Successful aging and the humility of perspective.
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Aging↗
Biomedical subjects
Christopher M Callahan
Publications and source records attributed to Christopher M Callahan.
Improving medication use for older adults: an integrated research agenda.
Effective health care is a core determinant of successful aging, and medications are one of the most important therapeutic tools of health care providers. Most older adults use at least one prescription drug. Costs for these drugs are a substantial out-of-pocket expense for Medicare beneficiaries, and low-income older adults must weigh these costs against those of other basic needs. Although medications bring welcome relief to millions of elderly persons with age-related conditions, adverse drug events are an important cause of illness and death in these patients. Thus, the appropriate, cost-effective use of medication is central to successful aging. Despite increasing attention to geriatric pharmacotherapy, there is an enormous need for additional research to improve the use of medications among older adults. The necessary research agenda encompasses much more than just the discovery of new drugs; better use of the current pharmacopeia has great potential to improve the lives of older adults. We review four domains of pharmaceutical research: drug discovery and delivery, drug efficacy and safety, pharmacoepidemiology and drug policy, and improved access to and use of drugs. These domains encompass both the pre- and postmarketing phases of drug research. Premarketing research currently has greater magnitude and a better infrastructure than postmarketing research, yet issues arising in the two phases of research are equally important to the health and safety of older adults. A national, federally supported pharmaceutical database could greatly enhance the infrastructure of postmarketing research. However, many major improvements in medication use among older adults will also depend on closing the gap between knowledge and practice and increasing the ability of older adults to manage their medications.
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Using information technology to improve the health care of older adults.
The high burden of illness and frailty common among our growing population of older adults often results in fragmentation of care across providers and health care systems, increasing the complexity and costs of caring for these patients. Information technology offers one way to meet this challenge. Scientists at the Regenstrief Institute have more than a quarter-century of experience in using medical informatics to support clinicians in the day-to-day care of older adults. Their research has progressed through several evolutionary cycles, beginning with the acquisition of relevant data and moving to studies of the most efficient and effective mechanisms that bring information to bear at the time of clinical decision making. Information technology designed with the input of the end user has the greatest promise of changing provider behavior because it balances technological challenges with the cultural context of the practice environment. One topic of active research is information technology to support transitions of care among sites and providers. These transitions place older adults at increased risk for avoidable illness, death, and health care costs. Information systems that improve communication among providers during these transitions have the potential to improve safety and reduce costs.
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Depression and Bipolar Support Alliance consensus statement on the unmet needs in diagnosis and treatment of mood disorders in late life.
OBJECTIVES: To review progress made during the past decade in late-life mood disorders and to identify areas of unmet need in health care delivery and research. PARTICIPANTS: The Consensus Development Panel consisted of experts in late-life mood disorders, geriatrics, primary care, mental health and aging policy research, and advocacy. EVIDENCE: (1) Literature reviews addressing risk factors, prevention, diagnosis, treatment, and delivery of services and (2) opinions and experiences of primary care and mental health care providers, policy analysts, and advocates. CONSENSUS PROCESS: The Consensus Development Panel listened to presentations and participated in discussions. Workgroups considered the evidence and prepared preliminary statements. Workgroup leaders presented drafts for discussion by the Consensus Development Panel. The final document was reviewed and edited to incorporate input from the entire Consensus Development Panel. CONCLUSIONS: Despite the availability of safe and efficacious treatments, mood disorders remain a significant health care issue for the elderly and are associated with disability, functional decline, diminished quality of life, mortality from comorbid medical conditions or suicide, demands on caregivers, and increased service utilization. Discriminatory coverage and reimbursement policies for mental health care are a challenge for the elderly, especially those with modest incomes, and for clinicians. Minorities are particularly underserved. Access to mental health care services for most elderly individuals is inadequate, and coordination of services is lacking. There is an immediate need for collaboration among patients, families, researchers, clinicians, governmental agencies, and third-party payers to improve diagnosis, treatment, and delivery of services for elderly persons with mood disorders.
Age Factors↗
A practical method of linking data from Medicare claims and a comprehensive electronic medical records system.
BACKGROUND: Linking administrative and clinical databases provides opportunities for richer studies to improve healthcare, but linkage may require sophisticated algorithms. Linking US Medicare data with large databases used for everyday clinical practice is seldom described in detail in medical literature. OBJECTIVES: Test a deterministic method of linking data from a local electronic medical records system to Medicare data, and report specific details of the algorithm used as well as lessons learned from the linkage process. SUBJECTS: Medicare beneficiaries with medical encounters in selected Indiana counties in the 5-year period ending in 1999. RESULTS: For 6,388 beneficiaries with Medicare data indicating inpatient encounters in the system, 98% had links to the clinical database. Of 7,231 patients hospitalized and registered in the local clinical system, 86% contained a link to Medicare data, and 69% contained a link even without using Social security number (SSN) as an identifier. Medicare data that conflicted with local hospital records by indicating no local hospitalization occurred in 1.8%. More than 2,000 claims contained hospital identifiers that did not exist in the hospital codebook. CONCLUSIONS: Details of a practical, deterministic method of linking Medicare claims to a large electronic records system have been applied and described. Most records were linked without SSN. A variety of inconsistencies were found and these, along with missing or incomplete data, can influence linking. Integrity of specific variables must be assessed carefully.
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Depression treatment in a sample of 1,801 depressed older adults in primary care.
OBJECTIVES: To examine rates and predictors of lifetime and recent depression treatment in a sample of 1,801 depressed older primary care patients DESIGN: Cross sectional survey data collected from 1999 to 2001 as part of a treatment effectiveness trial. SETTING: Eighteen primary care clinics belonging to eight organizations in five states. PARTICIPANTS: One thousand eight hundred one clinic users aged 60 and older who met diagnostic criteria for major depression or dysthymia. MEASUREMENTS: Lifetime depression treatment was defined as ever having received a prescription medication, counseling, or psychotherapy for depression. Potentially effective recent depression treatment was defined as 2 or more months of antidepressant medications or four or more sessions of counseling or psychotherapy for depression in the past 3 months. RESULTS: The mean age +/- standard deviation was 71.2 +/- 7.5; 65% of subjects were women. Twenty-three percent of the sample came from ethnic minority groups (12% were African American, 8% were Latino, and 3% belonged to other ethnic minorities). The median household income was $23,000. Most study participants (83%) reported depressive symptoms for 2 or more years, and most (71%) reported two or more prior depressive episodes. About 65% reported any lifetime depression treatment, and 46% reported some depression treatment in the past 3 months, although only 29% reported potentially effective recent depression treatment. Most of the treatment provided consisted of antidepressant medications, with newer antidepressants such as selective serotonin reuptake inhibitors constituting the majority (78%) of antidepressants used. Most participants indicated a preference for counseling or psychotherapy over antidepressant medications, but only 8% had received such treatment in the past 3 months, and only 1% reported four or more sessions of counseling. Men, African Americans, Latinos, those without two or more prior episodes of depression, and those who preferred counseling to antidepressant medications reported significantly lower rates of depression care. CONCLUSION: The findings suggest that there is considerable opportunity to improve care for older adults with depression. Particular efforts should be focused on improving access to depression care for older men, African Americans, Latinos, and patients who prefer treatments other than antidepressants.
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Collaborative care management of late-life depression in the primary care setting: a randomized controlled trial.
CONTEXT: Few depressed older adults receive effective treatment in primary care settings. OBJECTIVE: To determine the effectiveness of the Improving Mood-Promoting Access to Collaborative Treatment (IMPACT) collaborative care management program for late-life depression. DESIGN: Randomized controlled trial with recruitment from July 1999 to August 2001. SETTING: Eighteen primary care clinics from 8 health care organizations in 5 states. PARTICIPANTS: A total of 1801 patients aged 60 years or older with major depression (17%), dysthymic disorder (30%), or both (53%). INTERVENTION: Patients were randomly assigned to the IMPACT intervention (n = 906) or to usual care (n = 895). Intervention patients had access for up to 12 months to a depression care manager who was supervised by a psychiatrist and a primary care expert and who offered education, care management, and support of antidepressant management by the patient's primary care physician or a brief psychotherapy for depression, Problem Solving Treatment in Primary Care. MAIN OUTCOME MEASURES: Assessments at baseline and at 3, 6, and 12 months for depression, depression treatments, satisfaction with care, functional impairment, and quality of life. RESULTS: At 12 months, 45% of intervention patients had a 50% or greater reduction in depressive symptoms from baseline compared with 19% of usual care participants (odds ratio [OR], 3.45; 95% confidence interval [CI], 2.71-4.38; P<.001). Intervention patients also experienced greater rates of depression treatment (OR, 2.98; 95% CI, 2.34-3.79; P<.001), more satisfaction with depression care (OR, 3.38; 95% CI, 2.66-4.30; P<.001), lower depression severity (range, 0-4; between-group difference, -0.4; 95% CI, -0.46 to -0.33; P<.001), less functional impairment (range, 0-10; between-group difference, -0.91; 95% CI, -1.19 to -0.64; P<.001), and greater quality of life (range, 0-10; between-group difference, 0.56; 95% CI, 0.32-0.79; P<.001) than participants assigned to the usual care group. CONCLUSION: The IMPACT collaborative care model appears to be feasible and significantly more effective than usual care for depression in a wide range of primary care practices.
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Measuring and communicating the value of geriatrics.
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Six-item screener to identify cognitive impairment among potential subjects for clinical research.
OBJECTIVE: To design a brief cognitive screener with acceptable sensitivity and specificity for identifying subjects with cognitive impairment. DESIGN: Cohort one is assembled from a community-based survey coupled with a second-stage diagnostic evaluation using formal diagnostic criteria for dementia. Cohort two is assembled from referrals to a specialty clinic for dementing disorders that completed the same diagnostic evaluation. SETTING: Urban neighborhoods in Indianapolis, Indiana and the Indiana Alzheimer Disease Center. PATIENTS: Cohort one consists of 344 community-dwelling black persons identified from a random sample of 2212 black persons aged 65 and older residing in Indianapolis; cohort two consists of 651 subject referrals to the Alzheimer Disease Center. MEASUREMENTS: Formal diagnostic clinical assessments for dementia including scores on the Mini-mental state examination (MMSE), a six-item screener derived from the MMSE, the Blessed Dementia Rating Scale (BDRS), and the Word List Recall. Based on clinical evaluations, subjects were categorized as no cognitive impairment, cognitive impairment-not demented, or demented. RESULTS: The mean age of the community-based sample was 74.4 years, 59.4% of the sample were women, and the mean years of education was 10.1. The prevalence of dementia in this sample was 4.3% and the prevalence of cognitive impairment was 24.6%. Using a cut-off of three or more errors, the sensitivity and specificity of the six-item screener for a diagnosis of dementia was 88.7 and 88.0, respectively. In the same sample, the corresponding sensitivity and specificity for the MMSE using a cut-off score of 23 was 95.2 and 86.7. The performance of the two scales was comparable across the two populations studied and using either cognitive impairment or dementia as the gold standard. An increasing number of errors on the six-item screener is highly correlated with poorer scores on longer measures of cognitive impairment. CONCLUSIONS: The six-item screener is a brief and reliable instrument for identifying subjects with cognitive impairment and its diagnostic properties are comparable to the full MMSE. It can be administered by telephone or face-to-face interview and is easily scored by a simple summation of errors.
Black or African American↗
Low yield of thyroid-stimulating hormone testing in elderly patients with depression.
Although hypothyroidism is purportedly an important cause of depression, prior studies have involved small samples of young people and produced conflicting results. We examined the yield of thyroid-stimulating hormone (TSH) testing in a large group of elderly patients with major depression or dysthymic disorder. The study sample comprised 883 outpatients aged 60 years or older from 18 primary care sites enrolled in the intervention arm of a clinical trial of depression management. Thyroid function was assessed by a single TSH value. Depressive diagnoses were confirmed with the Structured Clinical Interview for DSM-IV (SCID) and depression severity was assessed with the HSCL-20, a modified depression scale of the Hopkins Symptom Checklist. TSH results were available for 725 (82.1%) participants. Although 32 (4.4%) of those tested had TSH>5 mIU/L, the vast majority (27/32) had marginally elevated results (5.1-9.4 mIU/L). Only five patients (0.7%) had TSH levels >10 mIU/L. Patients with elevated TSH did not differ from those with TSH < or = 5 mIU/L in the severity or symptom pattern of depression as measured by the baseline HSCL-20 score (P=.37) or SCID score (P=.44). These findings should caution physicians against acceptance of borderline TSH values as the primary cause of a patient's clinical depression.
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Improving depression outcomes in older adults with comorbid medical illness.
BACKGROUND: Depression is common in older adults and often coexists with multiple chronic diseases, which may complicate its diagnosis and treatment. OBJECTIVE: To determine whether or not the presence of multiple comorbid medical illnesses affects patient response to a multidisciplinary depression treatment program. DESIGN, SETTING AND PARTICIPANTS: Preplanned analyses of Improving Mood-Promoting Access to Collaborative Treatment (IMPACT), a randomized controlled trial of 1801 depressed older adults (> or =60 years), which was performed at 18 primary care clinics from eight health care organizations in five states across the United States from July 1999 to August 2001. INTERVENTION: Intervention patients had access for up to 12 months to a depression care manager, supervised by a psychiatrist and a primary care expert, who offered education, care management and support of antidepressant management by the patient's primary care physician, or provided brief psychotherapy (Problem-Solving Treatment in Primary Care). MEASUREMENTS: Depression, quality of life (QOL; scale of 0-10) and mental health component score (MCS) of the Short-Form 12 assessed at baseline, 3, 6 and 12 months. RESULTS: Patients suffered from an average of 3.8 chronic medical conditions. Although patients with more chronic medical conditions had higher depression severity at baseline, the number of chronic diseases did not affect the likelihood of response to the IMPACT intervention when compared to care as usual. Intervention patients experienced significantly lower depression during all follow-up time points as compared with patients in usual care independent of other comorbid illnesses (P<.001). Intervention patients were also more likely to experience substantial response (at least a 50% reduction in depressive symptoms) regardless of the number of comorbidities, to experience improved MCS-12 scores at 3 and 12 months, and to experience improved QOL. CONCLUSIONS: The presence of multiple comorbid medical illnesses did not affect patient response to a multidisciplinary depression treatment program. The IMPACT collaborative care model was equally effective for depressed older adults with or without comorbid medical illnesses.
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The efficacy of pentoxifylline in the treatment of vascular dementia: a systematic review.
This systematic review seeks to (1) summarize the pharmacologic effects of pentoxifylline on the cerebrovasculature and (2) review critically the studies evaluating pentoxifylline in the treatment of vascular dementia. To retrieve all relevant published and unpublished studies, we performed with no language restrictions computer keyword searches of MEDLINE, EMBASE, and Cochrane Library databases; reviewed bibliographies; and contacted the pharmaceutical manufacturer. We included pertinent articles if they met three quality criteria: randomized, double-blinded, and placebo-controlled study design; objective diagnostic criteria for vascular dementia; and reported original data. The literature search identified a total of 20 articles; however, only four studies met the quality criteria for inclusion in this systematic review. All four studies suggested a trend toward improved cognitive function in patients treated with pentoxifylline. Three of the studies performed a subgroup analysis using a stricter definition for vascular dementia. In these secondary analyses, the studies noted statistically significant differences in cognitive function between placebo and treatment groups. In conclusion, this systematic review suggested a potential therapeutic role for pentoxifylline in vascular dementia. However, few studies met the quality criteria for inclusion in this systematic review, and most of these studies were small and had methodologic limitations.
Cognition↗