Publications by authors named "Kenneth M Langa"

258 Publications

Dementia care needs for individuals and caregivers among Mexican Americans and non-Hispanic Whites.

Aging Ment Health 2021 Jun 7:1-12. Epub 2021 Jun 7.

Department of Health Behavior and Health Education, University of Michigan, School of Public Health, Ann Arbor, MI, USA.

Mexican Americans (MA) are more likely to have cognitive impairment and dementia (CID), be diagnosed at an earlier age and live with CID longer, compared to non-Hispanic Whites (NHW). While studies have examined unmet needs of individuals with CID and their caregivers, few have focused on MA populations in the U.S. This paper examines the needs of community-residing individuals with CID and their caregivers in Nueces County, Texas, a county with one of the largest MA populations in the U.S., while exploring ethnic differences in needs identified.

Using concept mapping, a mixed-method approach, qualitative input on perceived needs by informal caregivers and health professionals was collected. Participants then sorted and rated perceived needs. Using this information, multidimensional scaling and cluster analyses were conducted to map the relationship between perceived needs and determine their importance and priority.

Five clusters were derived for caregivers and four for the health professionals. Themes across both caregivers and health professionals highlighted the need for specialized and team-based medical care, caregiver support and training, along with socio-economic and physical needs that help with day-to-day care of individuals with CID. Among caregivers, MA rated financial resources as more important and of higher priority compared to NHW. The health professionals' perspectives were aligned with those of all caregivers.

By understanding the needs of caregivers and individuals with CID, we can help families deal with this disease and let caregivers thrive. This is especially important for minority populations like MAs.
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http://dx.doi.org/10.1080/13607863.2021.1925222DOI Listing
June 2021

The Longitudinal Association of Vision Impairment with Transitions to Cognitive Impairment and Dementia: Findings from The Aging, Demographics and Memory Study.

J Gerontol A Biol Sci Med Sci 2021 Jun 1. Epub 2021 Jun 1.

Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI 48105 USA.

Background: Vision impairment (VI) is associated with incident cognitive decline and dementia. However, it is not known whether VI is associated only with the transition to cognitive impairment, or whether it is also associated with later transitions to dementia.

Methods: We used data from the population-based Aging, Demographics and Memory Study (ADAMS) to investigate the association of visual acuity impairment (VI; defined as binocular presenting visual acuity <20/40) with transitions from cognitively normal (CN) to cognitive impairment no dementia (CIND) and from CIND to dementia. Multivariable Cox proportional hazards models and logistic regression were used to model the association of VI with cognitive transitions, adjusted for covariates.

Results: There were 351 participants included in this study (weighted percentages: 45% male, 64% age 70-79 years) with a mean follow-up time of 4.1 years. In a multivariable model, the hazard of dementia was elevated among those with VI (HR=1.63, 95%CI=1.04-2.58). Participants with VI had a greater hazard of transitioning from CN to CIND (HR=1.86, 95%CI=1.09-3.18). However, among those with CIND and VI a similar percentage transitioned to dementia (48%) and remained CIND (52%); there was no significant association between VI and transitioning from CIND to dementia (HR=0.94, 95%CI=0.56-1.55). Using logistic regression models, the same associations between VI and cognitive transitions were identified.

Conclusions: Poor vision is associated with the development of CIND. The association of VI and dementia appears to be due to the higher risk of dementia among individuals with CIND. Findings may inform the design of future interventional studies.
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http://dx.doi.org/10.1093/gerona/glab157DOI Listing
June 2021

Bilingualism, assessment language, and the Montreal Cognitive Assessment in Mexican Americans.

J Am Geriatr Soc 2021 May 7. Epub 2021 May 7.

Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, Michigan, USA.

Background/objectives: Assessment of cognition in linguistically diverse aging populations is a growing need. Bilingualism may complicate cognitive measurement precision, and bilingualism may vary across Hispanic/Latinx sub-populations. We examined the association among bilingualism, assessment language, and cognitive screening performance in a primarily non-immigrant Mexican American community.

Design: Prospective, community-based cohort study: The Brain Attack Surveillance in Corpus Christi (BASIC)-Cognitive study.

Setting: Nueces County, Texas.

Participants: Community-dwelling Mexican Americans age 65+, recruited door-to-door using a two-stage area probability sampling procedure.

Measurements: Montreal Cognitive Assessment (MoCA); self-reported bilingualism scale. Participants were classified as monolingual, Spanish dominant bilingual, English dominant bilingual, or balanced bilingual based upon bilingualism scale responses. Linear regressions examined relationships among bilingualism, demographics, cognitive assessment language, and MoCA scores.

Results: The analytic sample included 547 Mexican American participants (60% female). Fifty-eight percent were classified as balanced bilingual, the majority (88.6%) of whom selected assessment in English. Balanced bilinguals that completed the MoCA in English performed better than balanced bilinguals that completed the MoCA in Spanish (b = -4.0, p < 0.05). Among balanced bilinguals that took the MoCA in Spanish, education outside of the United States was associated with better performance (b = 4.4, p < 0.001). Adjusting for demographics and education, we found no association between the degree of bilingualism and MoCA performance (p's > 0.10).

Conclusion: Bilingualism is important to consider in cognitive aging studies in linguistically diverse communities. Future research should examine whether cognitive test language selection affects cognitive measurement precision in balanced bilinguals.
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http://dx.doi.org/10.1111/jgs.17209DOI Listing
May 2021

The Association Between Mild Cognitive Impairment Diagnosis and Patient Treatment Preferences: a Survey of Older Adults.

J Gen Intern Med 2021 May 7. Epub 2021 May 7.

Department of Internal Medicine and Cognitive Health Services Research Program, University of Michigan (U-M), Ann Arbor, MI, USA.

Background: Older patients (65+) with mild cognitive impairment (MCI) receive less guideline-concordant care for cardiovascular disease (CVD) and other conditions than patients with normal cognition (NC). One potential explanation is that patients with MCI want less treatment than patients with NC; however, the treatment preferences of patients with MCI have not been studied.

Objective: To determine whether patients with MCI have different treatment preferences than patients with NC.

Design: Cross-sectional survey conducted at two academic medical centers from February to December 2019 PARTICIPANTS: Dyads of older outpatients with MCI and NC and patient-designated surrogates.

Main Measures: The modified Life-Support Preferences-Predictions Questionnaire score measured patients' preferences for life-sustaining treatment decisions in six health scenarios including stroke and acute myocardial infarction (range, 0-24 treatments rejected with greater scores indicating lower desire for treatment).

Key Results: The survey response rate was 73.4%. Of 136 recruited dyads, 127 (93.4%) completed the survey (66 MCI and 61 NC). The median number of life-sustaining treatments rejected across health scenarios did not differ significantly between patients with MCI and patients with NC (4.5 vs 6.0; P=0.55). Most patients with MCI (80%) and NC (80%) desired life-sustaining treatments in their current health (P=0.99). After adjusting for patient and surrogate factors, the difference in mean counts of rejected treatments between patients with MCI and patients with NC was not statistically significant (adjusted ratio, 1.08, 95% CI, 0.80-1.44; P=0.63).

Conclusion: We did not find evidence that patients with MCI want less treatment than patients with NC. These findings suggest that other provider and system factors might contribute to patients with MCI getting less guideline-concordant care.
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http://dx.doi.org/10.1007/s11606-021-06839-wDOI Listing
May 2021

Preexisting Mild Cognitive Impairment, Dementia, and Receipt of Treatments for Acute Ischemic Stroke.

Stroke 2021 Jun 27;52(6):2134-2142. Epub 2021 Apr 27.

Department of Neurology and Stroke Program (D.A.L., L.B.M., D.B.Z., L.D.L.), University of Michigan, Ann Arbor.

Background And Purpose: Differences in acute ischemic stroke (AIS) treatment by cognitive status are unclear, but some studies have found patients with preexisting dementia get less treatment. We compared AIS care by preexisting cognitive status.

Methods: Cross-sectional analysis of prospectively obtained data on 836 adults ≥45 with AIS from the population-based Brain Attack Surveillance in Corpus Christi project from 2008 to 2013. We compared receipt of a composite quality measure representing the percentage of 7 treatments/procedures received (ordinal scale; values, <0.75, 0.75-0.99, and 1.0), a binary defect-free quality score, and individual treatments after AIS between patients with preexisting dementia (Informant Questionnaire on Cognitive Decline in the Elderly score ≥3.44), mild cognitive impairment (MCI, score 3.1-3.43), and normal cognition (score ≤3).

Results: Among patients with AIS, 42% had normal cognition (47% women; median age [interquartile range], 65 [56-76]), 32% had MCI (54% women; median age, 70 [60-78]), 26% had dementia (56% women; median age, 78 [64-85]). After AIS, 44% of patients with preexisting dementia and 55% of patients with preexisting MCI or normal cognition received defect-free care. Compared with cognitively normal patients, patients with preexisting MCI had similar cumulative odds (unadjusted cumulative odds ratio =0.99, =0.92), and patients with preexisting dementia had 36% lower cumulative odds of receiving the composite quality measure (unadjusted cumulative odds ratio [OR]=0.64, =0.005). However, the dementia-quality association became nonsignificant after adjusting for patient factors, namely sex, comorbidity, and body mass index (adjusted cumulative OR [acOR]=0.79, =0.19). Independent of patient factors, preexisting MCI was negatively associated with receipt of IV tPA (intravenous tissue-type plasminogen activator; acOR=0.36, =0.04), rehabilitation assessment (acOR=0.28, =0.016), and echocardiogram (acOR=0.48, <0.001). Preexisting dementia was negatively associated with receipt of antithrombotic by day 2 (acOR=0.39, =0.04) and echocardiogram (acOR=0.42, <0.001).

Conclusions: Patients with preexisting MCI and dementia, compared with cognitively normal patients, may receive less frequently some treatments and procedures, but not the composite quality measure, after AIS.
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http://dx.doi.org/10.1161/STROKEAHA.120.032258DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8154649PMC
June 2021

Association Between Risk Factors for Complications From COVID-19, Perceived Chances of Infection and Complications, and Protective Behavior in the US.

JAMA Netw Open 2021 03 1;4(3):e213984. Epub 2021 Mar 1.

Institute for Social Research, University of Michigan, Ann Arbor.

Importance: It is unknown whether adults who are susceptible to severe complications from COVID-19 recognize their susceptibility and modify behavior to reduce exposure.

Objective: To determine whether adults with risk factors for COVID-19 complications perceive an elevated chance of complications and undertake fewer higher infection risk behaviors.

Design, Setting, And Participants: This cross-sectional analysis, adjusted for sociodemographic characteristics, included civilian noninstitutionalized US adults of wave 18 of the Understanding America Study collected from November 11 to December 9, 2020.

Exposures: US Centers for Disease Control and Prevention-identified medical risk factors for COVID-19 complications and older age.

Main Outcomes And Measures: Primary outcomes were perceived percentage chance of infection and hospitalization and death if infected; whether 9 potentially higher infection risk activities were undertaken in the past week and, if so, whether a mask was worn; whether a mask was worn anywhere in the past week; and attitudes toward 12 aspects of mask wearing.

Results: In Understanding America Study wave 18 (n = 5910 participants with nonmissing data), the mean age was 48 years, and 52% were women. The response rate was 77%. Adults with 7 of 9 medical risk factors and aged 70 years and older reported a higher perceived chance of complications if infected. Adjusted mean perceived chance of hospitalization if infected ranged from 23.9% (95% CI, 22.2%-25.5%) for those with high blood pressure to 40.4% (95% CI, 34.6%-46.2%) for those with chronic lung disease and was associated with number of medical risk factors: 17.6% (95% CI, 16.4%-18.8%) and 41.8% (95% CI, 38.7%-45.0%) for adults with 0 vs 3 or more medical risk factors, respectively. Fewer potentially higher infection risk activities were undertaken by adults with 3 or more vs 0 risk factors: 2.83 (95% CI, 2.66-2.99) vs 3.12 (95% CI, 3.02-3.22). Wearing a mask sometime last week was nearly universal (90.1%). But during only 1 specific activity (visiting a grocery store or pharmacy) did more than half always wear a mask, and for only 1 activity (visiting a grocery store or pharmacy) was mask wearing more common among adults with 3 or more vs 0 conditions.

Conclusions And Relevance: In this cross-sectional survey study, adults with risk factors for COVID-19 complications reported higher perceived susceptibility to complications. During common activities, including visiting with friends, the majority of adults, including the highly susceptible, did not consistently wear masks.
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http://dx.doi.org/10.1001/jamanetworkopen.2021.3984DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8013830PMC
March 2021

Cumulative Genetic Risk and Are Independently Associated With Dementia Status in a Multiethnic, Population-Based Cohort.

Neurol Genet 2021 Apr 5;7(2):e576. Epub 2021 Mar 5.

Department of Epidemiology (K.M.B., S.L.R.K., J.A.S.), School of Public Health, University of Michigan; Survey Research Center (H.S.V., J.D.F., S.G.H., K.M.L., C.M.M., E.B.W.), Institute for Social Research, University of Michigan; VA Center for Clinical Management Research (K.M.L.), Ann Arbor, MI; Department of Neurology (J.J.M.), Columbia University, and the Taub Institute for Research on Alzheimer's Disease and the Aging Brain (J.J.M.), New York; and Department of Mental Health (K.S.B.), Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD.

Objective: Alzheimer disease (AD) is a common and costly neurodegenerative disorder. A large proportion of AD risk is heritable, and many genetic risk factors have been identified. The objective of this study was to test the hypothesis that cumulative genetic risk of known AD markers contributed to odds of dementia in a population-based sample.

Methods: In the US population-based Health and Retirement Study (waves 1995-2014), we evaluated the role of cumulative genetic risk of AD, with and without the alleles, on dementia status (dementia, cognitive impairment without dementia, borderline cognitive impairment without dementia, and cognitively normal). We used logistic regression, accounting for demographic covariates and genetic principal components, and analyses were stratified by European and African genetic ancestry.

Results: In the European ancestry sample (n = 8,399), both AD polygenic score excluding the genetic region (odds ratio [OR] = 1.10; 95% confidence interval [CI]: 1.00-1.20) and the presence of any alleles (OR = 2.42; 95% CI: 1.99-2.95) were associated with the odds of dementia relative to normal cognition in a mutually adjusted model. In the African ancestry sample (n = 1,605), the presence of any alleles was associated with 1.77 (95% CI: 1.20-2.61) times higher odds of dementia, whereas the AD polygenic score excluding the genetic region was not significantly associated with the odds of dementia relative to normal cognition 1.06 (95% CI: 0.97-1.30).

Conclusions: Cumulative genetic risk of AD and are both independent predictors of dementia in European ancestry. This study provides important insight into the polygenic nature of dementia and demonstrates the utility of polygenic scores in dementia research.
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http://dx.doi.org/10.1212/NXG.0000000000000576DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7938646PMC
April 2021

Prevalence of Central Nervous System-Active Polypharmacy Among Older Adults With Dementia in the US.

JAMA 2021 03;325(10):952-961

School of Social Policy and Practice, University of Pennsylvania, Philadelphia.

Importance: Community-dwelling older adults with dementia have a high prevalence of psychotropic and opioid use. In these patients, central nervous system (CNS)-active polypharmacy may increase the risk for impaired cognition, fall-related injury, and death.

Objective: To determine the extent of CNS-active polypharmacy among community-dwelling older adults with dementia in the US.

Design, Setting, And Participants: Cross-sectional analysis of all community-dwelling older adults with dementia (identified by International Classification of Diseases, Ninth Revision, Clinical Modification or International Statistical Classification of Diseases and Related Health Problems, Tenth Revision diagnosis codes; N = 1 159 968) and traditional Medicare coverage from 2015 to 2017. Medication exposure was estimated using prescription fills between October 1, 2017, and December 31, 2018.

Exposures: Part D coverage during the observation year (January 1-December 31, 2018).

Main Outcomes And Measures: The primary outcome was the prevalence of CNS-active polypharmacy in 2018, defined as exposure to 3 or more medications for longer than 30 days consecutively from the following classes: antidepressants, antipsychotics, antiepileptics, benzodiazepines, nonbenzodiazepine benzodiazepine receptor agonist hypnotics, and opioids. Among those who met the criterion for polypharmacy, duration of exposure, number of distinct medications and classes prescribed, common class combinations, and the most commonly used CNS-active medications also were determined.

Results: The study included 1 159 968 older adults with dementia (median age, 83.0 years [interquartile range {IQR}, 77.0-88.6 years]; 65.2% were female), of whom 13.9% (n = 161 412) met the criterion for CNS-active polypharmacy (32 139 610 polypharmacy-days of exposure). Those with CNS-active polypharmacy had a median age of 79.4 years (IQR, 74.0-85.5 years) and 71.2% were female. Among those who met the criterion for CNS-active polypharmacy, the median number of polypharmacy-days was 193 (IQR, 88-315 polypharmacy-days). Of those with CNS-active polypharmacy, 57.8% were exposed for longer than 180 days and 6.8% for 365 days; 29.4% were exposed to 5 or more medications and 5.2% were exposed to 5 or more medication classes. Ninety-two percent of polypharmacy-days included an antidepressant, 47.1% included an antipsychotic, and 40.7% included a benzodiazepine. The most common medication class combination included an antidepressant, an antiepileptic, and an antipsychotic (12.9% of polypharmacy-days). Gabapentin was the most common medication and was associated with 33.0% of polypharmacy-days.

Conclusions And Relevance: In this cross-sectional analysis of Medicare claims data, 13.9% of older adults with dementia in 2018 filled prescriptions consistent with CNS-active polypharmacy. The lack of information on prescribing indications limits judgments about clinical appropriateness of medication combinations for individual patients.
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http://dx.doi.org/10.1001/jama.2021.1195DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7944381PMC
March 2021

Incidence of Cognitive Impairment during Aging in Rural South Africa: Evidence from HAALSI, 2014 to 2019.

Neuroepidemiology 2021 3;55(2):100-108. Epub 2021 Mar 3.

Harvard Center for Population and Development Studies, Harvard T.H. Chan School of Public Health, Cambridge, Massachusetts, USA.

Introduction: Despite rapid population aging, there are currently limited data on the incidence of aging-related cognitive impairment in sub-Saharan Africa. We aimed to determine the incidence of cognitive impairment and its distribution across key demographic, social, and health-related factors among older adults in rural South Africa.

Methods: Data were from in-person interviews with 3,856 adults aged ≥40 who were free from cognitive impairment at baseline in the population-representative cohort, "Health and Aging in Africa: a Longitudinal Study of an INDEPTH Community in South Africa" (HAALSI), in Agincourt sub-district, Mpumalanga province, South Africa (2014-19). Cognitive impairment was defined as scoring <1.5 standard deviations below the mean of the baseline distribution of orientation and episodic memory scores. Incidence rates and rate ratios for cognitive impairment were estimated according to key demographic, social, and health-related factors, adjusted for age, sex/gender, and country of birth.

Results: The incidence of cognitive impairment was 25.7/1,000 person-years (PY; 95% confidence interval [CI]: 23.0-28.8), weighted for mortality (12%) and attrition (6%) over the 3.5-year mean follow-up (range: 1.5-4.8 years). Incidence increased with age, from 8.9/1,000 PY (95% CI: 5.2-16.8) among those aged 40-44 to 93.5/1,000 PY (95% CI: 75.9-116.3) among those aged 80+, and age-specific risks were similar by sex/gender. Incidence was strongly associated with formal education and literacy, as well as marital status, household assets, employment, and alcohol consumption but not with history of smoking, hypertension, stroke, angina, heart attack, diabetes, or prevalent HIV.

Conclusions: This study presents some of the first incidence rate estimates for aging-related cognitive impairment in rural South Africa. Social disparities in incident cognitive impairment rates were apparent in patterns similar to those observed in many high-income countries.
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http://dx.doi.org/10.1159/000513276DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8058235PMC
March 2021

The Influence of Cognitive Impairment on Post-Operative Outcomes.

Ann Surg 2021 Feb 10. Epub 2021 Feb 10.

Department of Internal Medicine and Cognitive Health Services Research Program, University of Michigan, Ann Arbor, MI Department of Neurology and Stroke Program, University of Michigan, Ann Arbor, MI Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI Department of Surgery, University of Michigan, Ann Arbor, MI Michigan Opioid Prescribing Engagement Network, Ann Arbor, MI VA Ann Arbor Healthcare System, Ann Arbor, MI Institute for Social Research, U-M, Ann Arbor, MI.

Objective: To examine differences in rates of elective surgery, postoperative mortality, and readmission by pre-existing cognitive status among Medicare beneficiaries undergoing surgery.

Background: Mild cognitive impairment (MCI) is common among older adults, but the impact of MCI on surgical outcomes is understudied.

Methods: We conducted a retrospective cohort study of individuals ≥65 who underwent surgery between 2001 and 2015 using data from the nationally-representative Health and Retirement Study linked with Medicare claims. Cognitive status was assessed by the modified Telephone Interview for Cognitive Status score and categorized as normal cognition (score: 12-27), MCI (7-11), and dementia (<7). Outcomes were 30- and 90-day postoperative mortality and readmissions. We used Cox proportional hazard models to estimate the risk of each outcome by cognition, adjusting for patient characteristics.

Results: In 6,590 patients, 69.9% had normal cognition, 20.1% had MCI, and 9.9% had dementia. Patients with MCI (79.9%) and dementia (73.6%) were less likely to undergo elective surgery than patients with normal cognition (85.9%). Patients with MCI had similar postoperative mortality and readmissions rates as patients with normal cognition. However, patients with dementia had significantly higher postoperative 90-day mortality (5.2% vs. 8.4%, p=0.002) and readmission rates (13.9% vs. 17.3%, p=0.038).

Conclusion: Patients with self-reported MCI are less likely to undergo elective surgery but have similar postoperative outcomes compared with patients with normal cognition. Despite the variability of defining MCI, our findings suggest that MCI may not confer additional risk for older individuals undergoing surgery, and should not be a barrier for surgical care.
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http://dx.doi.org/10.1097/SLA.0000000000004799DOI Listing
February 2021

Development, Validation, and Performance of a New Physical Functioning-Weighted Multimorbidity Index for Use in Administrative Data.

J Gen Intern Med 2021 Jan 19. Epub 2021 Jan 19.

Division of General Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA.

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http://dx.doi.org/10.1007/s11606-020-06486-7DOI Listing
January 2021

A Method to Quantify Mean Hypertension Treatment Daily Dose Intensity Using Health Care System Data.

JAMA Netw Open 2021 01 4;4(1):e2034059. Epub 2021 Jan 4.

Department of Preventive Medicine, University of Tennessee Health Science Center, Memphis.

Importance: Simple measures of hypertension treatment, such as achievement of blood pressure (BP) targets, ignore the intensity of treatment once the BP target is met. High-intensity treatment involves increased treatment burden and can be associated with potential adverse effects in older adults. A method was previously developed to identify older patients receiving intense hypertension treatment by low BP and number of BP medications using national Veterans Health Administration and Medicare Part D administrative pharmacy data to evaluate which BP medications a patient is likely taking on any given day.

Objective: To further develop and validate a method to more precisely quantify dose intensity of hypertension treatment using only health system administrative pharmacy fill data.

Design, Setting, And Participants: Observational, cross-sectional study of 319 randomly selected older veterans in the national Veterans Health Administration health care system who were taking multiple BP-lowering medications and had a total of 3625 ambulatory care visits from July 1, 2011, to June 30, 2013. Measure development and medical record review occurred January 1, 2017, through November 30, 2018, and data analysis was conducted from December 1, 2019, to August 31, 2020.

Main Outcomes And Measures: For each BP-lowering medication, a moderate hypertension daily dose (HDD) was defined as half the maximum dose above which no further clinical benefit has been demonstrated by that medication in hypertension trials. Patients' total HDD was calculated using pharmacy data (pharmacy HDDs), accounting for substantial delays in refills (>30 days) when a patient's pill supply was stretched (eg, cutting existing pills in half). As an external comparison, the pharmacy HDDs were correlated with doses manually extracted from clinicians' visit notes (clinically noted HDDs). How well the pharmacy HDDs correlated with clinically noted HDDs was calculated (using C statistics). To facilitate interpretation, HDDs were described in association with the number of medications.

Results: A total of 316 patients (99.1%) were male; the mean (SD) age was 75.6 (7.2) years. Pharmacy HDDs were highly correlated (r = 0.92) with clinically noted HDDs, with a mean (SD) of 2.7 (1.8) for pharmacy HDDs and 2.8 (1.8) for clinically noted HDDs. Pharmacy HDDs correlated with high-intensity, clinically noted HDDs ranging from a C statistic of 92.8% (95% CI, 92.0%-93.7%) for 2 or more clinically noted HDDs to 88.1% (95% CI, 85.5%-90.6%) for 6 or more clinically noted HDDs.

Conclusions And Relevance: This study suggests that health system pharmacy data may be used to accurately quantify hypertension regimen dose intensity. Together with clinic-measured BP, this tool can be used in future health system-based research or quality improvement efforts to fine-tune, manage, and optimize hypertension treatment in older adults.
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http://dx.doi.org/10.1001/jamanetworkopen.2020.34059DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7811181PMC
January 2021

Financial Presentation of Alzheimer Disease and Related Dementias.

JAMA Intern Med 2021 Feb;181(2):220-227

Federal Reserve Board of Governors & Howard University, Washington, DC.

Importance: Alzheimer disease and related dementias (ADRD), currently incurable neurodegenerative diseases, can threaten patients' financial status owing to memory deficits and changes in risk perception. Deteriorating financial capabilities are among the earliest signs of cognitive decline, but the frequency and extent of adverse financial events before and after diagnosis have not been characterized.

Objectives: To describe the financial presentation of ADRD using administrative credit data.

Design, Setting, And Participants: This retrospective secondary data analysis of consumer credit report outcomes from 1999 to 2018 linked to Medicare claims data included 81 364 Medicare beneficiaries living in single-person households.

Exposures: Occurrence of adverse financial events in those with vs without ADRD diagnosis and time of adverse financial event from ADRD diagnosis.

Main Outcomes And Measures: Missed payments on credit accounts (30 or more days late) and subprime credit scores.

Results: Overall, 54 062 (17 890 [33.1%] men; mean [SD] age, 74 [7.3] years) were never diagnosed with ADRD during the sample period and 27 302 had ADRD for at least 1 quarter of observation (8573 [31.4%] men; mean [SD] age, 79.4 [7.5] years). Single Medicare beneficiaries diagnosed with ADRD were more likely to miss payments on credit accounts as early as 6 years prior to diagnosis compared with demographically similar beneficiaries without ADRD (7.7% vs 7.3%; absolute difference, 0.4 percentage points [pp]; 95% CI, 0.07-0.70:) and to develop subprime credit scores 2.5 years prior to diagnosis (8.5% vs 8.1%; absolute difference, 0.38 pp; 95% CI, 0.04-0.72). By the quarter after diagnosis, patients with ADRD remained more likely to miss payments than similar beneficiaries who did not develop ADRD (7.9% vs 6.9%; absolute difference, 1.0 pp; 95% CI, 0.67-1.40) and more likely to have subprime credit scores than those without ADRD (8.2% vs 7.5%; absolute difference, 0.70 pp; 95% CI, 0.34-1.1). Adverse financial events were more common among patients with ADRD in lower-education census tracts. The patterns of adverse events associated with ADRD were unique compared with other medical conditions (eg, glaucoma, hip fracture).

Conclusions And Relevance: Alzheimer disease and related dementias were associated with adverse financial events years prior to clinical diagnosis that become more prevalent after diagnosis and were most common in lower-education census tracts.
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http://dx.doi.org/10.1001/jamainternmed.2020.6432DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7851732PMC
February 2021

Same-Sex Couples and Cognitive Impairment: Evidence from the Health and Retirement Study.

J Gerontol B Psychol Sci Soc Sci 2020 Nov 19. Epub 2020 Nov 19.

Department of Internal Medicine, Institute for Social Research and VA Center for Clinical Management Research, University of Michigan.

Objectives: We provide the first nationally representative population-based study of cognitive disparities among same-sex and different-sex couples in the United States.

Method: We analyzed data from the Health and Retirement Study (2000-2016). The sample included 23,669 respondents (196 same-sex partners and 23,473 different-sex partners) aged 50 and older who contributed to 85,117 person-period records (496 from same-sex partners and 84,621 from different-sex partners). Cognitive impairment was assessed using the modified version of the Telephone Interview for Cognitive Status (TICS). Mixed-effects discrete-time hazard regression models were estimated to predict the odds of cognitive impairment.

Results: The estimated odds of cognitive impairment were 78% (p < .01) higher for same-sex partners than for different-sex partners. This disparity was mainly explained by differences in marital status and, to a much lesser extent, by differences in physical and mental health. Specifically, a significantly higher proportion of same-sex partners than different-sex partners were cohabiting rather than legally married (72.98% vs. 5.42% in the study sample), and cohabitors had a significantly higher risk of cognitive impairment than their married counterparts (OR = 1.53, p < .001).

Discussion: The findings indicate that designing and implementing public policies and programs that work to eliminate societal homophobia, especially among older adults, is a critical step in reducing the elevated risk of cognitive impairment among older same-sex couples.
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http://dx.doi.org/10.1093/geronb/gbaa202DOI Listing
November 2020

Impact of Patient Mild Cognitive Impairment on Physician Decision-Making for Treatment.

J Alzheimers Dis 2020 ;78(4):1409-1417

Department of Neurology and Stroke Program, U-M, Ann Arbor, MI, USA.

Background: Older patients with mild cognitive impairment (MCI) should receive evidence-based treatments when clinically indicated. However, patients with MCI appear less likely than cognitively normal patients to receive evidence-based treatments.

Objective: To explore the influence of a patient's MCI diagnosis on physician decision-making.

Methods: Qualitative study of 18 physicians from cardiology, neurology, and internal medicine using semi-structured interviews. We sought to understand whether and how a patient's having MCI has influenced physicians' decisions about five categories of treatments or tests (surgery, invasive tests, non-invasive tests, rehabilitation, and preventive medication). We used qualitative content analysis to identify the unifying and recurrent themes.

Results: Most physician participants described MCI as influencing their recommendations for at least one treatment or test. We identified two major themes as factors that influenced physician recommendations in patients with MCI: Physicians assume that MCI patients' decreased cognitive ability will impact treatment; and physicians assume that MCI patients have poor health status and physical functioning that will impact treatment. These two themes were representative of physician beliefs that MCI patients have impaired independent decision-making, inability to adhere to treatment, inability to communicate treatment preferences, and increased risk and burden from treatment.

Conclusion: A patient's MCI diagnosis influences physician decision-making for treatment. Some physician assumptions about patients with MCI were not evidence-based. This phenomenon potentially explains why many patients with MCI get fewer effective treatments or tests than cognitively normal patients. Interventions that improve how physicians understand MCI and make decisions for treatments in patients with MCI are needed.
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http://dx.doi.org/10.3233/JAD-200700DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7952022PMC
January 2020

Mild cognitive impairment and receipt of procedures for acute ischemic stroke in older adults.

J Stroke Cerebrovasc Dis 2020 Oct 2;29(10):105083. Epub 2020 Aug 2.

Department of Internal Medicine and Cognitive Health Services Research Program, University of Michigan, NCRC 16-430W, 2800 Plymouth Road, Ann Arbor, MI 48109-2800, United States; Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, United States; VA Ann Arbor Healthcare System, University of Michigan, Ann Arbor, MI, United States; Institute for Social Research, University of Michigan, Ann Arbor, MI, United States. Electronic address:

Background And Purpose: Older patients with pre-existing mild cognitive impairment (MCI) receive less evidence-based care after acute myocardial infarction, however, whether they receive less care after acute ischemic stroke (AIS) is unknown. We compared receipt of guideline-concordant procedures after AIS between older adults with pre-existing MCI and normal cognition.

Methods: Prospective study of 591 adults ≥65 hospitalized for AIS between 2000 and 2014, and followed through 2015 using data from the nationally representative Health and Retirement Study, Medicare and American Hospital Association. We assessed pre-existing MCI (modified Telephone Interview for Cognitive Status score of 7-11) and normal cognition (score of 12-27). Primary outcome was a composite quality measure representing the number of 4 procedures (carotid imaging, cardiac monitoring, echocardiogram, and rehabilitation assessment) received within 30 days after AIS (ordinal scale with values of 0, 1, 2, 3-4).

Results: Among survivors of AIS, 26.9% had pre-existing MCI (62.9% were women, with a mean [SD] age of 82.4 [7.7] years), and 73.1% had normal cognition (51.4% were women, with a mean age of 78.4 [7.2] years). Patients with pre-existing MCI, compared to cognitively normal patients, had 39% lower cumulative odds of receiving the composite quality measure (unadjusted cumulative odds ratio, OR, 0.61 [95% CI, 0.43-0.87]; P=0.006). However, this association became non-significant after adjusting for patient and hospital factors (adjusted cumulative OR, 0.83 [95% CI, 0.56-1.24]; P=0.37). Lower cumulative odds of receiving the composite quality measure were associated with older patient age (adjusted cumulative OR per 1-year older age, 0.97 [95% CI, 0.95-0.99]; P=0.01) and Southern hospitals (adjusted cumulative OR for South vs North, 0.54 [95% CI, 0.31-0.94]; P=0.03).

Conclusions: Differences in receipt of guideline-concordant procedures after AIS exist between patients with pre-existing MCI and normal cognition. These differences were largely explained by patient and regional factors associated with receiving less AIS care.
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http://dx.doi.org/10.1016/j.jstrokecerebrovasdis.2020.105083DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7490756PMC
October 2020

Comparison of Health Outcomes Among High- and Low-Income Adults Aged 55 to 64 Years in the US vs England.

JAMA Intern Med 2020 09;180(9):1185-1193

Department of Internal Medicine, School of Medicine, University of Michigan, Ann Arbor.

Importance: Socioeconomic differences in life expectancy, health, and disability have been found in European countries as well as in the US. Identifying the extent and pattern of health disparities, both within and across the US and England, may be important for informing public health and public policy aimed at reducing these disparities.

Objective: To compare the health of US adults aged 55 to 64 years with the health of their peers in England across the high and low ranges of income in each country.

Design, Setting, And Participants: Using data from the Health and Retirement Study (HRS) and the English Longitudinal Study of Ageing (ELSA) for 2008-2016, a pooled cross-sectional analysis of comparably measured health outcomes, with adjustment for demographic characteristics and socioeconomic status, was conducted. The analysis sample included community-dwelling adults aged 55 to 64 years from the HRS and ELSA, resulting in 46 887 person-years of observations. Data analysis was conducted from September 17, 2019, to May 12, 2020.

Exposures: Residence in the US or England and yearly income.

Main Outcomes And Measures: Sixteen health outcomes were compared, including 5 self-assessed outcomes, 3 directly measured outcomes, and 8 self-reported physician-diagnosed health conditions.

Results: This cross-sectional study included 12 879 individuals and 31 928 person-years from HRS (mean [SD] age, 59.2 [2.8] years; 51.9% women) and 5693 individuals and 14 959 person-years from ELSA (mean [SD] age, 59.3 [2.9] years; 51.0% women). After adjusting for individual-level demographic characteristics and socioeconomic status, a substantial health gap between lower-income and higher-income adults was found in both countries, but the health gap between the bottom 20% and the top 20% of the income distribution was significantly greater in the US than England on 13 of 16 measures. The adjusted US-England difference in the prevalence gap between the bottom 20% and the top 20% ranged from 3.6 percentage points (95% CI, 2.0-5.2 percentage points) in stroke to 9.7 percentage points (95% CI, 5.4-13.9 percentage points) for functional limitation. Among individuals in the lowest income group in each country, those in the US group vs the England group had significantly worse outcomes on many health measures (10 of 16 outcomes in the bottom income decile); the significant differences in adjusted prevalence of health problems in the US vs England for the bottom income decile ranged from 7.6% (95% CI, 6.0%-9.3%) vs 3.8% (95% CI, 2.6%-4.9%) for stroke to 75.7% (95% CI, 72.7%-78.8%) vs 59.5% (95% CI, 56.3%-62.7%) for functional limitation. Among individuals in the highest income group, those in the US group vs England group had worse outcomes on fewer health measures (4 of 16 outcomes in the top income decile); the significant differences in adjusted prevalence of health problems in the US vs England for the top income decile ranged from 36.9% (95% CI, 33.4%-40.4%) vs 30.0% (95% CI, 27.2%-32.7%) for hypertension to 35.4% (95% CI, 32.0%-38.7%) vs 22.5% (95% CI, 19.9%-25.1%) for arthritis.

Conclusions And Relevance: For most health outcomes examined in this cross-sectional study, the health gap between adults with low vs high income appeared to be larger in the US than in England, and the health disadvantages in the US compared with England are apparently more pronounced among individuals with low income. Public policy and public health interventions aimed at improving the health of adults with lower income should be a priority in the US.
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http://dx.doi.org/10.1001/jamainternmed.2020.2802DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7358980PMC
September 2020

Hypertension and Cognitive Health Among Older Adults in India.

J Am Geriatr Soc 2020 08;68 Suppl 3:S29-S35

Division of General Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA.

Objectives: To assess the prevalence of diagnosed and undiagnosed hypertension and their relationship to cognitive function in older adults in India.

Design: Longitudinal Aging Study in India-Diagnostic Assessment of Dementia (LASI-DAD), an in-depth national study of late-life cognition and dementia.

Setting: Geriatric hospitals and respondents' homes across 14 states in India.

Participants: N = 2,874 individuals aged 60 years and older from LASI-DAD.

Measurements: Hypertension was identified by self-report of physician diagnosis or measured blood pressure (BP) of 140/90 mmHg or higher. Undiagnosed hypertension was defined as hypertensive BP measurements, but no physician diagnosis. Controlled hypertension was defined as BP lower than 140/90 mmHg among those with a physician diagnosis. Total hypertension included both diagnosed and undiagnosed hypertension. A summary cognition score, derived from the sum of 18 cognitive tests administered in the LASI-DAD (range = 0-360) was used to assess cognitive function.

Results: Total hypertension prevalence was 63.2% (41.5% diagnosed and 21.6% undiagnosed). Among those with hypertension, 34.5% were undiagnosed, 34.2% were diagnosed but uncontrolled, and 31.3% were diagnosed and controlled. Neither diagnosed nor undiagnosed hypertension was related to cognitive function in fully adjusted models. Older age, female sex, less education, being widowed, rural residence, residing in the north or central regions, being in a scheduled caste or tribe, low consumption, being underweight, and history of stroke were all independently associated with worse cognitive test performance.

Conclusion: Two-thirds of older Indian adults had hypertension, with the majority being undiagnosed or diagnosed but not adequately controlled. Hypertension was not independently associated with cognitive function, whereas sociodemographic factors were independently related to cognitive function. J Am Geriatr Soc 68:S29-S35, 2020.
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http://dx.doi.org/10.1111/jgs.16741DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7523549PMC
August 2020

Sleep Difficulties and Cognition for 10 Years in a National Sample of U.S. Older Adults.

Innov Aging 2020 29;4(4):igaa025. Epub 2020 Jun 29.

Department of Internal Medicine, Institute for Social Research, Institute for Healthcare Policy and Innovation, Veterans Affairs Ann Arbor Healthcare System, University of Michigan.

Background And Objectives: Sleep difficulties are common among older adults and are associated with cognitive decline. We used data from a large, nationally representative longitudinal survey of adults aged older than 50 in the United States to examine the relationship between specific sleep difficulties and cognitive function over time.

Research Design And Methods: Longitudinal data from the 2004-2014 waves of the Health and Retirement Study were used in the current study. We examined sleep difficulties and cognitive function within participants and across time ( = 16 201). Sleep difficulty measures included difficulty initiating sleep, nocturnal awakenings, early morning awakenings, and waking up feeling rested from rarely/never (1) to most nights (3). The modified Telephone Interview for Cognitive Status was used to measure cognitive function. Generalized linear mixed models were used with time-varying covariates to examine the relationship between sleep difficulties and cognitive function over time.

Results: In covariate-adjusted models, compared to "never" reporting sleep difficulty, difficulty initiating sleep "most nights" was associated with worse cognitive function over time (Year 2014: = -0.40, 95% CI: -0.63 to -0.16, < .01) as was difficulty waking up too early "most nights" (Year 2014: = -0.31, 95% CI: -0.56 to -0.07, < .05). In covariate-adjusted analyses, compared to "never" reporting waking up feeling rested, cognitive function was higher among those who reported waking up feeling rested "some nights" (Year 2010: = 0.21, 95% CI: 0.02 to 0.40, < .05).

Discussion And Implications: Our findings highlight an association between early morning awakenings and worse cognitive function, but also an association between waking up feeling rested and better cognitive function over time.
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http://dx.doi.org/10.1093/geroni/igaa025DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7408188PMC
June 2020

Changes in Health Care Access and Utilization for Low-SES Adults Aged 51-64 Years After Medicaid Expansion.

J Gerontol B Psychol Sci Soc Sci 2021 Jun;76(6):1218-1230

Department of Internal Medicine, University of Michigan, Ann Arbor.

Objectives: Whether the Affordable Care Act (ACA) insurance expansions improved access to care and health for adults aged 51-64 years has not been closely examined. This study examined longitudinal changes in access, utilization, and health for low-socioeconomic status adults aged 51-64 years before and after the ACA Medicaid expansion.

Methods: Longitudinal difference-in-differences (DID) study before (2010-2014) and after (2016) Medicaid expansion, including N = 2,088 noninstitutionalized low-education adults aged 51-64 years (n = 633 in Medicaid expansion states, n = 1,455 in nonexpansion states) from the nationally representative biennial Health and Retirement Study. Outcomes included coverage (any, Medicaid, and private), access (usual source of care, difficulty finding a physician, foregone care, cost-related medication nonadherence, and out-of-pocket costs), utilization (outpatient visit and hospitalization), and health status.

Results: Low-education adults aged 51-64 years had increased rates of Medicaid coverage (+10.6 percentage points [pp] in expansion states, +3.2 pp in nonexpansion states, DID +7.4 pp, p = .001) and increased likelihood of hospitalizations (+9.2 pp in expansion states, -1.1 pp in nonexpansion states, DID +10.4 pp, p = .003) in Medicaid expansion compared with nonexpansion states after 2014. Those in expansion states also had a smaller increase in limitations in paid work/housework over time, compared to those in nonexpansion states (+3.6 pp in expansion states, +11.0 pp in nonexpansion states, DID -7.5 pp, p = .006). There were no other significant differences in access, utilization, or health trends between expansion and nonexpansion states.

Discussion: After Medicaid expansion, low-education status adults aged 51-64 years were more likely to be hospitalized, suggesting poor baseline access to chronic disease management and pent-up demand for hospital services.
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http://dx.doi.org/10.1093/geronb/gbaa123DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8200354PMC
June 2021

Prevalence of Lifetime History of Traumatic Brain Injury among Older Male Veterans Compared with Civilians: A Nationally Representative Study.

J Neurotrauma 2020 12 26;37(24):2680-2685. Epub 2020 Aug 26.

Department of Neurology, University of California, San Francisco, San Francisco, California, USA.

Traumatic brain injury (TBI) is common among older adults as well as among veterans in the United States and can increase risk for dementia. We compared prevalence of TBI in older male veterans and civilians using a nationally representative sample. We examined data from 599 male respondents to the 2014 wave of the Health and Retirement Study (HRS), a nationally representative survey of older adults, randomly selected to participate in a comprehensive TBI survey. Respondents self-reported no injury, non-TBI head/neck injury (NTI), or TBI. We used weighted analyses to examine prevalence of injury and relative risk of injury subtypes. Among male veterans, we found a national prevalence of more than 70% for lifetime history of any head/neck injury (TBI plus NTI), 14.3% for multiple NTI, and 36% for lifetime history of at least one TBI. In contrast, prevalence estimates for male civilians were 58% for lifetime history of head/neck injury, 4.8% for multiple NTI, and 45% for lifetime history of at least one TBI (all comparisons,  < 0.001). Male civilians have higher self-reported TBI prevalence, whereas male veterans have higher self-reported NTI and multiple-NTI prevalence. Further research on drivers of the unexpectedly higher prevalence of lifetime history of TBI in male civilians, as well as on mechanisms and sequelae of the highly prevalent non-TBI head/neck injuries among older male veterans, is warranted.
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http://dx.doi.org/10.1089/neu.2020.7062DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7869884PMC
December 2020

Association of Blood Pressure and Cognition after Stroke.

J Stroke Cerebrovasc Dis 2020 Jul 4;29(7):104754. Epub 2020 May 4.

Department of Neurology, University of Michigan Medical School, and Department of Epidemiology, University of Michigan School of Public Health, Ann Arbor, Michigan.

Background And Aim: It is unclear whether blood pressure (BP) is associated with cognition after stroke. We examined associations between systolic and diastolic BP (SBP, DBP), pulse pressure (PP), mean arterial pressure (MAP), and cognition, each measured 90 days after stroke.

Methods: Cross-sectional analysis of prospectively obtained data of 432 dementia-free subjects greater than or equal to 45 (median age, 66; 45% female) with stroke (92% ischemic; median NIH stroke score, 3 [IQR, 2-6]) from the population-based Brain Attack Surveillance in Corpus Christi (BASIC) project in 2011-2013.

Primary Outcome: Modified Mini-Mental Status Examination (3MSE; range, 0-100).

Secondary Outcomes: Animal Fluency Test (AFT; range, 0-10) and Trail Making Tests A and B (number of correct items [range, 0-25]/completion time [Trails A: 0-180 seconds; Trails B: 0-300 second]). Linear or tobit regression adjusted associations for age, education, and race/ethnicity as well as variables significantly associated with BP and cognition.

Results: Higher SBP, lower DBP, higher PP, and lower MAP each were associated with worse cognitive performance for all 4 tests (all P < .001). After adjusting for patient factors, no BP measures were associated with any of the 4 tests (all P > .05). Lower cognitive performance was associated with older age, less education, Mexican American ethnicity, diabetes, higher stroke severity, more depressive symptoms, and lower BMI. Among survivors with hypertension, anti-hypertensive medication use 90 days after stroke was significantly associated with higher AFT scores (P = .02) but not other tests (P > .15).

Conclusions: Stroke survivors' BP levels were not associated with cognitive performance at 90 days independent of sociodemographic and clinical factors.
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http://dx.doi.org/10.1016/j.jstrokecerebrovasdis.2020.104754DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7934908PMC
July 2020

Neuropsychological assessment of mild cognitive impairment in Latinx adults: A scoping review.

Neuropsychology 2020 Jul 13;34(5):493-510. Epub 2020 Apr 13.

Stroke Program, University of Michigan Medical School.

Latinx populations are rapidly growing and aging in the United States. There is a critical need to accurately and efficiently detect those at risk for dementia, particularly those with mild cognitive impairment (MCI). MCI diagnosis often relies on neuropsychological assessment, although cultural, demographic, and linguistic characteristics may impact test scores. This study provides a scoping review of neuropsychological studies on MCI in Hispanic/Latinx populations to evaluate how studies report and account for these factors in diagnosis of MCI. Studies were identified using Web of Science, PubMed, and Scopus, using search terms (Hispanic* OR Latin* OR "Mexican American*" OR "Puerto Ric*" OR Caribbean) and ("Mild Cognitive Impairment" OR MCI). Studies using neuropsychological tests in diagnosis of MCI for Latinx individuals in the United States were identified. Sample characterization (e.g., country of origin, literacy, language preference and proficiency), neuropsychological testing methods (e.g., test selection and translation, normative data source), and method of MCI diagnosis were reviewed. Forty-four articles met inclusion criteria. There was considerable variability in reporting of demographic, cultural and linguistic factors across studies of MCI in Latinx individuals. For example, only 5% of studies reported nativity status, 52% reported information on language preference and use, and 34% reported the method and/or source of test translation and adaptation. Future studies of diagnosis of MCI in Latinx individuals should report cultural details and use of appropriate neuropsychological assessment tools and normative data. This is important to accurately estimate the prevalence of MCI in Latinx individuals. (PsycInfo Database Record (c) 2020 APA, all rights reserved).
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http://dx.doi.org/10.1037/neu0000628DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8209654PMC
July 2020

Is social capital protective against hospital readmissions?

BMC Health Serv Res 2020 Mar 24;20(1):248. Epub 2020 Mar 24.

University of Michigan, School of Public Health, Ann Arbor, USA.

Background: To evaluate the association between social capital and 30-day readmission to the hospital among Medicare beneficiaries overall, beneficiaries with dementia and related memory disorders, and beneficiaries with dual eligibility for Medicaid.

Methods: Using Health and Retirement Study (HRS) data linked with 2008-2015 Medicare claims from traditional Medicare beneficiaries hospitalized during the study period (1246 unique respondents, 2212 total responses), we examined whether dementia and related memory disorders and dual eligibility were associated with social capital. We then estimated a multiple regression model to test whether social capital was associated with a reduced likelihood of readmission.

Results: Dementia was associated with an - 0.241 standard deviation (sd) change in social capital (95% CI: - 0.378, - 0.103), dual eligibility with a - 0.461 sd change (95% CI: - 0.611, - 0.310), and the occurrence of both was associated with an additional - 0.236 sd change (95% CI: - 0.525, - 0.053). 30-day readmission rates were 14.47% over the study period. In both adjusted and unadjusted models, social capital was associated with small and nonsignificant differences in 30-day readmissions. These effects did not vary across dementia status and socioeconomic status.

Conclusions: Dementia and dual eligibility were associated with lower social capital, but social capital was not associated with the risk of readmission for any population.
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http://dx.doi.org/10.1186/s12913-020-05092-xDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7092426PMC
March 2020

Physician decision-making and recommendations for stroke and myocardial infarction treatments in older adults with mild cognitive impairment.

PLoS One 2020 17;15(3):e0230446. Epub 2020 Mar 17.

Department of Neurology and Stroke Program, U-M, Ann Arbor, MI, United States of America.

Evidence suggests that older adults with mild cognitive impairment (MCI) might not receive evidence-based treatments. We explored the impact of patient MCI on physician decision-making and recommendations for acute ischemic stroke (AIS) and acute myocardial infarction (AMI) in a pilot concurrent mixed-methods study of physicians recruited from one academic center. The mailed survey included a clinical vignette of AIS or AMI where the patient cognitive status was randomized (normal cognition, MCI, or early-stage dementia). The primary outcome was a composite summary measure of the proportion of guideline-concordant treatments recommended. Linear regression compared the primary outcome across patient cognition groups adjusting for physician characteristics. Semi-structured interviews done with 18 physicians (4 cardiologists, 9 neurologists, 5 internists) using a standard guide. Survey response rate was 72% (82/114) (49/61 neurologists; 33/53 cardiologists). As patient cognition worsened, neurologists recommended less guideline-concordant treatments after AIS (Ptrend<0.001 across patient cognition groups). Cardiologists did not after AMI (Ptrend = 0.11) in adjusted analyses. Neurologists' recommendation of guideline-concordant treatments after AIS was non-significantly lower in patients with MCI (composite measure, 0.13 points lower; P = 0.14) and significantly lower in patients with early-stage dementia (0.33 points lower; P<0.001) compared to cognitively normal patients. Interviews identified themes that may explain these findings including physicians assumed patients with MCI, compared with cognitively normal patients, have limited life expectancy, frailty and poor functioning, prefer less treatment, might adhere less to treatment, and have greater risks or burdens from treatment. These results suggest that patient MCI influences physician decision-making and recommendations for AIS and AMI treatments.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0230446PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7077853PMC
June 2020

The Relationship of Loneliness to End-of-Life Experience in Older Americans: A Cohort Study.

J Am Geriatr Soc 2020 05 3;68(5):1064-1071. Epub 2020 Mar 3.

Division of Hospital Medicine, University of Michigan, Ann Arbor, Michigan.

Objectives: Little is known about the relationship between loneliness and end-of-life (EOL) experience including symptom burden, intensity of care, and advance care planning among older adults.

Design: Secondary analysis of the Health and Retirement Study (HRS).

Setting: Population based.

Participants: Decedents older than 50 years who died between 2004 and 2014 (n = 8700). Exclusions included those who were ineligible for surveys assessing loneliness (n = 2932) or had missing or incomplete loneliness or symptom data (n = 2872).

Measurements: Individuals were characterized as lonely based on responses to the three-item Revised University of California, Los Angeles Loneliness Scale in the most recent HRS survey before death. Outcomes were proxy reports of total EOL symptom burden, intensity of EOL care (eg, late hospice enrollment, place of death, hospitalizations, use of life support), and advance care planning. Results were expressed as adjusted odds ratios (aORs) with 95% confidence intervals (CIs).

Results: One-third of 2896 decedents (n = 942) were lonely. After adjusting for demographics, socioeconomic status, multimorbidity, depressive symptoms, family and friends, and social support, loneliness was independently associated with increased total symptom burden at EOL (ß = .13; P = .004). Compared with nonlonely individuals, lonely decedents were more likely to use life support in the last 2 years of life (35.5% vs 29.4%; aOR = 1.36; 95% CI = 1.08-1.71) and more likely to die in a nursing home (18.4% vs 14.2%; aOR = 1.78; 95% CI = 1.30-2.42). No significant differences in other measures of intense care (late hospice enrollment, number of hospitalizations, or dialysis use) or likelihood of advance care planning were observed.

Conclusion: Lonely older people may be burdened by more symptoms and may be exposed to more intense EOL care compared with nonlonely people. Interventions aiming to screen for, prevent, and mitigate loneliness during the vulnerable EOL period are necessary. J Am Geriatr Soc 68:1064-1071, 2020.
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http://dx.doi.org/10.1111/jgs.16354DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7234919PMC
May 2020

Physical and Functional Impairment Among Older Adults With a History of Traumatic Brain Injury.

J Head Trauma Rehabil 2020 Jul/Aug;35(4):E320-E329

San Francisco Veterans Affairs Medical Center, San Francisco, California (Drs Kornblith, Yaffe, and Gardner); Division of General Medicine, University of Michigan Health System, Ann Arbor (Dr Langa); Veterans Affairs Center for Practice Management and Outcomes Research, Washington, District of Columbia (Dr Langa); Institute for Social Research, University of Michigan, Ann Arbor (Dr Langa); Institute of Gerontology, University of Michigan, Ann Arbor (Dr Langa); Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor (Dr Langa); and Departments of Neurology (Drs Yaffe and Gardner) and Psychiatry & Epidemiology & Biostatistics (Dr Yaffe), University of California San Francisco (UCSF).

Objectives: To examine the association of lifetime history of traumatic brain injury (TBI) with later-life physical impairment (PI) and functional impairment (FI) and to evaluate the impact of neurobehavioral symptoms that frequently co-occur with TBI on these relations.

Participants: A total of 1148 respondents to the 2014 Wave of the Health and Retirement Study, a nationally representative survey of older community-dwelling adults, randomly selected to participate in a TBI exposure survey. They reported no prior TBI (n = 737) or prior TBI (n = 411).

Design: Cross-sectional survey study.

Main Measures: Physical impairment (self-reported difficulty with ≥1 of 8 physical activities); FI (self-reported difficulty with ≥1 of 11 activities of daily living); self-reported current neurobehavioral symptoms (pain, sleep problems, depression, subjective memory impairment); The Ohio State University TBI Identification Method (OSU-TBI-ID)-short form.

Analyses: Stepwise logistic regression models ([1] unadjusted; [2] adjusted for demographics and medical comorbidities; [3] additionally adjusted for neurobehavioral symptoms) compared PI and FI between TBI groups.

Results: Traumatic brain injury-exposed (mean: 33.6 years postinjury) respondents were younger, less likely to be female, and reported more comorbidities and neurobehavioral symptoms. Although TBI was significantly associated with increased odds of PI and FI in unadjusted models and models adjusted for demographics/comorbidities (adjusted odds ratio, 95% confidence interval: PI 1.62, 1.21-2.17; FI 1.60, 1.20-2.14), this association was no longer statistically significant after further adjustment for neurobehavioral symptoms.

Conclusion: History of TBI is associated with substantial PI and FI among community-dwelling older adults. Further research is warranted to determine whether aggressive management of neurobehavioral symptoms in this population may mitigate long-term PI and FI in this population.
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http://dx.doi.org/10.1097/HTR.0000000000000552DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7335322PMC
July 2021

Biomarker-Informed Treatment Decisions in Cognitively Impaired Patients Do Not Apply to Preclinical Alzheimer Disease-Reply.

JAMA Intern Med 2019 12;179(12):1737

Veterans Affairs Center for Clinical Management Research, Ann Arbor, Michigan.

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http://dx.doi.org/10.1001/jamainternmed.2019.5078DOI Listing
December 2019

Methods and Early Recruitment of a Community-Based Study of Cognitive Impairment Among Mexican Americans and Non-Hispanic Whites: The BASIC-Cognitive Study.

J Alzheimers Dis 2020 ;73(1):185-196

University of Michigan, School of Public Health, Ann Arbor, MI, USA.

Background: As the Mexican American (MA) population grows and ages, there is an urgent need to estimate the prevalence of cognitive impairment or dementia (CID), cognitive trajectories, and identify community resource needs. The Brain Attack Surveillance in Corpus Christi (BASIC)-Cognitive project is a population-based study to address these issues among older MAs and non-Hispanic whites (NHW) and their informal care providers.

Objective: Present the methodology and initial recruitment findings for the BASIC-Cognitive project.

Method: Random, door-to-door case ascertainment is used in Nueces County, Texas, to recruit community-dwelling and nursing home residents ≥65 and informal care providers. Households are identified from a two-stage area probability sample, using Census data to aim for equal balance of MAs and NHWs. Individuals with cognitive screens indicative of possible CID complete neuropsychological assessment (Harmonized Cognitive Assessment Protocol from the Health and Retirement Study). Informal care providers complete comprehensive interview and needs assessment. Study pairs repeat procedures at 2-year follow-up. Asset and concept mapping are performed to identify community resources and study care providers' perceptions of needs for individuals with CID.

Results: 1,030 age-eligible households were identified, or 27% of households for whom age could be determined. 1,320 individuals were age-eligible, corresponding to 1.3 adults per eligible household. Initial recruitment yielded robust participation in the MA eligible population (60% of 689 individuals that completed cognitive screening).

Conclusion: The BASIC-Cognitive study will provide critical information regarding the prevalence of CID in MAs, the impact of caregiving, and allocation of community resources to meet the needs of this population.
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http://dx.doi.org/10.3233/JAD-190761DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7282317PMC
April 2021