CI 0.83, 1.72). Depressive symptoms were associated with non-adherence to the medication domain of the discharge instructions (OR 1.75; 95% CI 1.02, 2.99), but not with follow-up appointments (OR 1.25; 95% CI 0.62, 2.52), lifestyle recommendations (RR 0.94; 95% CI 0.75, 1.17), or overall non-adherence to the discharge instructions (COR 1.17; 95% CI 0.78, 1.75). Non-adherence to one or more domains of the discharge instructions at 5 days (OR 1.58; 95% CI 0.94, 2.65) or 15 days (OR 1.37; 95% CI 0.68, 2.74) post-hospital discharge was not significantly associated with 30-day unplanned hospital readmission. Because a significant association between depressive symptoms and 30-day unplanned hospital readmission was not observed, mediation was not assessed. Conclusions: In this sample of hospitalized adults aged 65 and older, neither depressive symptoms nor non-adherence to discharge instructions was significantly associated with 30-day unplanned hospital readmission. Hence, targeting interventions toward patients with depressive symptoms may not result in decreased hospital readmission. While depressive symptoms were associated with non-adherence to medication, other factors may play a greater role in predicting non-adherence to the discharge instructions. Further research is needed to identify predictors of non-adherence to the discharge instructions as well as to understand perceived barriers to non- adherence.
    • Development and Usability Testing of a Mobile Health Game Application for Older Adults on Warfarin

      Opoku-Agyemang, Ernest; Johantgen, Mary E.; Nahm, Eun-Shim (2020)
      Background: Chronic disease management constitutes a special challenge in the United States due to deficiencies in the healthcare system. Chronic disease self-management (CDSM) using technology and gaming principles is a promising way to overcome these challenges. Yet, there are few disease-specific apps to benefit the populations likely to benefit from such innovations. Purpose: This proof of concept study evaluated the feasibility of a Warfarin game app for older adults. The aims were to: 1) Design and develop a mobile game app to educate patients on Warfarin; and 2) Conduct usability testing of the game app among patients on Warfarin receiving care at an anticoagulation clinic. Methods: Following the design and development of a Warfarin app called Coumadin Hero, the usability testing of the app was conducted with 25 participants. Heuristics and user testing were conducted. The Technology Acceptance Model (TAM) was the theory that informed the study design and implementation. An adaptation of the Perceived Health Web Site Usability Questionnaire (PHWSUQ) was used to assess the participant usability. Descriptive and correlational statistics were used to analyze game play data and responses to survey questionnaires. Results: The median percent correct of Vitamin K food identification was 79%. Generally, participants had higher knowledge of Vitamin K levels in green vegetables (92% - 96%). User technology experience and demographic characteristics were not associated with Vitamin K food knowledge or level of satisfaction. The overwhelming majority of users found the app easy to learn and use. The ease of reading and finding information were 68 – 72%, respectively. Conclusion: Because self-management is vital for people taking Warfarin, using a game app as a supplement to traditional teaching could have significant positive impact on their health. As apps are increasingly easy to develop and smartphone use increases, apps should be developed to help people manage chronic diseases. Findings from this study support people’s interest and ability to use apps.
    • The effect of age on the outcomes of combination antiretrovrial treatment in resource limited settings

      Stafford, Kristen Alyce; Baumgarten, Mona (2015)
      Background: HIV is one of the most closely monitored epidemics in the world. Despite this, little attention has been placed on older adults living with HIV, especially in resource limited settings. Objectives: The objectives of this research were to estimate 1) the association between age at combination antiretroviral therapy (cART) initiation and mean CD4 cell count over time by strata of baseline CD4 cell count as well variability of immune reconstitution, and 2) whether older age is associated with more rapid regimen change due to cART associated toxicities and side-effects. Methods: We conducted a retrospective cohort study of adults who initiated cART between August 1, 2004 and September 1, 2012 in 157 PEPFAR funded clinics supported by AIDSRelief in four countries in sub-Saharan Africa. Results: Of the 452,819 patients enrolled, 181,354 met the study eligibility criteria. Patients age 40 and older had significantly lower mean CD4 cell counts and less variability as compared to patients aged 20 - 39 with each strata of baseline CD4 cell count up to five years after cART initiation. The differences in mean CD4 cell count were more pronounced in the higher strata of baseline CD4 cell count than in lower strata. Older patients progressed to regimen change due to toxicity or side-effect more rapidly than younger patients within regimens containing D4T and AZT. There was no difference in the hazard of regimen change within TDF containing regimens comparing older to younger patients. Conclusions: While we found statistically significant differences at most time points following the initiation of cART for all strata, it was only in the highest strata of baseline CD4 cell count (> 350 cells/mm3) that the difference between age groups was what we, a priori, defined as an important difference of 50 cells. Older groups may demonstrate less variability in CD4 cell reconstitution than younger groups. The faster progression to regimen change among older adults on D4T and AZT warrants a discussion on closer monitoring of older patients for toxicity and side-effects earlier after the initiation of cART.
    • The Effect of Resources on Caregiving Experiences in the U.S. Population and among Korean American Caregivers

      Hong, Michin; Harrington, Donna (2011)
      Informal caregivers play a major role in providing long-term care (LTC) for older adults. Given the demands of caregiving, caregivers experience various negative caregiving outcomes and eventually worse health. Despite extensive research, prior research reveals limited knowledge about caregiver health because of a lack of attention toward the role of resources, inconsistent findings, and a dearth of ethnic specific detailed knowledge. Thus, this study aims to examine a health model with two different samples drawn from (1) the 2004 National Long-term Caregiver Survey (NLTCS) and (2) a Korean American (KA) caregiver survey. The health model is built upon the Conservation of Resource (COR) Theory and consists of various sets of variables. Structural equation modeling was used to test the health model in each sample. The measurement models and the initial structural models produced poor model fit; however, after modifications were made the final structural models fit well in each data set. In the NLTCS model, more difficult caregiving condition (i.e., caring for older adults with more health problems and longer caregiving time) was related to having fewer resources (i.e., less feeling of mastery, fewer financial resources, less social support, and less family harmony) and negative primary outcomes (i.e., more stress and burden). Moreover, more resources were related to better primary outcomes and better physical health of caregivers. On the other hand, caregiving condition was not associated with resources in the KA model. However, other paths from caregiving condition to primary outcomes, and from resources (i.e., higher self-efficacy, more financial resources, greater social network, greater family harmony, and higher English proficiency) to primary outcomes and to health were also found in the KA models. The findings indicate that resources are related to primary outcomes as well as the final health outcomes across ethnicities, and the importance of resources may be particularly high among the KA population. This study suggests that caregiver support policies and culturally competent programs be expanded. Further studies using longitudinal data and different indicators of the constructs of interest are needed. Finally, some modifications are suggested for better application of the COR theory to caregiving condition.
    • The Effect of Three-year Weight History on Quantitative Ultrasound Parameters in Older Mainland Chinese Women and Men

      Sanchez, Ana Maria; Magaziner, Jay (2015)
      Title: The Effect of Three-year Weight History on Quantitative Ultrasound Parameters in Older Mainland Chinese Women and Men Background: Finding risk factors for poor bone quality that are relevant to China is useful for targeting higher-risk women for bone quantitative ultrasound (QUS) testing. Weight history has typically been measured as the difference in weight between two time points. Incorporating an additional indicator of weight variability over this time period may enhance this measure. Objective: To examine the relationship between bone QUS and weight history (including weight variability) in pre and postmenopausal women, women transitioning into menopause (TIM) and men over 65 years of age. Methods: This was a retrospective, clinic-based study of 1201 postmenopausal, 862 pre-menopausal and 419 TIM women, and 424 older men in Guangdong Province, China. Weight was measured yearly over a three year period. Weight history over 3 years was defined as (1) weight trend (the slope of weight on year) and weight variability (the root mean square error (RMSE) around the slope of weight on year) (2) weight trajectories (3-year trajectories estimated by growth mixture modeling), and (3) weight change (the percent change in weight from baseline). Stiffness index (SI) of the os calcaneus [assessed using a Lunar Achilles Insight QUS device (GE Medical Systems Inc., USA)], age, height and weight were measured once at the end of year 3. Z-scores were used to compare regression lines for predicting SI from the weight history variables among study groups. Results: Weight variability (weight-RMSE) was significantly and negatively associated with SI, independent of weight, weight trend, age and height (β = -1.32; P< 0.03) among postmenopausal women. No other associations between weight history and SI were detected. Slopes for the association between SI and weight-RMSE were not significantly different between postmenopausal women and the other study groups. Conclusions: This study provides evidence that measuring weight variability, in addition to weight change, may provide a more complete assessment of the influence of weight history on bone. Further work is needed to investigate methods of quantifying weight variability that could be used in a clinical setting.
    • Evaluating the Relationship between Muscle and Bone Modeling Response in Older Adults

      Reider, Lisa; Magaziner, Jay (2014)
      Background: Bone modeling, the process that continually adjusts bone strength in response to prevalent muscle-loading forces throughout an individual's lifespan, may play an important role in bone fragility with age. Femoral stress, an index of bone modeling response can be estimated using measurements of DXA derived bone geometry and loading information incorporated into an engineering model. Assuming that individuals have adapted to habitual muscle loading forces, greater stresses indicate a diminished response and a weaker bone Aims/Methods: The aims of this dissertation were to 1) evaluate the association of femoral stress with measures of lean mass and muscle strength among healthy older adults participating in the Health ABC study using linear regression; 2) determine whether femoral stress predicts incident fracture among the same cohort of older adults using cox proportional hazards models; and 3) evaluate the association of femoral stress with measures of lean mass and muscle strength in women after hip fracture participating in the 3rd and 4th cohort of the Baltimore Hip Studies using linear regression and to determine whether femoral stress changes the year following fracture using longitudinal data analysis. Results: Lean mass explained more of the variation in femoral stress than measures of muscle strength among healthy older men and women as well as in women with hip fracture. Remaining variability in femoral stress may reflect individual variation in modeling response. After adjusting for measures of lean mass and strength, women in the highest tertile of femoral stress had 77% higher hazard of fracture and men in the highest tertile of femoral stress had 84% higher hazard of fracture relative to women and men in the lowest tertile, respectively. This suggests that deficiencies in bone modeling response may be an important predictor of fracture. Femoral stress did not appear to change the year following fracture in older women. Conclusion: Future studies should focus on refining measures of bone modeling response by incorporating better measures of muscle force. While femoral stress does not have clinical applications per se, it allows us to investigate a potentially important mechanism underlying bone fragility and provides a framework for thinking about treatments that could improve the interaction between muscle and bone.
    • Examination of Social Exclusion as a Construct and Its Impact on Mortality and Survival Time among Older Adults

      Lee, Joonyup; Cagle, John G.; DeForge, Bruce R. (2020)
      Although social exclusion may be an important predictor of mortality, there is a lack of empirical evidence on the impact of social exclusion on mortality/survival time among older adults in the U.S. The study reported in this dissertation examined the effects of social exclusion on mortality and survival time using a nationally representative sample of adults over 50 years of age. The primary goal was to better understand how social exclusion affects mortality and survival time among older adults. Data were drawn from the 2010 and 2014 Health and Retirement Study (core wave, exit wave, and psychosocial supplement) and focused on older adults aged 65 years or older (8,439 participants). Social exclusion indicators were based on previous conceptual and empirical frameworks, and a total of 21 possible indicators were measured. On the basis of correlation analyses, three indicators were excluded due to very low correlation coefficients or statistical nonsignificance. The remaining indicators nested in four social exclusion domains (material resources, social, health, and community). Average inter-item correlations supported the reliability of the remaining 18 indicators, and multiple regression models supported the validity of the four domains. The results of a Cox regression model revealed that the material resources domain had a higher influence on mortality than did the other three domains. Six individual indicators (wealth, car availability, social activity, social membership, self-rated health, and disability) were associated with mortality, adjusting for demographic variables. Kaplan–Meier survival analyses based on each indicator showed that all social exclusion indicators were significantly associated with survival rate with the exception of social support, city/town satisfaction, and neighborhood safety. The findings from this dissertation indicate that social exclusion affected mortality and survival time among older adults in the U.S. However, not all indicators were associated with mortality and survival time. The results of the dissertation imply that policies can be modified to improve social participation and access to transportation and that multidimensional services or interventions focusing on the more influential social exclusion indicators are needed (e.g., connecting resources, facilitating social connections). Further, there is a need to reconcile the differences between conceptual and empirical domains/indicators.
    • Exploration of Coping Strategies in Older, Community Dwelling, HIV Positive Individuals in Baltimore

      DeGrezia, Mary G.; Kauffman, Karen (2012)
      Background: The CDC reports that by 2015 50% of HIV-positive individuals in the U.S. will be at least 50 years old. Individuals with HIV develop more comorbid health conditions at an earlier age than those without HIV. Older adults with HIV are a sizeable, growing population. However, published qualitative data on how older adults cope with HIV, comorbid conditions, and related stressors are extremely limited. Objectives: The purpose of this exploratory study was to identify comorbid conditions and other related stressors experienced by HIV-positive community-dwelling older adults in Baltimore and to understand how they cope. Methods: Forty HIV-positive individuals aged 50 and older (range 50-69 years; male, N=17, mean age 55; female, N=23, mean age 56) affiliated with at least one of two Baltimore-based HIV support groups with older adult members were recruited via purposeful sampling and interviewed to the point of data saturation. Data were analyzed using an interpretive hermeneutic methodology and qualitative content analysis. Results: Participants experienced one or more comorbid condition (range 1-18; male mean = 7; female mean = 6). The most frequently reported comorbid conditions for both genders were hypertension 48%, depression 43%, hypercholesterolemia 38%, memory difficulties 35%, Hepatitis C 34%, and anxiety 33%. Related stressors included HIV-related fear, perceived and actual stigma, multiple medications to treat comorbid conditions, and financial concerns. Participants learned to cope with stressors by accessing support, helping selves and helping others, and tapping into one's own spirituality. Employing these strategies helped participants cope, develop hope, and work toward psychological well-being. Conclusions: Participants employed active and meaning-based coping strategies to engage in life despite HIV, comorbid conditions, and related stressors. Findings are significant because this study is among the first to give voice to older HIV-positive community dwelling individuals in Baltimore about how they cope with HIV, comorbidities, and related stressors. Nurses' increased understanding of the impact of HIV, comorbidities, and related stressors in HIV-positive older adults along with knowledge of their active and meaning-based coping strategies can lead to holistic patient care with interventions encouraging hope and psychological well-being.
    • Factors Associated with Length of Stay and Discharge Disposition in Older Trauma Patients

      Brotemarkle, Rebecca Ann; Resnick, Barbara (2013)
      Factors Associated with Length of Stay and Discharge Disposition in Older Trauma Patients Abstract Background: Trauma patients over the age of 65 are living longer and staying active at older ages. Older trauma patients tend to have longer lengths of stay (LOS) and to be discharged more often to rehabilitation and skilled nursing facilities. Understanding the factors that influence LOS and discharge disposition is needed to guide interventions focused on decreasing LOS and assuring that patients are discharged to the least restrictive setting. Purpose: The purpose of this study was to explore the impact of patient and system related factors on LOS and discharge disposition for older adults hospitalized for traumatic injury. Methods: This was a secondary data analysis using descriptive data from rehabilitation notes during inpatient encounters. Data analysis was done using structural equation modeling and logistic regression. Results: 132 patients were randomly selected from 1387 patients admitted to a level 1 trauma center. The majority were Caucasian (83.9%, n = 111), 46.9% (n = 62) were males with an average age of 78.3 (S.D. = 9.7) years. On average participants had 2.29 (S.D. = 1.96) comorbidities and approximately two thirds (65.9%, n = 87) were rated as having severe injuries. The average length of stay was 4.3 (S.D. = 4.0) days with 57.6% (n = 76) of patients discharged to a facility. The model had a fair fit to the data and demonstrated that younger patients who had more comorbidities, were likely to have more pain. Older patients with more comorbidities, higher injury severity, more days from admission to evaluation, and lower pain were more likely to have a longer LOS which explained 37% of the variance in LOS. Based on logistic regression analysis, having longer LOS (O.R. = .049, 95% CI .008 - .301, p=.001) and more pain (O.R. = .531, 95% CI .310 - .908, p=.021) were associated with decreased likelihood of returning home versus being discharged to a facility. Conclusion: Increased focus on pain and pain management, consideration of comorbidities, and decreasing time from admission to initial evaluation by rehabilitation therapists among older trauma patients may help to decrease LOS and facilitate discharge to the least restrictive setting.
    • Interactions between older persons with cognitive impairment and staff in an adult day care setting

      Berry, Marijean; Oktay, Julianne S. (2003)
      As society ages, an increasing number of elderly people suffering from dementia of various etiologies, especially Alzheimer's Disease, will require professional care. Understanding the nature of interactions between caregivers and people with dementia can help social workers, and other health professionals, to improve the services they provide to their elderly clients. This qualitative study explored the experience of seven cognitively-impaired participants as they interacted with five staff members in an adult day care setting. The researcher employed participant observation and interviewing as primary methods of data collection. Prolonged engagement over sixteen months, peer debriefing, triangulation, member checking, negative case analysis, and auditing enhanced the validity of the study. Derived from symbolic interactionism, concepts of self and society, along with dramaturgical notions of roles, stage, and script, supplied a framework to organize information. Grounded theory, thick description, and narrative interpretation were used to analyze the data. Based on analysis, interactions, including verbal and nonverbal gestures, routines, and structured activities, were divided into six major analytic categories. Nurturance describes the staff's efforts to care for clients. Management encompasses the staff's maintaining order and ensuring the safety of clients. Dignity concerns staff's balancing the amount of assistance offered to clients with respect for their autonomy. Social Grace corresponds to clients' early socialization patterns. Emotional Connectedness applies to the emotional communication between clients and staff. The Continuing Self refers to the continuity of clients' selves from the past to the present. These categories were further separated into two broader themes: actions taken by staff, and the internal processes of clients. Specifically, Nurturance, Management, and Dignity describe staff-initiated interactions by which staff cares for, stimulates, and respects clients. Social Grace, Emotional Connectedness, and Continuing Self relate to clients' inner dynamics as affected by client-staff interactions. These social interactions are hypothesized to kindle clients' ingrained patterns of socialization and recall early emotional bonds, linking who clients are now with who they were. Consideration was given to the limitations of this small study about people with dementia, and to its implications for more research, for theory development, and for practice issues involving social work and other health care professions.
    • Management of Traumatic Brain Injury with Statins among Older Medicare Beneficiaries

      Khokhar, Bilal; Simoni-Wastila, Linda; 0000-0003-0143-1390 (2016)
      Background: Traumatic brain injury (TBI) is a major health concern for older adults aged 65 and older. Older TBI patients are at increased risk of primary injury (in-hospital and all-cause mortality) and secondary injury (stroke, depression, and Alzheimer's disease and related dementias (ADRD)). There is limited research regarding optimal pharmacotherapeutic options and management of TBI patients; however, several studies have highlighted statins, used to treat hyperlipidemia, as potential pharmacologic agents to reduce inflammation and improve impaired cerebral blood flow associated with primary and secondary injury. The objectives of the study are to: 1) quantify statin utilization, and 2) determine the associations between statin use and primary and secondary injury among TBI patients. Methods: Statin use (atorvastatin, fluvastatin, lovastatin, pravastatin, rosuvastatin, and simvastatin), primary injury, and secondary injury were examined among Medicare beneficiaries hospitalized with a TBI between 2006 and 2010. Logistic regression was used to investigate the relationship between pre-TBI statin use and in-hospital mortality, while discrete time analysis was used to investigate the relationship between statin use following TBI and all-cause mortality and secondary injury. Results: Among the 75,698 beneficiaries who met study criteria, 37,874 (50.0%) beneficiaries used a statin at least once during the study period. The most common statin used was simvastatin, followed by atorvastatin. Fluvastatin was the least used statin. Pre-TBI use of atorvastatin (odds ratio (OR) 0.88; 95% confidence interval (CI) 0.82, 0.96), simvastatin (OR 0.84; 95% CI 0.79, 0.91), and rosuvastatin (OR 0.79; 95% CI 0.67, 0.94) were associated with significant decreases in the risk of in-hospital mortality. Any statin use was associated with reduced all-cause mortality following TBI-hospitalization discharge. Atorvastatin and simvastatin use also were associated with reductions in all secondary injury outcomes. Conclusion: Tens of thousands of older adults are hospitalized annually with TBI and experience disabling primary and secondary injury; findings from these analyses have salient implications for reducing the risk of TBI complications among older adults. The evidence generated suggests that preemptive use of statins may decrease the risk of in-hospital and all-cause mortality, as well as reduce the likelihood of stroke, depression, and ADRD.
    • Neurological and Psychological Sequelae and Healthcare Utilization Patterns of Older US Adults with Repetitive Traumatic Brain Injury

      Chauhan, Aparna V.; Albrecht, Jennifer S; 0000-0001-5685-7167 (2020)
      Background: Traumatic brain injury (TBI) is a leading cause of injury-related death and disability among older adults. Older adults experience adverse health outcomes and increased healthcare utilization following TBI. Additionally, they are at risk of repetitive TBI, which may compound health problems and increase resource utilization further. However, little is known about repetitive TBI among older adults. Objective: To identify incidence, predictors, and outcomes of repetitive TBI. Specifically, I investigated the association between repetitive TBI and depression, ischemic stroke, Alzheimer’s disease and related dementias (ADRD), and insomnia. In addition, I assessed healthcare utilization following repetitive TBI in inpatient, outpatient, and emergency department settings. Methods: I conducted a retrospective cohort study of a 5% sample of US Medicare beneficiaries greater than or equal to 65 years of age. I estimated incidence of and identified risk factors for repetitive TBI using a log-binomial model. Repetitive TBI was identified as another diagnostic code for TBI occurring >90 days after the index TBI. Associations between repetitive TBI and selected outcomes were assessed using a discrete time model with a complementary log-log link. Negative binomial models were used to assess healthcare utilization associated with repetitive TBI. Results: Among 38,064 beneficiaries in the sample, annual incidence of repetitive TBI was 3%. Age, epilepsy, Parkinson’s disease, ADRD, depression, and atrial fibrillation were associated with increased risk of repetitive TBI. Incidence of depression and ADRD was elevated following single TBI, and was even more elevated following repetitive TBI. Healthcare utilization was significantly higher in those with repetitive TBI, beyond single TBI, across all points of service. Conclusions: In this sample of older adult Medicare beneficiaries, I found 3% annual incidence of repetitive TBI and identified factors associated with repetitive TBI. Additionally, I found that repetitive TBI was associated with increased risk of depression and ADRD and increased healthcare utilization that was even greater than the risk observed with single TBI. Targeting interventions to reduce the occurrence of repetitive TBI in older adults could reduce risk of these adverse health outcomes and inform healthcare utilization.
    • Outcomes of Older Adults Admitted to a Level I Trauma Center

      Tang, Ying; Smith, Gordon S., M.B., Ch.B., M.P.H. (2013)
      Background: The outcomes of injury and the associated risk factors among older adults are poorly understood. Objective: To examine the associations of pre-existing medical conditions (PMCs) and mechanism of injury (MOI) with the outcomes and to estimate the impact of injury upon long-term mortality of older adults. Methods: Injured older adults admitted to the Shock Trauma Center, University of Maryland Medical Center, between July 1, 1995 and November 30, 2008 were followed until the end of 2008. Logistic regression and Cox proportional hazard models were fit to analyze the outcomes. Standardized mortality ratios (SMRs) and relative survival ratios (RSRs), comparing the observed to the expected proportion of Maryland older adult population were calculated. Results: Among 6,162 injured older adults, 27% developed in-hospital complications, 15% (N=918) died within 30 days of admission, and 43% (N=2,323) of those who were discharged died during the follow-up. Hypertension, prior myocardial infarction, congestive heart failure, and chronic obstructive pulmonary disease (COPD) were associated with increased odds of in-hospital complications, with adjusted ORs ranging from 1.2 (95% confidence interval (CI): 1.1-1.5) to 2.2 (95% CI: 1.6-3.0). Hypertension was associated with lower odds (OR=0.7, 95% CI: 0.6-0.8) while COPD with increased odds of 30-day mortality (OR=1.5, 95% CI: 1.1-2.1). All PMCs, except hypertension, were associated with increased hazard of death after discharge (adjusted hazard ratios range: 1.1-1.7). MVC injuries were associated with higher odds of complications than fall injuries (adjusted ORs range: 1.3-2.2). Older adults with MVC injuries had lower odds of 30-day mortality (OR=0.8, 95% CI: 0.6-0.9) and a lower hazard of death after discharge (HR=0.6, 95% CI: 0.6-0.7). SMR was 4.5 (95% CI: 4.1-4.8) at 6 months and 1.4 (95% CI: 1.2-1.5) between 5-10 years after discharge. The RSR was 91.0% (95% CI: 90.1%-91.9%) at 6 months and 72.6% (95% CI: 69.3%-75.8%) at 10 years after discharge. Conclusions: The associations between PMCs and outcomes are disease-specific. Older adults sustaining MVC injuries have a better survival compared to those sustaining fall injuries. The impact of injury on mortality is most evident during the first 6 months after discharge and can last as long as 10 years.
    • Prescription Opioids and Traumatic Brain Injury in Older Adults

      Herrera, Anthony; Albrecht, Jennifer S.; 0000-0001-5345-1241 (2021)
      Older adults using opioids in the US increased annually from 1999 to 2011. This is a significant public health concern because prescription opioid use increases fall-risk, the most common cause of traumatic brain injury (TBI) among older adults and a leading cause of disability and mortality. No studies have investigated the association between prescription opioid use and TBI. This dissertation characterized prescription opioid use in Medicare beneficiaries aged ≥65 years and examined the relationship between opioid use and incident TBI. Using Medicare administrative claims data from 2010 – 2015, I assessed how older adult prescription opioid use has changed over time, as well as changes in opioid prescriber specialties and pre-opioid diagnoses/ procedures. I also used these data to estimate risk for TBI associated with prescription opioid use. Next, I used R Adams Cowley Shock Trauma Center Registry (STR) data from 2015 – 2019 to explore the relationship between prescription opioid use and TBI injury mechanisms and severity. I found that the percent of older adults using prescription opioids decreased from 35.4% to 32.9% (p<0.001). Primary care physicians prescribed the most opioids, but their share of prescriptions dropped from 59.0% to 52.8% (p<0.001). Back pain remained the most common diagnosis among older adult opioid users, unchanged over time (24.1% to 25.3%, p=0.594). Opioid use increased TBI risk (odd ratio: 1.34, 95% confidence interval: 1.28 - 1.40) among older adults, regardless of opioid dosage and duration differences. Compared to non-users in the STR data, older adult opioid users who sustained TBI were 85% more likely to be injured in a fall compared to a motor vehicle incident (OR 1.85, 95% CI 1.20 – 2.86). Opioid use was associated with a 39% increase in sustaining more severe TBIs. (OR 1.39, 95% CI 1.09 – 1.79). This dissertation found opioid prescriptions decreasing among older adults. This parallels reductions in primary care opioid prescribing as well as changes in opioid-related diagnoses and procedures. These are the first studies to provide evidence that prescription opioids raise TBI risk and severity in older adults. Future studies could refine the association between opioid and TBI using data with definite dosing details
    • The relationship between stress appraisal, coping behavior, and subjective well-being in Chinese elderly with a diagnosis of congestive heart failure

      Lee, Wen-Lin; Spellbring, Ann Marie (1999)
      The purpose of this study was to examine the relationships between stress appraisal, coping behavior, and subjective well-being. The theoretical framework for the investigation was based on a process theory of stress and coping developed by Lazarus and Folkman (1984). A descriptive correlational research design was used to examine the relationships among the variables. Convenience sampling was used to select the subjects from three hospitals in Northern Taiwan. A convenience sample of 133 Chinese elderly aged 60 and over had a diagnosis of Congestive Heart Failure. Subjects were interviewed with structured questionnaires. Stress appraisal was measured by the Appraisal Scale. Coping was measured by the revised Ways of Coping Checklist. Subjective well-being was measured by the Philadelphia Geriatric Center Morale Scale. Descriptive statistics were reported for several demographic variables. Several multiple regressions were performed to determine the significance of the independent variables. Those Chinese elderly patients who perceived Congestive Heart Failure as a challenge, used more problem-focused coping and less emotional-focused coping. When Congestive Heart Failure is viewed as a threat or harm, they used more emotional-focused coping. There were no significant relationships between benefit appraisal and coping behaviors. The seven significant predictors of subjective well-being were identified as higher income, less threat and harm appraisals, less avoidance coping behavior, and higher health perception. Demographics (age, gender, education and income), severity of illness, and comorbidity variables together explained a significant amount of the variance (11%) in subjective well-being, but only income was an individually significant predictor. Stress appraisal, coping behaviors, physical functioning, and health perception contributed an additional statistically significant amount variance (46%) of subjective well-being after controlling for demographic variables, severity of illness, and comorbidity. Additional findings indicated that men had significantly higher physical functioning and subjective well-being than women. In addition, men used more problem-focused coping. Findings provide more information for health care providers to recognize the variables that influence subjective well-being, identify patients at greater risk for lower subjective well-being, and assist patients to achieve the highest subjective well-being possible within the constraints of their heart disease.
    • Sarcopenia and PRAISEDD-2 Intervention's Impact on Diet, Physical Activity, and Body Composition

      Hammersla, Margaret; Resnick, Barbara (2017)
      Background: Older adults with a low socioeconomic status and African Americans are more sedentary than the general population. This contributes to the development of sarcopenia and has a negative impact on the health and function of these individuals. PRAISEDD-2 was a 24-month quasi-experimetnal study of low income adults living in senior housing. A focused 3-month intervention included education about stroke prevention and heart health through adherence to heart healthy diets, regular exercise, and prescribed medication combined with exercise classes that included verbal encouragement, blood pressure feedback, and role modeling. Classes continued to be offered in months 4-24 but only included a monthly motivational intervention. The impact of the PRAISEDD-2 intervention on diet (fat, sodium, and protein intake), time spent in physical activity, and body composition are examined in the study reported here. Design: Diet and body composition measures were collected at baseline, 3, 6, 12, and 24 months. Sample included 29 residents of a low-income senior housing complex in Baltimore, MD. Complete data was obtain from 13 participants. Generalized estimating equations (GEE) were used to examine change over the time periods. An intention-to-treat (ITT) paradigm was followed. Results: At 3 months, participants experienced a decrease in sodium (p<0.01) and fat intake (p<0.01), as well as in a decrease in percent body fat (p<.001). However, at 24 months, fat intake (p<0.001) and percent body fat (p<0.001) increased, although protein intake increased (p<.001). No significant change was noted in physical activity (p=.056) or sodium intake (p=0.69) at 24 months. Conclusions: The findings from this study provided some support for the feasibility and preliminary efficacy of the PRAISEDD-2 intervention. The changes that occurred in the early 3 month period were likely due to the intensive nature of the education and exercise classes. Future research should focus on building a stronger self-efficacy based motivational component into the exercise classes to strengthen long term adherence to the recommended dietary change and physical activity, essential to promote decrease in body fat and increases in muscle mass. Interventions may need to be sustained longer to achieve more permanent changes in diet and exercise.
    • Staff-resident Interactions in Assisted Living: Optimizing the Quality of Daily Care Interactions

      Paudel, Anju; Galik, Elizabeth; Resnick, Barbara; 0000-0002-1784-5427 (2021)
      Background: A considerable amount of research has focused on understanding and improving staff-resident interactions in long-term care. Much of this work has focused on social communications between staff and residents in nursing home settings. Attention to care interactions in assisted living (AL) is lacking. Purpose: The purpose of this dissertation was to: (1) describe the staff-resident interactions in AL; (2) explore the resident and facility factors associated with the care interactions in AL; and (3) test the feasibility and preliminary efficacy of the Promoting Positive Care Interactions (PPCI)—a four-step intervention designed to establish positive care interactions between the staff and residents with cognitive impairment or dementia in AL. Methods: Utilizing baseline data in a randomized trial that included 379 residents from 59 AL facilities, aim 1 used descriptive statistics to describe the quality of staff-resident interactions in AL and aim 2 used stepwise regression to examine factors influencing interactions. Aim 3 involved pilot-testing of PPCI intervention in one AL community in Maryland using a single group pretest-posttest design. Feasibility was demonstrated with the evidence of delivery, receipt, and enactment of PPCI. Preliminary efficacy was evaluated with repeated measures ANOVA for staff outcomes and descriptive change in summary scores for facility outcomes. Results: Although majority of the interactions observed were positive, almost 25% were negative and neutral suggesting a need to improve the interactions in ALs. Factors influencing interactions included resident agitation and facility ownership which accounted for 8.2% of variance. Additionally, PPCI was implemented as intended with 100% staff exposure to education and considerable staff engagement in mentoring sessions. While there was an improvement in AL environment and policy, no significant changes were observed in staff outcomes post PPCI. Conclusions: Understanding the quality of staff-resident interactions in AL and the factors that influenced these interactions guided the development of PPCI. Pilot testing supported the feasibility and preliminary staff adoption of PPCI in ALs. PPCI will be further tested with a randomized trial, and a hybrid model with both online education and in-person mentoring and coaching of staff to improve staff knowledge and behavior related to care interactions.