Managing Depression among Diverse Older Adults in Primary Care: The BRIGHTEN Program

Objectives: A variety of specific cultural adaptations have been proposed for older adult and minority mental health interventions. The objective of this study was to determine whether the BRIGHTEN Program, an individually tailored, interdisciplinary “virtual” team intervention, would equally meet the needs of a highly diverse sample of older adults with depression.

Methods: Older adults who screened positive for depression were recruited from primary and specialty care settings to participate in the BRIGHTEN program. A secondary data analysis of 131 older adults (37.4% African-American, 29.0% Hispanic, 29.8% Non-Hispanic White) was conducted to explore the effects of demographic variables (race/ethnicity, income and education) on treatment outcome.

Results: Compared to baseline, participants demonstrated significant improvements on the SF-12 Mental Health Composite and depression (GDS-15) scores at 6-month follow-up. There were no differences on outcome measures based on race/ethnicity, income or education with one exception—a difference between 12th grade and graduate degree education on SF-12 Mental Health Composite scores.

Conclusions: While not explicitly tailored for specific ethnic groups, the BRIGHTEN program may be equally effective in reducing depression symptoms and improving mental health functioning in a highly socioeconomically and ethnically diverse, community-dwelling older adult population.

Clinical Implications: Implications for behavioral health integration in primary care are discussed.     

Community Program Improves Quality of Life and Self‐Management in Older Adults with Diabetes Mellitus and Comorbidity

Objectives

To compare the effect of a 6‐month community‐based intervention with that of usual care on quality of life, depressive symptoms, anxiety, self‐efficacy, self‐management, and healthcare costs in older adults with type 2 diabetes mellitus (T2DM ) and 2 or more comorbidities.

Design

Multisite, single‐blind, parallel, pragmatic, randomized controlled trial.

Setting

Four communities in Ontario, Canada.

Participants

Community‐dwelling older adults (≥65) with T2DM and 2 or more comorbidities randomized into intervention (n = 80) and control (n = 79) groups (N = 159).

Intervention

Client‐driven, customized self‐management program with up to 3 in‐home visits from a registered nurse or registered dietitian, a monthly group wellness program, monthly provider team case conferences, and care coordination and system navigation.

Measurements

Quality‐of‐life measures included the Physical Component Summary (PCS , primary outcome) and Mental Component Summary (MCS , secondary outcome) scores of the Medical Outcomes Study 12‐item Short‐Form Health Survey (SF ‐12). Other secondary outcome measures were the Generalized Anxiety Disorder Scale, Center for Epidemiologic Studies Depression Scale (CES ‐D‐10), Summary of Diabetes Self‐Care Activities (SDSCA ), Self‐Efficacy for Managing Chronic Disease, and healthcare costs.

Results

Morbidity burden was high (average of eight comorbidities). Intention‐to‐treat analyses using analysis of covariance showed a group difference favoring the intervention for the MCS (mean difference = 2.68, 95% confidence interval (CI ) = 0.28–5.09, P  = .03), SDSCA (mean difference = 3.79, 95% CI  = 1.02–6.56, P  = .01), and CES ‐D‐10 (mean difference = ?1.45, 95% CI  = ?0.13 to ?2.76, P  = .03). No group differences were seen in PCS score, anxiety, self‐efficacy, or total healthcare costs.

Conclusion

Participation in a 6‐month community‐based intervention improved quality of life and self‐management and reduced depressive symptoms in older adults with T2DM and comorbidity without increasing total healthcare costs.

     

Prevalence of Primary Hyperparathyroidism in Patients with Diabetes Mellitus

The prevalence of previous or current primary hyperparathyroidism in 704 patients (390 male) with proven diabetes mellitus was 0.99 % (7 patients, all female). One patient was known to have both disorders when the study commenced and 6 were discovered from the past history or by screening for hypercalcaemia. Diabetes was diagnosed at age 12 years or later, hyperparathyroidism from 45 years. Two patients were insulin-dependent. Diabetes preceded hyperparathyroidism in 3 patients, followed it in 2, and occurred during the same year in 2. The prevalence is significantly greater (p < 0.02 to <0.001) than that of hyperparathyroidism in general populations (0.10–0.36 %). When adjusted for the age and sex distribution of the population of the Halton Health District the expected prevalence of 0.82 % remains significantly greater, except for the general population with 0.36 % prevalence (0.1 > p > 0.05). This increased three- to fourfold prevalence of hyperparathyroidism in diabetes arises mainly from females, in whom the prevalences at age 15 years or over and at age 45 years or over are 2.23 % and 2.54 %, respectively. © 1997 by John Wiley & Sons, Ltd.     

Linking Glycemic Control and Executive Function in Rural Older Adults with Diabetes Mellitus

OBJECTIVES: To examine the association between glycemic control and the executive functioning domain of cognition and to identify risk factors for inadequate glycemic control that may explain this relationship. DESIGN: Cross‐sectional study. SETTING: In‐person interviews conducted in participants' homes. PARTICIPANTS: Ninety‐five rural older African Americans, American Indians, and whites with diabetes mellitus (DM) from three counties in south‐central North Carolina. MEASUREMENTS: Participants underwent uniform evaluations. Glycemic control was measured using a validated method, and executive function was assessed using a previously established set of measures and scoring procedure. Information pertaining to medication for treatment of DM, knowledge of DM, and DM self‐care behaviors were obtained. RESULTS: In linear regression models adjusting for sex, age, education, ethnicity, duration of DM, and depressive symptoms, executive function was significantly associated with glycemic control. A 1‐point higher executive function score was associated with a 0.47 lower glycosylated hemoglobin value (P=.01). The association between glycemic control and executive function became nonsignificant (P=.08) when controlling for several glycemic control risk factors, including use of DM medication and DM knowledge. CONCLUSION: These results suggest that poor glycemic control is associated with impairments in performance on composite measures of executive function and that modifiable risk factors for glycemic control such as use of DM medication and DM knowledge may explain this relationship.     

Management of Cardiovascular Disease Risk Factors in Older Adults with Type 2 Diabetes Mellitus: 2002–2012 Literature Review

Type 2 diabetes mellitus (DM) is one of the most common chronic conditions in older adults and is often accompanied by comorbidities and geriatric syndromes. The management of cardiovascular disease risk factors in older adults with DM is important to clinicians. The literature was reviewed from 2002 to 2012 to provide an American Geriatrics Society expert panel with an evidence base for updating and making new recommendations for improving the care of older adults with type 2 DM. This review includes only the domains of the management of blood pressure, lipid control, glycemic control, and use of aspirin. Over the last 10 years, new randomized controlled trials (RCT) designed to study different blood pressure treatment targets did not find evidence that intensive systolic blood pressure control (<130 mmHg) resulted in lower rates of myocardial infarction and mortality than less‐intensive control. There are risks of side effects with achieving systolic blood pressure of less than 120 mmHg. Lipid‐lowering statins are effective in reducing cardiovascular events in middle‐aged and older adults, but data on niacin and fibrates is limited. Trials of statins and other lipid‐lowering agents do not evaluate the cardiovascular effects on outcomes from treating lipids to different low‐density lipoprotein cholesterol targets. No RCTs of lipid‐lowering drugs enrolled significant numbers of adults aged 80 and older with or without DM. Three major RCTs that investigated intensive glycemic control did not find reductions in primary cardiovascular endpoints, and one study reported greater mortality with glycosylated hemoglobin of less than 6%. Two recently published RCTs were designed to study the cardiovascular benefits of aspirin use by individuals with DM. Neither trial found significantly fewer primary cardiovascular endpoints with aspirin than in control groups. Overall, RCTs enrolled few adults aged 80 and older or with significant comorbidities. More research is needed for clinicians to effectively customize care to older adults with DM because of heterogeneity in health status, comorbidities, duration of disease, frailty and functional status, and differences in life expectancy.     

Diabetes Management According to Health Status in Older Adults with Type 2 Diabetes Staying in Geriatric Care Facilities

Background:About 25% of adults >70 years suffer from type 2 diabetes. Due to the heterogeneity of the geriatric population, guidelines emphasize the need to individualize glycemic goals and simplify treatment strategies with the main focus of avoiding hypoglycemia. The aim of this study was to assess glycemic control in patients with type 2 diabetes in geriatric care facilities based on their individual health status.Methods:170 medical records of older adults with type 2 diabetes in geriatric care facilities were retrospectively assessed (64.7% female, age 80 ± 9 years; glycated hemoglobin 6.8% ± 3.6% [51 ± 16 mmol/mol]; body mass index 27.9 ± 5.8 kg/m²). Based on the individual health status, patients were allocated to three groups (healthy n = 27, complex n = 86, and poor n = 57).Results:The overall blood glucose (BG) value was highest in the poor health group with 188 ± 47 mg/dL (poor) vs 167 ± 42 mg/dL (complex) vs 150 ± 34 mg/dL (healthy). BG values of 1.6% (poor) vs 2.8% (complex) vs 1.5% (healthy) of patients were below 90 mg/dL. 36.8% (poor) vs 23.4% (complex) vs 18.5% (healthy) of patients received insulin as the main diabetes therapy, but of these only 14.3% (poor) vs 20% (complex) vs 40% (healthy) were treated with basal insulin.Conclusions:Overall, BG values were higher in the poor and complex health group. There were a few low BG values in all groups. Although recommended by international guidelines, basal insulin therapy with its low complexity and low hypoglycemic risk is still underused, especially in the poor health group. Therefore, simplification of diabetes therapy should be considered further.     

Failure to Intensify Antihypertensive Treatment by Primary Care Providers: A Cohort Study in Adults with Diabetes Mellitus and Hypertension

Background Although tight blood pressure control is crucial in reducing vascular complications of diabetes, primary care providers often fail to appropriately intensify antihypertensive medications. Objective To identify novel visit-based factors associated with intensification of antihypertensive medications in adults with diabetes. Design Non-concurrent prospective cohort study. Patients A total of 254 patients with type 2 diabetes and hypertension enrolled in an academically affiliated managed care program. Over a 24-month interval (1999–2001), we identified 1,374 visits at which blood pressure was suboptimally controlled (systolic BP ≥ 140 mmHg or diastolic BP ≥ 90 mmHg). Measurements and Main Results Intensification of antihypertensive medications at each visit was the primary outcome. Primary care providers intensified antihypertensive treatment in only 176 (13%) of 1,374 visits at which blood pressure was elevated. As expected, higher mean systolic and mean diastolic blood pressures were important predictors of intensification. Treatment was also more likely to be intensified at visits that were “routine” odds ratio (OR) 2.08; 95% Confidence Interval [95% CI] 1.36–3.18), or that paired patients with their usual primary care provider (OR 1.84; 95% CI 1.11–3.06). In contrast, several factors were associated with failure to intensify treatment, including capillary glucose >150 mg/dL (OR 0.54; 95% CI 0.31–0.94) and the presence of coronary heart disease (OR 0.61; 95% CI 0.38–0.95). Co-management by a cardiologist accounted partly for this failure (OR 0.65; 95% CI 0.41–1.03). Conclusions Failure to appropriately intensify antihypertensive treatment is common in diabetes care. Clinical distractions and shortcomings in continuity and coordination of care are possible targets for improvement.