Glycemic Control: Risk Factors, Quality of Life, Workforce Participation, and Mortality Among US Adults with Type 2 Diabetes

Despite research showing the benefits of glycemic control, it remains suboptimal among adults with diabetes in the United States. Possible reasons include unaddressed risk factors as well as lack of awareness of its immediate and long term consequences. The objectives of this study were to, using cross-sectional data, 1) ascertain the association between suboptimal (Hemoglobin A1c (HbA1c) ≥7%), borderline (HbA1c 7-8.9%), and poor (HbA1c ≥9%) glycemic control and potentially new risk factors (e.g. work characteristics), and 2) assess whether aspects of poor health and well-being such as poor health related quality of life (HRQOL), unemployment, and missed-work are associated with glycemic control; and 3) using prospective data, assess the relationship between mortality risk and glycemic control in US adults with type 2 diabetes. Data from the 1988-1994 and 1999-2004 National Health and Nutrition Examination Surveys were used. HbA1c values were used to create dichotomous glycemic control indicators. Binary logistic regression models were used to assess relationships between risk factors, employment status and glycemic control. Multinomial logistic regression analyses were conducted to assess relationships between glycemic control and HRQOL variables. Zero-inflated Poisson regression models were used to assess relationships between missed work days and glycemic control. Cox-proportional hazard models were used to assess effects of glycemic control on mortality risk. Using STATA software, analyses were weighted to account for complex survey design and non-response. Multivariable models adjusted for socio-demographics, body mass index, among other variables. Results revealed that being a farm worker and working over 40 hours/week were risk factors for suboptimal glycemic control. Having greater days of poor mental was associated with suboptimal, borderline, and poor glycemic control. Having greater days of inactivity was associated with poor glycemic control while having greater days of poor physical health was associated with borderline glycemic control. There were no statistically significant relationships between glycemic control, self-reported general health, employment, and missed work. Finally, having an HbA1c value less than 6.5% was protective against mortality. The findings suggest that work-related factors are important in a person’s ability to reach optimal diabetes management levels. Poor glycemic control appears to have significant detrimental effects on HRQOL.

The palatability of monosodium glutamate-enhanced vegetables as rated by Cuban-American older adults at a congregate meal site

The purpose of this study was to investigate the efficacy of using monosodium glutamate (MSG) as a means to increase palatability and prospective consumption of vegetables at a congregate meal site with Cuban-American clients. Thirty to 32 subjects participated in hedonic testing each day. MSG-enhanced (2 g MSG/500 g vegetable) and non-enhanced beets, string beans, carrots and peas were evaluated for palatability, preference and prospective consumption. Results showed that MSG significantly increased both palatability and prospective consumption of string beans (ps < .05) but not of the other 3 vegetables tested. These findings provide some evidence that MSG can be used to increase the palatability of vegetables served at congregate meal sites. However, these results suggest that older adults may not find the palatability of some vegetables to be improved by MSG and that optimal flavor enhancement cannot be achieved by adding the same amount of MSG to every vegetable.

Non-Pharmacological Approaches for Pain Management in Sickle Cell Disease: Development of a Mindfulness-Based Intervention

Background: Sickle Cell Disease (SCD) is a genetic hematological disorder that affects more than 7 million people globally (NHLBI, 2009). It is estimated that 50% of adults with SCD experience pain on most days, with 1/3 experiencing chronic pain daily (Smith et al., 2008). Persons with SCD also experience higher levels of pain catastrophizing (feelings of helplessness, pain rumination and magnification) than other chronic pain conditions, which is associated with increases in pain intensity, pain behavior, analgesic consumption, frequency and duration of hospital visits, and with reduced daily activities (Sullivan, Bishop, & Pivik, 1995; Keefe et al., 2000; Gil et al., 1992 & 1993). Therefore effective interventions are needed that can successfully be used manage pain and pain-related outcomes (e.g., pain catastrophizing) in persons with SCD. A review of the literature demonstrated limited information regarding the feasibility and efficacy of non-pharmacological approaches for pain in persons with SCD, finding an average effect size of .33 on pain reduction across measurable non-pharmacological studies. Second, a prospective study on persons with SCD that received care for a vaso-occlusive crisis (VOC; N = 95) found: (1) high levels of patient reported depression (29%) and anxiety (34%), and (2) that unemployment was significantly associated with increased frequency of acute care encounters and hospital admissions per person. Research suggests that one promising category of non-pharmacological interventions for managing both physical and affective components of pain are Mindfulness-based Interventions (MBIs; Thompson et al., 2010; Cox et al., 2013). The primary goal of this dissertation was thus to develop and test the feasibility, acceptability, and efficacy of a telephonic MBI for pain catastrophizing in persons with SCD and chronic pain.

Methods: First, a telephonic MBI was developed through an informal process that involved iterative feedback from patients, clinical experts in SCD and pain management, social workers, psychologists, and mindfulness clinicians. Through this process, relevant topics and skills were selected to adapt in each MBI session. Second, a pilot randomized controlled trial was conducted to test the feasibility, acceptability, and efficacy of the telephonic MBI for pain catastrophizing in persons with SCD and chronic pain. Acceptability and feasibility were determined by assessment of recruitment, attrition, dropout, and refusal rates (including refusal reasons), along with semi-structured interviews with nine randomly selected patients at the end of study. Participants completed assessments at baseline, Week 1, 3, and 6 to assess efficacy of the intervention on decreasing pain catastrophizing and other pain-related outcomes.

Results: A telephonic MBI is feasible and acceptable for persons with SCD and chronic pain. Seventy-eight patients with SCD and chronic pain were approached, and 76% (N = 60) were enrolled and randomized. The MBI attendance rate, approximately 57% of participants completing at least four mindfulness sessions, was deemed acceptable, and participants that received the telephonic MBI described it as acceptable, easy to access, and consume in post-intervention interviews. The amount of missing data was undesirable (MBI condition, 40%; control condition, 25%), but fell within the range of expected missing outcome data for a RCT with multiple follow-up assessments. Efficacy of the MBI on pain catastrophizing could not be determined due to small sample size and degree of missing data, but trajectory analyses conducted for the MBI condition only trended in the right direction and pain catastrophizing approached statistically significance.

Conclusion: Overall results showed that at telephonic group-based MBI is acceptable and feasible for persons with SCD and chronic pain. Though the study was not able to determine treatment efficacy nor powered to detect a statistically significant difference between conditions, participants (1) described the intervention as acceptable, and (2) the observed effect sizes for the MBI condition demonstrated large effects of the MBI on pain catastrophizing, mental health, and physical health. Replication of this MBI study with a larger sample size, active control group, and additional assessments at the end of each week (e.g., Week 1 through Week 6) is needed to determine treatment efficacy. Many lessons were learned that will guide the development of future studies including which MBI strategies were most helpful, methods to encourage continued participation, and how to improve data capture.

Best Practices: Lessons Learned by a South Florida Non-Profit Community Based Organization while Designing and Implementing a Career Exploration Evidence Informed Framework in Urban Communities

All A’s was designed to support of the agency’s family strengthening initiatives in South Florida. All A’s uses evidence informed strategies poised to be an inclusive curriculum that teaches self-determination and adaptive behavior skills. The framework incorporates problem based learning and adult learning theory and follows the Universal Design for Learning. Since 2012, the agency has served over 8500 youth and 4,000 adults using the framework. The framework addresses educational underachievement and career readiness in at risk populations. It is used to enhance participants AWARENESS of setting SMART goals to achieve future goals and career aspirations. Participants are provided with ACCESS to resources and opportunities for creating and implementing an ACTION plan as they pursue and ACHIEVE their goals. All A’s promotes protective factors and expose youth to career pathways in Science, Technology, Engineering and Math (STEM) related fields. Youth participate in college tours, job site visits, job shadowing, high school visits, online college and career preparation assistance, service learning projects, STEM projects, and the Winning Futures© mentoring program. Adults are assisted with résumé development; learn job search strategies, interview techniques, job shadowing experiences, computer and financial literacy programs. Adults and youth are also given the opportunity to complete industry-recognized certifications in high demand industries (food service, general labor, and construction), and test preparation for the General Educational Development Test.

Childhood Physical Activity Involvement in Active and Inactive Female Adults

Current trends show progressive declines in levels of physical activity from childhood through adolescence and adulthood, most notably for females. The current study examined organized activity involvement in active and inactive females (age 18) using retrospective data. Results indicated that active females participated in significantly more physical activities than inactive females from age 6 to age 18. No significant differences were found between groups for non-physical activities. In addition, parents of active and inactive females were the most influential factor in initiating physical activity. However, parents of active females initiated more physical activity involvement than did parents of inactive females. Results also indicate that certain periods in childhood and adolescence appear to be critical for developing long-term physical activity habits.

UPTAKE OF THE PERIODIC HEALTH EXAM AMONG ADULTS WITH INTELLECTUAL AND DEVELOPMENTAL DISABILITIES FROM 2003 TO 2015

Background: Over the past decade, annual heath exams have been de-emphasized for the general population but emphasized for adults with intellectual and developmental disabilities (IDD). The purpose of this project was to determine if there has been an increase in the uptake of the health exam among adults with IDD in Ontario, to what extent, and the effect on the quality of preventive care provided. Methods: Using administrative health data, the proportion of adults (18-64 years old) with IDD who received a health exam (long appointment, general assessment, and “true” health exam), a high value on the primary care quality composite score (PCQS), and a health exam or high PCQS each year was compared to the proportion in a propensity score matched sample of the general population. Negative binomial and segmented negative binomial regression controlling for age and sex were used to determine the relative risk of having a health exam/high PCQS/health exam or PCQS over time. Results: Pre joinpoint, the long appointment and general assessment health exam definitions saw a decrease and the “true” health exam saw an increase in the likelihood of adults having a health exam. Post joinpoint, all health exam definitions saw a decrease in the likelihood of adults having a health exam. Pre joinpoint, all PCQS measures (high PCQS, long appointment or high PCQS, “true” health exam or high PCQS) saw an increase in the likelihood for adults to achieve a high PCQS or high PCQS/have a health exam. Post joinpoint, all PCQS measures saw a decrease in the likelihood for adults to achieve a high PCQS or high PCQS/have a health exam. Achieving a high PCQS was strongly associated with having a health exam regardless of health exam definition or IDD status. Conclusions: Despite the publication of guidelines, only a small proportion of adults with IDD are receiving health exams. This indicates that the publication of guidelines alone was not sufficient to change practice. More targeted measures, such as the implementation of an IDD-specific health exam fee code, should be considered to increase the uptake of the health exam among adults with IDD.

Fear of Falling and Balance Confidence in Older Adults with Diabetes Mellitus

Several determinants of fear of falling (FoF) and low balance confidence overlap with the consequences/complications of diabetes mellitus (DM). FoF is strongly associated with low balance confidence, and balance confidence mediates the relationship between FoF and balance and physical function. The purpose of this thesis was two-fold: (1) to examine the prevalence, severity and determinants of FoF in older adults (aged≥65) with DM, and (2) to evaluate the validity of the short version of the Activities-specific Balance Confidence scale (ABC-6) and its association with balance and postural control in older adults with DM. Three separate studies were conducted of older adults with DM (DM-group) and without DM (noDM-group). Study I revealed that although FoF prevalence adjusted for age and sex was not different between-groups, the DM-group had 8.8% fewer participants in the low and 8.4% more in the high Falls-Efficacy Scale International categories when compared to the noDM-group. Higher FoF severity in the DM-group was associated with poor physical performance, being female, fall history and clinical depressive symptoms. Study II provided evidence of convergent, discriminant and concurrent validity of the ABC-6 for use in older adults with DM with and without diabetic peripheral neuropathy (DPN). Notably, the ABC-6 was more sensitive in detecting subtle differences in balance confidence between the DM-group and noDM-group when compared to the original ABC scale (ABC-16), and can be administered in less time. Study III explored balance confidence (ABC-6) and its association with balance and postural control in older adults with DM. Subtle differences in axial segmental control (i.e., lower trunk roll velocity and higher head-trunk correlations) while walking and lower balance confidence were apparent in the DM-group, even in the absence of DPN, when compared to the noDM-group. Balance confidence partially explained the variance in head-trunk stiffening between-groups, and consequently low balance confidence in older adults with DM may contribute to the dependence on postural control strategies that are normally only utilized in high-risk situations. Findings from this thesis will help to guide the development of protocols for screening and intervention recommendations of patient education and targeted rehabilitation programs for older adults with DM.

STOPPFrail (Screening Tool of Older Persons Prescriptions in Frail Adults with Limited Life Expectancy): Consensus Validation

Background: To validate STOPPFrail, a list of explicit criteria for potentially inappropriate medications (PIMs) in frailer older adults with limited life expectancy. A Delphi consensus survey of an expert panel (n = 17) comprising specialists in geriatric medicine, clinical pharmacology, palliative care, psychiatry of old age, clinical pharmacy and general practice.
Methods: STOPPFrail criteria was initially created by the authors based on clinical
experience and appraisal of the available literature. Criteria were organised according to physiological system. Each criterion was accompanied by an explanation. Panellists ranked their agreement with each criterion on a 5-point Likert scale and invited to provide written feedback. Criteria with a median Likert response of 4/5 (agree/strongly agree) and a 25th centile of ≥4 were included in the final criteria.
Results: Three Delphi rounds were required. All panellists completed all rounds. Thirty criteria were proposed for inclusion; 26 were accepted. No new criteria were added. The first two criteria suggest deprescribing medications with no indication or where compliance is poor. The remaining 24 criteria include lipid-lowering therapies, alpha-blockers for hypertension, anti-platelets, neuroleptics, proton pump inhibitors, H-2 receptor antagonists, anti-spasmodics, theophylline, leukotriene antagonists, calcium supplements, bone anti-resorptive therapy, selective oestrogen receptor modulators, non-steroidal antiinflammatories, corticosteroids, 5-alpha reductase inhibitors, alpha-1 selective blockers, muscarinic antagonists, oral diabetic agents, ACE-inhibitors, angiotensin receptor blockers, systemic oestrogens, multivitamins, nutritional supplements and prophylactic antibiotics. Anticoagulants and anti-depressants were excluded. Despite incorporation of panellists’ suggestions, memantine and acetyl-cholinesterase inhibitors remained inconclusive.
Conclusion: STOPPFrail comprises 26 criteria, which have been judged by broad consensus, to be potentially inappropriate in frailer older patients with limited life expectancy. STOPPFrail may assist in deprescribing medications in these patients.

Non-contact Pressure-based Sleep/Wake Discrimination

Poor sleep is increasingly being recognised as an important prognostic parameter of health. For those with suspected sleep disorders, patients are referred to sleep clinics which guide treatment. However, sleep clinics are not always a viable option due to their high cost, a lack of experienced practitioners, lengthy waiting lists and an unrepresentative sleeping environment. A home-based non-contact sleep/wake monitoring system may be used as a guide for treatment potentially stratifying patients by clinical need or highlighting longitudinal changes in sleep and nocturnal patterns. This paper presents the evaluation of an under-mattress sleep monitoring system for non-contact sleep/wake discrimination. A large dataset of sensor data with concomitant sleep/wake state was collected from both younger and older adults participating in a circadian sleep study. A thorough training/testing/validation procedure was configured and optimised feature extraction and sleep/wake discrimination algorithms evaluated both within and across the two cohorts. An accuracy, sensitivity and specificity of 74.3%, 95.5%, and 53.2% is reported over all subjects using an external validation
dataset (71.9%, 87.9% and 56%, and 77.5%, 98% and 57% is reported for younger and older subjects respectively). These results compare favourably with similar research, however this system provides an ambient alternative suitable for long term continuous sleep monitoring, particularly amongst vulnerable populations.

Non-invasive diagnosis of pediatric tuberculosis

Thesis (Master's)--University of Washington, 2016-08

Mental health nurses’ attitudes, behaviour, experience and knowledge regarding adults with a diagnosis of borderline personality disorder: systematic, integrative literature review

Aims and objectives To establish whether mental health nurses responses to people with borderline personality disorder are problematic and, if so, to inform solutions to support change. Background There is some evidence that people diagnosed with borderline personality disorder are unpopular among mental health nurses who respond to them in ways which could be counter-therapeutic. Interventions to improve nurses’ attitudes have had limited success. Design Systematic, integrative literature review. Methods Computerised databases were searched from inception to April 2015 for papers describing primary research focused on mental health nurses’ attitudes, behaviour, experience, and knowledge regarding adults diagnosed with borderline personality disorder. Analysis of qualitative studies employed metasynthesis; analysis of quantitative studies was informed by the theory of planned behaviour. Results Forty studies were included. Only one used direct observation of clinical practice. Nurses’ knowledge and experiences vary widely. They find the group very challenging to work with, report having many training needs, and, objectively, their attitudes are poorer than other professionals’ and poorer than towards other diagnostic groups. Nurses say they need a coherent therapeutic framework to guide their practice, and their experience of caregiving seems improved where this exists. Conclusions Mental health nurses’ responses to people with borderline personality disorder are sometimes counter-therapeutic. As interventions to change them have had limited success there is a need for fresh thinking. Observational research to better understand the link between attitudes and clinical practice is required. Evidence-based education about borderline personality disorder is necessary, but developing nurses to lead in the design, implementation and teaching of coherent therapeutic frameworks may have greater benefits. Relevance to clinical practice There should be greater focus on development and implementation of a team-wide approach, with nurses as equal partners, when working with patients with borderline personality disorder.

Education at last! Taiwanese grandmothers "go to school"

Language socialization is a life-long process in which individuals are continuously socialized into new roles, statuses, and practices. This process becomes more complex in multilingual contexts. However, we know little of the language socialization of older adults and we know even less of minority-speaking elders' experiences of linguistic marginalization in contemporary communicative milieus. In this ethnographic and discourse-analytic study, I examine the language socialization of non-Mandarin-speaking elderly Taiwanese women in senior adult education programs in a rural township in Taiwan. Through examining autobiographical narratives, master narratives about elders, and classroom discourses, this study explores the historical construction of their sociolinguistic marginalization and their negotiation and resistance of such marginalization. The majority of the elderly women were denied education when they were young. Some received Japanese education during the Japanese colonization period. While the uneducated and illiterate elders have a strong aspiration for learning, they are dismissed as "unable to learn" by their teachers, peer students, and community leaders. By contrast, the Japanese literate exhibit a strong learning identity associated with colonial modernity. These two groups, however, have to contend with the social stereotype associated with their non-Mandarin speaking status. Under a Mandarin-only ideology that links Mandarin with modernity, discourses that have actively mobilized the category of “illiterate” to reference the older population are part and parcel of Taiwan’s modern identity. By demonstrating how these women are treated, in official discourses and in classroom interactions, as children for their lack of Mandarin abilities, I argue that the literacy education that set out to “compensate” these women for their earlier lack of educational opportunity has paradoxically reinforced their marginalization. Further, in recent years, they have become even more marginalized as the government has prioritized the education of recent young female marriage immigrants from Southeast Asia, who are considered in charge of educating the “future sons and daughters of Taiwan.” This research demonstrates how language socialization is a contested and life-long process and calls attention to the effects of language ideologies on literacy and language education. The findings have policy implications for improving literacy and language education both within Taiwan and elsewhere in the world.

Supporting self-management: development and evaluation of a digital resource for adults with asthma

The problem: Around 300 million people worldwide have asthma and prevalence is increasing. Support for optimal self-management can be effective in improving a range of outcomes and is cost effective, but is underutilised as a treatment strategy. Supporting optimum self-management using digital technology shows promise, but how best to do this is not clear. Aim: The purpose of this project was to explore the potential role of a digital intervention in promoting optimum self-management in adults with asthma. Methods: Following the MRC Guidance on the Development and Evaluation of Complex Interventions which advocates using theory, evidence, user testing and appropriate modelling and piloting, this project had 3 phases. Phase 1: Examination of the literature to inform phases 2 and 3, using systematic review methods and focussed literature searching. Phase 2: Developing the Living Well with Asthma website. A prototype (paper-based) version of the website was developed iteratively with input from a multidisciplinary expert panel, empirical evidence from the literature (from phase 1), and potential end users via focus groups (adults with asthma and practice nurses). Implementation and behaviour change theories informed this process. The paper-based designs were converted to the website through an iterative user centred process (think aloud studies with adults with asthma). Participants considered contents, layout, and navigation. Development was agile using feedback from the think aloud sessions immediately to inform design and subsequent think aloud sessions. Phase 3: A pilot randomised controlled trial over 12 weeks to evaluate the feasibility of a Phase 3 trial of Living Well with Asthma to support self-management. Primary outcomes were 1) recruitment & retention; 2) website use; 3) Asthma Control Questionnaire (ACQ) score change from baseline; 4) Mini Asthma Quality of Life (AQLQ) score change from baseline. Secondary outcomes were patient activation, adherence, lung function, fractional exhaled nitric oxide (FeNO), generic quality of life measure (EQ-5D), medication use, prescribing and health services contacts. Results: Phase1: Demonstrated that while digital interventions show promise, with some evidence of effectiveness in certain outcomes, participants were poorly characterised, telling us little about the reach of these interventions. The interventions themselves were poorly described making drawing definitive conclusions about what worked and what did not impossible. Phase 2: The literature indicated that important aspects to cover in any self-management intervention (digital or not) included: asthma action plans, regular health professional review, trigger avoidance, psychological functioning, self-monitoring, inhaler technique, and goal setting. The website asked users to aim to be symptom free. Key behaviours targeted to achieve this include: optimising medication use (including inhaler technique); attending primary care asthma reviews; using asthma action plans; increasing physical activity levels; and stopping smoking. The website had 11 sections, plus email reminders, which promoted these behaviours. Feedback during think aloud studies was mainly positive with most changes focussing on clarification of language, order of pages and usability issues mainly relating to navigation difficulties. Phase 3: To achieve our recruitment target 5383 potential participants were invited, leading to 51 participants randomised (25 to intervention group). Age range 16-78 years; 75% female; 28% from most deprived quintile. Nineteen (76%) of the intervention group used the website for an average of 23 minutes. Non-significant improvements in favour of the intervention group observed in the ACQ score (-0.36; 95% confidence interval: -0.96, 0.23; p=0.225), and mini-AQLQ scores (0.38; -0.13, 0.89; p=0.136). A significant improvement was observed in the activity limitation domain of the mini-AQLQ (0.60; 0.05 to 1.15; p = 0.034). Secondary outcomes showed increased patient activation and reduced reliance on reliever medication. There was no significant difference in the remaining secondary outcomes. There were no adverse events. Conclusion: Living Well with Asthma has been shown to be acceptable to potential end users, and has potential for effectiveness. This intervention merits further development, and subsequent evaluation in a Phase III full scale RCT.

Barriers to and facilitators of older adult’s adherence to health recommendations: Towards an EngAging two-way health communication

Non-adherence to health recommendations (e.g. medical prescriptions) presents potential costs for healthcare, which could be prevented or mitigated. This is often attributed to a person’s rational choice, to not adhere. However, this may also be determined by individual and contextual factors implied in the recommendations communication process. In accordance, this chapter focuses specifically on barriers to and facilitators of adherence to recommendations and engagement with the healthcare process, particularly concerning the communication between health professionals and patients. For this, the authors present examples of engagement increment through different degrees of participation, from a one-way/directive towards a two-way/engaging communication process. This focuses specifically on a vulnerable population group with increasing healthcare needs: older adults. Future possibilities for two-way engaging communications are discussed, aimed at promoting increased adherence to health recommendations and people’s self-regulation of their own health.

Glasgow Psychosis Screening tool for use in adults with Intellectual Disabilities (GPS-ID): development and psychometric properties

Background: Prevalence of psychosis is known to be higher in adults with intellectual disabilities (ID) than in the general adult population. However, there have been no attempts to develop a psychosis screening tool specifically for the adult ID population. The present study describes the development and preliminary evaluation of a new measure, the Glasgow Psychosis Screening tool for use in Adults with Intellectual Disabilities (GPS-ID). Method: An item pool was generated following: 1) focus groups with adults with ID and psychosis, and their carers and/or workers; 2) expert input from clinicians. A draft scale was compiled and refined following expert feedback. The new scale, along with the Psychotic Symptom Rating Scales was administered to 20 adults with ID (10 with and 10 without psychosis) and their relative or carers. Results: The GPS-ID total score, self-report subscale and informant rating-subscale differentiated psychosis and non-psychosis groups. The tool had good internal consistency (Cronbach’s α=0.91), and a cut-off score ≥4 yielded high sensitivity (90%) and specificity (100%). The method of tool development supports face and content validity. Criterion validity was not supported. Conclusions: Preliminary investigation of the tool’s psychometric properties is positive, although further investigation is required. The tool is accessible to adults with mild to moderate ID and can be completed in 15-30 minutes. The GPS-ID is not a diagnostic tool, therefore any adult exceeding the cut-off score of ≥4 should receive further assessment.