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Biomedical subjects

Anthony J Perkins

Publications and source records attributed to Anthony J Perkins.

At least 19 recordsLinked to original sources
PubMed2006

Effectiveness of collaborative care for older adults with Alzheimer disease in primary care: a randomized controlled trial.

CONTEXT: Most older adults with dementia will be cared for by primary care physicians, but the primary care practice environment presents important challenges to providing quality care. OBJECTIVE: To test the effectiveness of a collaborative care model to improve the quality of care for patients with Alzheimer disease. DESIGN, SETTING, AND PATIENTS: Controlled clinical trial of 153 older adults with Alzheimer disease and their caregivers who were randomized by physician to receive collaborative care management (n = 84) or augmented usual care (n = 69) at primary care practices within 2 US university-affiliated health care systems from January 2002 through August 2004. Eligible patients (identified via screening or medical record) met diagnostic criteria for Alzheimer disease and had a self-identified caregiver. INTERVENTION: Intervention patients received 1 year of care management by an interdisciplinary team led by an advanced practice nurse working with the patient's family caregiver and integrated within primary care. The team used standard protocols to initiate treatment and identify, monitor, and treat behavioral and psychological symptoms of dementia, stressing nonpharmacological management. MAIN OUTCOME MEASURES: Neuropsychiatric Inventory (NPI) administered at baseline and at 6, 12, and 18 months. Secondary outcomes included the Cornell Scale for Depression in Dementia (CSDD), cognition, activities of daily living, resource use, and caregiver's depression severity. RESULTS: Initiated by caregivers' reports, 89% of intervention patients triggered at least 1 protocol for behavioral and psychological symptoms of dementia with a mean of 4 per patient from a total of 8 possible protocols. Intervention patients were more likely to receive cholinesterase inhibitors (79.8% vs 55.1%; P = .002) and antidepressants (45.2% vs 27.5%; P = .03). Intervention patients had significantly fewer behavioral and psychological symptoms of dementia as measured by the total NPI score at 12 months (mean difference, -5.6; P = .01) and at 18 months (mean difference, -5.4; P = .01). Intervention caregivers also reported significant improvements in distress as measured by the caregiver NPI at 12 months; at 18 months, caregivers showed improvement in depression as measured by the Patient Health Questionnaire-9. No group differences were found on the CSDD, cognition, activities of daily living, or on rates of hospitalization, nursing home placement, or death. CONCLUSIONS: Collaborative care for the treatment of Alzheimer disease resulted in significant improvement in the quality of care and in behavioral and psychological symptoms of dementia among primary care patients and their caregivers. These improvements were achieved without significantly increasing the use of antipsychotics or sedative-hypnotics. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT00246896.

Activities of Daily Living↗
PubMed2006

Who refuses the diagnostic assessment for dementia in primary care?

OBJECTIVE: Early screening and detection of dementia in primary care remains controversial. At least half of the patients identified as cognitively impaired by screening instruments do not meet criteria for dementia and some patients refuse further evaluation following a positive screen. The aim of this study was to identify the characteristics of patients who refuse a clinical diagnostic assessment for dementia after screening. DESIGN: Cross sectional study. SETTING: Seven primary care practice centers in Indianapolis. PARTICIPANTS: Four hundred and thirty-four individuals aged 65 and older who screened positive for dementia with a mean age of 74.6, 67% women, and 68% African-American. MAIN OUTCOME MEASURE: Patients' acceptance of undergoing a dementia diagnostic assessment that included neuropsychological testing, caregiver interview, and medical chart review. RESULTS: Among patients with positive screening results for dementia, approximately half (47.7%) refused further assessment to confirm their screening results. In a bivariate analysis, possible factors associated with a higher probability of refusing dementia assessment were older age and better screening score. In a multiple logistic regression model, performing well on the temporal orientation of the screening instrument was associated with a higher probability of refusing diagnostic assessment for dementia (OR = 1.37; p = 0.001). Also, African-American patients aged 80 and older were more likely to refuse the diagnostic assessment than African-Americans less than 80 years of age (OR = 3.1, p < 0.001), while there was no significant age association for white patients (OR = 0.9, p = 0.728). CONCLUSIONS: Older primary care patients who perceived themselves as having no cognitive symptoms refused dementia diagnostic assessment despite their positive screening results. We must improve our understanding of the decision-making process driving patients' beliefs and behaviors about the benefits and risks of dementia screening and diagnosis before implementing any broad-based screening initiatives for dementia.

Black or African American↗
PubMed2006

Assessment of differential item functioning for demographic comparisons in the MOS SF-36 health survey.

OBJECTIVE: To investigate whether items of the Medical Outcomes Study (MOS) 36-Item Short-Form Health Status Survey (SF-36) exhibited differential item functioning (DIF) with respect to age, education, race, and gender. METHODS: The data for this study come from two large national datasets, the MOS and the 1990 National Survey of Functional Health Status (NSFHS). We used logistic regression to identify items exhibiting DIF. RESULTS: We found DIF to be most problematic for age comparisons. Items flagged for age DIF were vigorous activities, bend/kneel/stoop, bathing or dressing, limited in kind of work, health in general, get sick easier than others, expect health to get worse, felt calm and peaceful, and all four vitality items. Items flagged for education DIF include vigorous activities, health in general, health is excellent, felt calm and peaceful, and been a happy person. Vigorous activities, walk more than a mile, health in general, and expect health to get worse were identified as DIF when comparing African-Americans with whites. No items were identified for gender DIF. CONCLUSIONS: We found several consistent patterns of DIF using two national datasets with different population characteristics. In the current study, the effect of DIF rarely transferred to the scale level. Further research is needed to corroborate these results and determine qualitatively why DIF may occur for these specific items.

Adolescent↗
PubMed2006

Comorbidity profile of dementia patients in primary care: are they sicker?

OBJECTIVES: To compare the medical comorbidity of older patients with and without dementia in primary care. DESIGN: Cross-sectional study. SETTING: Wishard Health Services, which includes a university-affiliated, urban public hospital and seven community-based primary care practice centers in Indianapolis. PARTICIPANTS: Three thousand thirteen patients aged 65 and older attending seven primary care centers in Indianapolis, Indiana. MEASUREMENTS: An expert panel diagnosed dementia using International Classification of Diseases, 10th Revision, criteria. Comorbidity was assessed using 10 physician-diagnosed chronic comorbid conditions and the Chronic Disease Score (CDS). RESULTS: Patients with dementia attending primary care have on average 2.4 chronic conditions and receive 5.1 medications. Approximately 50% of dementia patients in this setting are exposed to at least one anticholinergic medication, and 20% are prescribed at least one psychotropic medication. After adjusting for patients' age, race, and sex, patients with and without dementia have a similar level of comorbidity (mean number of chronic medical conditions, 2.4 vs 2.3, P=.66; average CDS, 5.8 vs 6.2, P=.83). CONCLUSION: Multiple medical comorbid conditions are common in older adults with and without dementia in primary care. Despite their cholinergic deficit, a substantial proportion of patients with dementia are exposed to anticholinergic medications. Models of care that incorporate this medical complexity are needed to improve the treatment of dementia in primary care.

Aged↗
PubMed2006

Limitation of a single clinical data source for measuring physicians' performance on quality indicators.

OBJECTIVES: To determine the extent to which relying on only one source of data leads to incomplete assessment of pneumococcal polysaccharide vaccine (PPV) or mammography. DESIGN: Cross-sectional survey. SETTING: An urban Midwestern academic medical center in 1998/99. PARTICIPANTS: Medicare beneficiaries aged 65 and older with at least one health encounter. MEASUREMENTS: Completion of PPV and mammography was assessed using local and Medicare records. The study compared sources of records and assessed association between services and demographics and comorbidity. RESULTS: Adding Medicare data to local data increased the computed 1-year PPV from 8.8% (264/3,002) to 15.0% and increased the 1998/99 mammography rate from 40% (343/847) to 67%. Local data sources missed 40% of PPV and 39% of mammography; Centers for Medicare and Medicaid Services sources missed 50% of PPV and 2% of mammography. The vaccinated were younger than the nonvaccinated (74 vs 76, P<.001). African Americans and those with more comorbidity were less likely to receive PPV over 8 years. Of 555 patients with a Medicare record of mammography, whites and those without Medicaid were significantly less likely to have a local record of mammography (P<.001). CONCLUSION: Neither administrative nor local clinical records provide a complete or accurate assessment of these quality indicators. Accurate assessment of quality indicators requires pooling data from multiple sources across a broad region.

Aged↗
PubMed2005

Implementing a screening and diagnosis program for dementia in primary care.

BACKGROUND: Primary care physicians are positioned to provide early recognition and treatment of dementia. We evaluated the feasibility and utility of a comprehensive screening and diagnosis program for dementia in primary care. METHODS: We screened individuals aged 65 and older attending 7 urban and racially diverse primary care practices in Indianapolis. Dementia was diagnosed according to International Classification of Diseases (ICD)-10 criteria by an expert panel using the results of neuropsychologic testing and information collected from patients, caregivers, and medical records. RESULTS: Among 3,340 patients screened, 434 scored positive but only 227 would agree to a formal diagnostic assessment. Among those who completed the diagnostic assessment, 47% were diagnosed with dementia, 33% had cognitive impairment-no dementia (CIND), and 20% were considered to have no cognitive deficit. The overall estimated prevalence of dementia was 6.0% (95% confidence interval (CI) 5.5% to 6.6%) and the overall estimate of the program cost was $128 per patient screened for dementia and $3,983 per patient diagnosed with dementia. Only 19% of patients with confirmed dementia diagnosis had documentation of dementia in their medical record. CONCLUSIONS: Dementia is common and undiagnosed in primary care. Screening instruments alone have insufficient specificity to establish a valid diagnosis of dementia when used in a comprehensive screening program; these results may not be generalized to older adults presenting with cognitive complaints. Multiple health system and patient-level factors present barriers to this formal assessment and thus render the current standard of care for dementia diagnosis impractical in primary care settings.

Aged↗
PubMed2005

Treatment of depression improves physical functioning in older adults.

OBJECTIVES: To determine the effect of collaborative care management for depression on physical functioning in older adults. DESIGN: Multisite randomized clinical trial. SETTING: Eighteen primary care clinics from eight healthcare organizations. PARTICIPANTS: One thousand eight hundred one patients aged 60 and older with major depressive disorder. INTERVENTION: Patients were randomized to the Improving Mood: Promoting Access to Collaborative Treatment (IMPACT) intervention (n=906) or to a control group receiving usual care (n=895). Control patients had access to all health services available as part of usual care. Intervention patients had access for 12 months to a depression clinical specialist who coordinated depression care with their primary care physician. MEASUREMENTS: The 12-item short form Physical Component Summary (PCS) score (range 0-100) and instrumental activities of daily living (IADLs) (range 0-7). RESULTS: The mean patient age was 71.2, 65% were women, and 77% were white. At baseline, the mean PCS was 40.2, and the mean number of IADL dependencies was 0.7; 45% of participants rated their health as fair or poor. Intervention patients experienced significantly better physical functioning at 1 year than usual-care patients as measured using between-group differences on the PCS of 1.71 (95% confidence interval (CI)=0.96-2.46) and IADLs of -0.15 (95% CI=-0.29 to -0.01). Intervention patients were also less likely to rate their health as fair or poor (37.3% vs 52.4%, P<.001). Combining both study groups, patients whose depression improved were more likely to experience improvement in physical functioning. CONCLUSION: The IMPACT collaborative care model for late-life depression improves physical function more than usual care.

Activities of Daily Living↗
PubMed2004

Common comorbidity scales were similar in their ability to predict health care costs and mortality.

OBJECTIVE: To compare the ability of commonly used measures of medical comorbidity (ambulatory care groups [ACGs], Charlson comorbidity index, chronic disease score, number of prescribed medications, and number of chronic diseases) to predict mortality and health care costs over 1 year. STUDY DESIGN AND SETTING: A prospective cohort study of community-dwelling older adults (n=3,496) attending a large primary care practice. RESULTS: For predicting health care charges, the number of medications had the highest predictive validity (R(2)=13.6%) after adjusting for demographics. ACGs (R(2)=16.4%) and the number of medications (15.0%) had the highest predictive validity for predicting ambulatory visits. ACGs and the Charlson comorbidity index (area under the receiver operator characteristic [ROC] curve=0.695-0.767) performed better than medication-based measures (area under the ROC curve=0.662-0.679) for predicting mortality. There is relatively little difference, however, in the predictive validity across these scales. CONCLUSION: In an outpatient setting, a simple count of medications may be the most efficient comorbidity measure for predicting utilization and health-care charges over the ensuing year. In contrast, diagnosis-based measures have greater predictive validity for 1-year mortality. Current comorbidity measures, however, have only poor to moderate predictive validity for costs or mortality over 1 year.

Black or African American↗
PubMed2004

Risk factors for nonelective hospitalization in frail and older adult, inner-city outpatients.

PURPOSE: In our study, we sought to improve the accuracy of predicting the risk of hospitalization and to identify older, inner-city patients who could be targeted for preventive interventions. DESIGN AND METHODS: Participants (56% were African American) in a randomized trial were from a primary care practice and included 1,041 patients living in the inner city who were either > or = 75 years of age or were > or = 50 years of age with severe disease. As a secondary analysis, we assessed patient characteristics at baseline involving five domains of health, including utilization and satisfaction. We followed participants for 12 months and recorded the occurrence of nonelective hospitalization within the study period. We developed a multivariate model using logistic regression to predict this outcome. RESULTS: The following patient characteristics independently predicted an increased risk for nonelective hospitalization: having the diagnosis of congestive heart failure, diabetes mellitus, or anemia; and having more medications prescribed, having a lower body mass index, and having more emergency department visits during the previous year. Better physical functioning reduced the risk of hospitalization. IMPLICATIONS: Moderate accuracy of a prediction model (0.73) was observed. In addition to focusing on patients with chronic disease, helping them maintain physical functioning may help reduce nonelective hospitalization.

Black or African American↗
PubMed2004

Monitoring depression treatment outcomes with the patient health questionnaire-9.

BACKGROUND: Although effective treatment of depressed patients requires regular follow-up contacts and symptom monitoring, an efficient method for assessing treatment outcome is lacking. We investigated responsiveness to treatment, reproducibility, and minimal clinically important difference of the Patient Health Questionnaire-9 (PHQ-9), a standard instrument for diagnosing depression in primary care. METHODS: This study included 434 intervention subjects from the IMPACT study, a multisite treatment trial of late-life depression (63% female, mean age 71 years). Changes in PHQ-9 scores over the course of time were evaluated with respect to change scores of the SCL-20 depression scale as well as 2 independent structured diagnostic interviews for depression during a 6-month period. Test-retest reliability and minimal clinically important difference were assessed in 2 subgroups of patients who completed the PHQ-9 twice exactly 7 days apart. RESULTS: The PHQ-9 responsiveness as measured by effect size was significantly greater than the SCL-20 at 3 months (-1.3 versus -0.9) and equivalent at 6 months (-1.3 versus -1.2). With respect to structured diagnostic interviews, both the PHQ-9 and the SCL-20 change scores accurately discriminated patients with persistent major depression, partial remission, and full remission. Test-retest reliability of the PHQ-9 was excellent, and its minimal clinically important difference for individual change, estimated as 2 standard errors of measurement, was 5 points on the 0 to 27 point PHQ-9 scale. CONCLUSIONS: Well-validated as a diagnostic measure, the PHQ-9 has now proven to be a responsive and reliable measure of depression treatment outcomes. Its responsiveness to treatment coupled with its brevity makes the PHQ-9 an attractive tool for gauging response to treatment in individual patient care as well as in clinical research.

Aged↗
PubMed2003

Acceptance of dementia screening in continuous care retirement communities: a mailed survey.

BACKGROUND: In a recent systematic review of the evidence for dementia screening to support recommendations from the US Preventive Services Task Force, we found no evidence regarding the interest or willingness of older adults to be screened, and insufficient evidence to provide an estimate of the potential harms of dementia screening. OBJECTIVE: In an attempt to address the acceptability of dementia screening, we asked older adults living in two Continuous Care Retirement Communities (CCRC) if they would agree to routine screening for memory problems. DESIGN: Cross-sectional study using self-administered mailed survey questionnaires. SETTING: Two CCRCs in Orange County, North Carolina. PARTICIPANTS: 500 residents of the independent living section of CCRCs. RESULTS: There was a 64% survey response rate. Of these, 49% of participants stated they would agree to routine screening for memory problems. In comparison to people who would not agree to routine memory screening, those who accepted memory screening were more likely to accept depression screening, be male, use drug-administration assisted devices, and take more medications. CONCLUSION: Approximately half of the residents in this affluent residential community setting were not willing to be screened routinely for memory problems. This high refusal rate indicates that dementia screening may be associated with perceived harms. We must improve our understanding of the decision-making process driving individual's beliefs and behaviors about dementia screening before implementing any broad-based screening initiatives for dementia or cognitive impairment.

Aged↗
PubMed2003

Predictors of life satisfaction in retired physicians and spouses.

BACKGROUND: With the current demographic changes, adjustment to retirement has become a major concern for physicians. Yet information on adjustment to retirement gathered from retired physicians is sparse. Information on physician spouses following retirement is currently not available. Therefore, we conducted a survey of a multi-disciplinary group of retired physicians and their spouses on adjustment to retirement. METHODS: A mail survey was sent to 1834 alumni who graduated from medical school prior to 1965. Responses were received from 795 (43 %) physicians and 455 spouses. Of the physicians, 678 indicated that they were retired or semi-retired. Life satisfaction was measured on a 9-point Likert scale. RESULTS: Levels of life satisfaction were high for both physicians and spouses. Approximately 88 % of both groups reported being mostly satisfied or better with their lives. Factors associated with better life satisfaction for physicians included better health, optimism, feelings of financial security, participation in activities and hobbies and a good sexual relationship. For spouses, good health, having a husband willing to help with chores, quality of relationships including sexual relationship and attending theatre or sporting events were associated with higher levels of life satisfaction. Spouses who had never worked reported higher levels of life satisfaction than spouses who had worked and were now retired. For changes in life satisfaction since physician retirement, predictors for both physicians and spouses were similar to those for life satisfaction. However, for physicians, both younger age and more years in retirement were independently associated with improved life satisfaction. Issues regarding loss of role and methods and reasons for retirement influenced satisfaction in the early retirees. For spouses, major challenges involved coping with changes in the marital relationship. CONCLUSIONS: Physicians and their spouses reported high levels of life satisfaction. The factors predicting life satisfaction and change in life satisfaction following retirement differed for physicians and spouses. For physicians, life satisfaction and change in life satisfaction were affected by time since retirement.

Adaptation, Psychological↗
PubMed2003

Comparison of tailored interventions to increase mammography screening in nonadherent older women.

BACKGROUND: Recent increases in mammography use have led to a decrease in mortality from breast cancer. METHODS: Building on the Health Belief Model, the Transtheoretical Model, and past effectiveness of tailored interventions, we conducted a prospective randomized trial (n = 773) to test the efficacy on mammography adherence of tailored interventions delivered by five different methods, i.e., telephone counseling, in-person counseling, physician letter, and combinations of telephone with letter and in-person with letter. RESULTS: All five interventions increased mammography adherence significantly relative to usual care (odds ratios, 1.93 to 3.55) at 6 months post intervention. The combination of in-person with physician letter was significantly more effective than telephone alone or letter alone. Women thinking about getting a mammogram at baseline were more likely to be adherent by 6 months; even those in usual care achieved 48% adherence compared with 50-70% in the intervention groups. In contrast, women not thinking about getting a mammogram needed the interventions to increase their adherence from 13% to over 30%. CONCLUSIONS: All five interventions were effective at increasing mammography adherence. Women not thinking about getting a mammogram were most likely to benefit from these tailored interventions while other women might need less intensive interventions.

Breast Neoplasms↗
PubMed2003

Mass media release of medical research results: an analysis of antihypertensive drug prescribing in the aftermath of the calcium channel blocker scare of March 1995.

BACKGROUND: Disclosure of medical research results to the public creates tension between lay medical reporters and the medical profession. OBJECTIVE: To explore the early effect of media attention on the risks associated with short-acting calcium channel blockers (CCBs) for treating hypertension after publication at a national meeting and following publication. DESIGN: Time-series analysis of prescription claims data. SETTING AND DATA SOURCE: National third-party pharmaceutical benefits manager. PATIENTS: Employed or retired persons and their families, 18 years of age or older, receiving prescription benefits from 1 of 4 national companies that contracted with the pharmaceutical benefits manager exclusively for prescription drug coverage. MEASUREMENTS: Prescription claims for antihypertensive drugs by fill date converted to a percentage of all cardiovascular drug claims. Data were grouped into weekly intervals before and immediately after the national release of negative information about CCBs on March 10, 1995 and following publication of the results on August 23, 1995. RESULTS: The most prevalent antihypertensive drugs were diuretics (21% of cardiovascular prescription claims) and calcium channel blockers (19%). A 10% decline in prescriptions filled for CCBs occurred 4 weeks following the intense media attention. Only prescriptions for long-acting calcium channel blockers declined. Alpha-1-blocker prescriptions increased by approximately the same amount that prescriptions for CCBs declined, suggesting substitution of one drug for the other. Changes in diuretic or beta-blocker prescriptions filled were not statistically significant. No immediate change in other cardiovascular drug classes occurred following journal publication. CONCLUSIONS: Intense media publicity regarding a controversial study measurably and unpredictably changed prescription claims.

Adolescent↗
PubMed2003

Difference in bone mass between black and white American children: attributable to body build, sex hormone levels, or bone turnover?

A cross-sectional study of 232 healthy children, with about equal numbers of boys and girls and blacks and whites, aged 4 to 16 yr, was conducted to investigate the racial differences in bone mineral. Bone mineral content (BMC) by dual x-ray absorptiometry was found to be similar between blacks and whites at the spine after controlling for age and Tanner stage. However, total body BMC was higher in blacks, compared with whites of the same age and Tanner stage. Height and weight alone reduced the racial difference in BMC from 152 g to 66 g in girls and from 163 g to 105 g in boys, in whom the difference was further reduced to 66 g after accounting for lean and fat body mass and subscapular skinfold. The only significant sex hormone was androstenedione, which explained another 4-5 g of the racial difference in total body BMC for both boys and girls. Among the biochemical variables, only 25OH vitamin D reduced the residual racial difference in total body BMC to 39 g in girls, whereas serum PTH, urine free deoxypyridinoline ratio, and 1,25(OH)(2) vitamin D reduced the residual difference to 25 g in boys. The residual racial differences in bone mass were not statistically significant.

Adolescent↗
PubMed2002

Risk of mortality for dementia in a developing country: the Yoruba in Nigeria.

BACKGROUND: Limited data exist on the impact of dementia in developing nations, including its association with mortality. OBJECTIVE: The purpose of this paper is to assess the relationship between dementia and five-year mortality on a community dwelling elderly Yoruba population in the developing country of Nigeria and to compare those results with those from an elderly African-American community in Indianapolis. METHODS: A two-phase design was used to ascertain dementia status in two sites. In the first phase, the Community Screening Instrument for Dementia (CSI-D) was administered. In the second phase, subjects were sampled for the clinical assessment according to their CSI-D performance category. Proportional hazards regression was used to assess the relationship between mortality and cognitive status at both sites after adjusting for demographics and chronic disease conditions. RESULTS: For the entire screened population, poor and intermediate performance on the CSI-D is associated with increased mortality at both sites; however the effect of CSI-D performance did not significantly differ between the two sites. For the clinically assessed sample, dementia was significantly associated with increased mortality at both sites (Ibadan RR = 2.83, Indianapolis RR = 2.05), but the effect was not significantly different across the two sites. CONCLUSION: Dementia resulted in an increased risk of mortality for Yoruba of a magnitude similar to African-Americans suggesting that the impact of dementia on mortality risk may be similar for developing and developed countries.

Aged↗
PubMed2002

Relationships between comorbidity and health behaviors related to hypertension in NHANES III.

BACKGROUND: Health behaviors such as diet, exercise, and smoking are frequently studied among persons with one particular diagnosis; however, comorbidities that complicate our understanding of behavior patterns are often present. In addition, behaviors and conditions may vary by demographic factors. This study describes the prevalence of behaviors related to hypertension among persons with one to three diagnoses and investigates the relative contribution of demographic factors and increased morbidity on these measures. METHODS: Data are from a nationally representative sample of adults over age 30 from the NHANES III. Behaviors are compared among three groups: those with hypertension alone (N = 2,944), hypertension plus type 2 diabetes (N = 557), and hypertension, type 2 diabetes, and history of a heart attack (N = 116). RESULTS: Demographic factors explained more of the variance in behavioral measures than morbidity level. Trends in behavior prevalence across morbidity levels were apparent for measures of alcohol and smoking. No group differences were found for exercise, fat intake, or sodium intake after controlling for demographic factors. CONCLUSIONS: Some behaviors were more strongly associated with increased levels of morbidity than others. Longitudinal studies are needed to better describe the reasons for behavior change in the face of various health conditions.

Adult↗