Care of Older Adults: Role of Primary Care Physicians in the Treatment of Cataracts and Macular Degeneration

This article aims to facilitate optimal management of cataracts and age‐related macular degeneration (AMD) by providing information on indications, risk factors, referral guidelines, and treatments and to describe techniques to maximize quality of life (QOL) for people with irreversible vision loss. A review of PubMed and other online databases was performed for peer‐reviewed English‐language articles from 1980 through August 2012 on visual impairment in elderly adults. Search terms included vision loss, visual impairment, blind, low vision, QOL combined with age‐related, elderly, and aging. Articles were selected that discussed vision loss in elderly adults, effects of vision impairment on QOL, and care strategies to manage vision loss in older adults. The ability of primary care physicians (PCPs) to identify early signs of cataracts and AMD in individuals at risk of vision loss is critical to early diagnosis and management of these common age‐related eye diseases. PCPs can help preserve vision by issuing aptly timed referrals and encouraging behavioral modifications that reduce risk factors. With knowledge of referral guidelines for soliciting low‐vision rehabilitation services, visual aids, and community support resources, PCPs can considerably increase the QOL of individuals with uncorrectable vision loss. By offering appropriately timed referrals, promoting behavioral modifications, and allocating low‐vision care resources, PCPs may play a critical role in preserving visual health and enhancing the QOL for the elderly population.     

Alcohol Counseling Reflects Higher Quality of Primary Care

Background  Some primary care physicians do not conduct alcohol screening because they assume their patients do not want to discuss alcohol use. Objectives  To assess whether (1) alcohol counseling can improve patient-perceived quality of primary care, and (2) higher quality of primary care is associated with subsequent decreased alcohol consumption. Design  A prospective cohort study. Subjects  Two hundred eighty-eight patients in an academic primary care practice who had unhealthy alcohol use. Measurements  The primary outcome was quality of care received [measured with the communication, whole-person knowledge, and trust scales of the Primary Care Assessment Survey (PCAS)]. The secondary outcome was drinking risky amounts in the past 30 days (measured with the Timeline Followback method). Results  Alcohol counseling was significantly associated with higher quality of primary care in the areas of communication (adjusted mean PCAS scale scores: 85 vs. 76) and whole-person knowledge (67 vs. 59). The quality of primary care was not associated with drinking risky amounts 6 months later. Conclusions  Although quality of primary care may not necessarily affect drinking, brief counseling for unhealthy alcohol use may enhance the quality of primary care. Results of this study were presented at the following meetings: the annual national meeting of the Society of General Internal Medicine, Chicago, May 2004 and the annual national meeting of the Research Society on Alcoholism, Vancouver, Canada, June 2004. This study was funded by a grant from the Robert Wood Johnson Foundation (grant 031489). Dr. Samet received support from the National Institute on Alcohol Abuse and Alcoholism (K24-AA015674).     

Primary Care Validation of a Single-Question Alcohol Screening Test

BACKGROUND

Unhealthy alcohol use is prevalent but under-diagnosed in primary care settings.

OBJECTIVE

To validate, in primary care, a single-item screening test for unhealthy alcohol use recommended by the National Institute on Alcohol Abuse and Alcoholism (NIAAA).

DESIGN

Cross-sectional study.

PARTICIPANTS

Adult English-speaking patients recruited from primary care waiting rooms.

MEASUREMENTS

Participants were asked the single screening question, “How many times in the past year have you had X or more drinks in a day?”, where X is 5 for men and 4 for women, and a response of >1 is considered positive. Unhealthy alcohol use was defined as the presence of an alcohol use disorder, as determined by a standardized diagnostic interview, or risky consumption, as determined using a validated 30-day calendar method.

MAIN RESULTS

Of 394 eligible primary care patients, 286 (73%) completed the interview. The single-question screen was 81.8% sensitive (95% confidence interval (CI) 72.5% to 88.5%) and 79.3% specific (95% CI 73.1% to 84.4%) for the detection of unhealthy alcohol use. It was slightly more sensitive (87.9%, 95% CI 72.7% to 95.2%) but was less specific (66.8%, 95% CI 60.8% to 72.3%) for the detection of a current alcohol use disorder. Test characteristics were similar to that of a commonly used three-item screen, and were affected very little by subject demographic characteristics.

CONCLUSIONS

The single screening question recommended by the NIAAA accurately identified unhealthy alcohol use in this sample of primary care patients. These findings support the use of this brief screen in primary care.

     

Decreasing Prevalence of Alcohol Consumption Among Greek Adolescents

Aim of this study: To obtain data on alcohol consumption among school children of secondary education and to investigate any correlation to their health behaviors and parental socioeconomic status. Methods: A questionnaire was distributed to students from a representative sample of 15 schools from Thessaloniki, the second (after Athens) largest metropolitan city of Greece. A total of 1185 students (505 males, 680 females) participated. Results: 286 males (56.6%) and 329 females (48.4%) reported consuming alcohol. The initiation of drinking was at the age of 13.2 years for boys and 13 years for girls. Alcohol drinking was positively associated with socio-demographic variables and negative health behaviors such as parental low level of education, lack of physical exercise, coffee consumption, and smoking. Conclusions: Although our results show a decrease in alcohol use, which is more pronounced in male students, the prevalence of frequent alcohol consumption is among the highest in Europe's countries.     

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.     

Primary Care Psychology: An Opportunity for Closing the Gap in Mental Health Services for Older Adults

Older adults, particularly in minority and lower income communities, continue to receive less mental health care relative to the general population. Concurrently, there has been increasing emphasis on the need to integrate mental health services into primary care settings. This push toward integration presents a unique opportunity to help close the gap in mental health services to underserved populations, including older adults. We discuss factors that have influenced this trend and specifically address the role of primary care–based psychologists in treating psychological disorders in older adults. A primary care psychology service at an urban training clinic is described and data are presented on 134 consecutive older adult patients who received services. Finally, two cases are presented to illustrate how integrated care can reach older adults who may not otherwise seek services or would get services only after psychological issues had become more acute. These cases support the view that integrated primary care can serve as a vital, flexible tool for enhancing timely mental health care for older adults, particularly within underserved populations. This population-based approach to providing brief services to a wide range of patients does not eliminate the need for more intensive services provided in mental health care settings but, rather, serves as a complement to those services.     

The Role of Primary Care Physicians in Cancer Care

BACKGROUND  The demand for oncology services in the United States (US) is increasing, whereas a shortage of oncologists looms. There is the need for a better understanding of the involvement of primary care physicians (PCPs) in cancer care. OBJECTIVE  To characterize the role of PCPs in cancer care, compare it with that of oncologists, and identify factors explaining greater PCP involvement in cancer care. DESIGN  National survey of physicians caring for cancer patients conducted by the Cancer Care Outcomes Research and Surveillance Consortium. PARTICIPANTS  1694 PCPs; 1621 oncologists. MEASUREMENTS  Questionnaires mailed during 2005 and 2006 examined the participation of physicians in 12 aspects of care for cancer patients. MAIN RESULTS  Over 90% of PCPs fulfilled general medical care roles for patients with cancer such as managing comorbid conditions, chronic pain, or depression; establishing do-not-resuscitate status; and referring patients to hospice. Oncologists were less involved in these roles. Determining the treatment preferences of individual patients and deciding on the use of surgery were the only cancer care roles in which ≥50% of PCPs participated. Twenty-two percent of PCPs reported no direct involvement in cancer care roles while 19% reported heavy involvement. PCPs who were aged ≥50 years, were internists or geriatricians, taught medical students, saw more cancer patients, or experienced referral barriers fulfilled more roles. Rural practice location was not associated with greater PCP involvement in cancer care. CONCLUSIONS  PCPs across the US have an active role in cancer patient management. Determining the optimal interface between PCPs and oncologists in delivering and coordinating cancer care is an important area for future research.     

Implementing Routine Cognitive Screening of Older Adults in Primary Care: Process and Impact on Physician Behavior

Background Early detection of cognitive impairment is a goal of high-quality geriatric medical care, but new approaches are needed to reduce rates of missed cases. Objective To evaluate whether adding routine cognitive screening to primary care visits for older adults increases rates of dementia diagnosis, specialist referral, or prescribing of antidementia medications. Setting Four primary care clinics in a university-affiliated primary care network. Design A quality improvement screening project and quasiexperimental comparison of 2 intervention clinics and 2 control clinics. The Mini-Cog was administered by medical assistants to intervention clinic patients aged 65+ years. Rates of dementia diagnoses, referrals, and medication prescribing were tracked over time using computerized administrative data. Results Twenty-six medical assistants successfully screened 70% (n = 524) of all eligible patients who made at least 1 clinic visit during the intervention period; 18% screened positive. There were no complaints about workflow interruption. Relative to baseline rates and control clinics, Mini-Cog screening was associated with increased dementia diagnoses, specialist referrals, and prescribing of cognitive enhancing medications. Patients without previous dementia indicators who had a positive Mini-Cog were more likely than all other patients to receive a new dementia diagnosis, specialty referral, or cognitive enhancing medication. However, relevant physician action occurred in only 17% of screen-positive patients. Responses were most related to the lowest Mini-Cog score level (0/5) and advanced age. Conclusion Mini-Cog screening by office staff is feasible in primary care practice and has measurable effects on physician behavior. However, new physician action relevant to dementia was likely to occur only when impairment was severe, and additional efforts are needed to help primary care physicians follow up appropriately on information suggesting cognitive impairment in older patients. An erratum to this article can be found at     

Alcohol and Other Drug Dependence Severity Among Older Adults in Treatment: Measuring Characteristics and Outcomes

ABSTRACT

The number of older adults is increasing, yet little is known about their responses to treatment for substance dependence. While age-appropriate measures have been developed for depression and alcohol screening among older adults, severity and outcome measurement for this population has not been addressed. The purpose of the present study was (1) to add to the limited but growing literature on the older adult's response to treatment, and (2) examine the utility of a well-known measure of severity, the Addiction Severity Index (ASI; McLellan et al., 1992 McLellan, A. T., Kushner, H., Metzger, D., Peters, R., Smith, L., Grissom, G., Pettinati, H. and Argerious, M. 1992. Addiction severity Index , 5th, Philadelphia: Veterans Administration and National Institute on Drugs and Alcohol.  [Google Scholar]), in measuring baseline acuity and one-year outcomes among older adults in treatment for alcohol and drug dependence. Participants (N = 67) completed the ASI and other measures at baseline and at 6 and 12 months post-treatment. ASI alcohol, drug, family/social, and psychiatric composite scores improved significantly over time. Medical, employment, and legal scores did not change. Continuous abstinence was maintained by 71% at 6 months and 60% at 12 months after discharge. The ASI captured changes in participant functioning over time, indicating it is a useful tool in measuring severity and outcomes among older adults.     

Social and Financial Resources and High‐Risk Alcohol Consumption Among Older Adults

Background: This study examined long‐term mutual predictive associations between social and financial resources and high‐risk alcohol consumption in later life. Method: A sample of 55‐ to 65‐year‐old older adults (n = 719) was surveyed at baseline and 10 years and 20 years later. At each contact point, participants completed an inventory that assessed social and financial resources and alcohol consumption. Results: Over the 20‐year interval, there was evidence of both social causation and social selection processes in relation to high‐risk alcohol consumption. In support of a social causation perspective, higher levels of some social resources, such as participation in social activities, friends’ approval of drinking, quality of relationship with spouse, and financial resources, were associated with a subsequent increased likelihood of high‐risk alcohol consumption. Conversely, indicating the presence of social selection, high‐risk alcohol consumption was associated with subsequent higher levels of friends’ approval of drinking and quality of the spousal relationship, but lower quality of relationships with extended family members. Conclusions: These findings reflect mutual influence processes in which older adults’ social resources and high‐risk alcohol consumption can alter each other. Older adults may benefit from information about how social factors can affect their drinking habits; accordingly, information about social causation effects could be used to guide effective prevention and intervention efforts aimed at reducing the risk that late‐life social factors may amplify their excessive alcohol consumption.     

Doctoral Clinical Geropsychology Training in a Primary Care Setting

Abstract

Most older adults diagnosed with a mental disorder receive treatment in primary care settings that lack personnel skilled in geropsychological diagnosis and treatment. The Ferkauf Older Adult Program of Yeshiva University endeavors to bridge this gap by providing training in geriatric psychology, through coursework and diverse clinical practica, to clinical psychology doctoral students within a large urban professional psychology program. In an innovative effort to provide the most disadvantaged elderly with comprehensive mental health treatment and maximize trainee exposure to an interdisciplinary treatment model, the program also pairs selected doctoral psychology trainees with medical residents to optimize integrated mental health service delivery for primary care elderly. The program has the following core objectives: (1) Infuse the mental health and aging knowledge base into the regular graduate curriculum; (2) Provide interdisciplinary training in geropsychological diagnostic and consultative services within an urban primary care setting; (3) Provide interdisciplinary training in the practice of psychological and neuropsychological evaluation of elderly; (4) Provide training in geropsychological psychotherapeutic intervention, including individual, couples/family, and brief/psycho-educational therapies with outpatient older adults. These objectives are achieved by pooling the resources of a graduate school of psychology, a local public hospital, and an academic medical center to achieve educational and clinical service goals.