Medication adherence in rheumatoid arthritis patients: older is wiser

OBJECTIVES: To create a profile of individuals nonadherent to their medications in an age-stratified sample (ages 34-84) of community-dwelling rheumatoid arthritis patients. The relative contributions of age, cognitive function, disability, emotional state, lifestyle, and beliefs about illness to nonadherence were assessed. DESIGN: A direct observation approach was used in conjunction with structural equation modeling. All participants were administered a preliminary assessment battery. Medications were then transferred to vials with microelectronic caps that recorded medication events for all medications for the next 4 weeks. PARTICIPANTS AND SETTING: A volunteer sample of 121 community-dwelling rheumatoid arthritis (RA) patients were recruited from newspaper ads, posters, and via informal physician contact from private rheumatology practices in Atlanta and Athens, Georgia. Written verification of the RA diagnosis and a disease severity rating were obtained from personal physicians before patients were enrolled in the study. Patients were tested in a private physician's office, and their medication adherence was monitored electronically for a month in their every-day work and home settings. MEASUREMENTS AND RESULTS: Structural equation modeling techniques were used to develop a model of adherence behavior. Cognitive and psychosocial measures were used to construct latent variables to predict adherence errors. The model of medication adherence explained 39% of the variance in adherence errors. The model demonstrated that older adults made the fewest adherence errors, and middle-aged adults made the most. A busy lifestyle, age, and cognitive deficits predicted nonadherence, whereas coping with arthritis-related moods predicted adherence. Illness severity, medication load, and physical function did not predict adherence errors. Omission of medication accounted for nearly all errors. CONCLUSION: Despite strong evidence for normal, age-related cognitive decline in this sample, older adults had sufficient cognitive function to manage medications. A busy lifestyle and middle age were more determinant of who was at risk of nonadherence than beliefs about medication or illness. Thus, practicing physicians should not assume that older adults have insufficient cognitive resources to manage medications and that they will be the most likely to make adherence errors. Very busy middle-aged adults seem to be at the greatest risk of managing medications improperly.     

Patient-centered culturally sensitive health care: Model testing and refinement.

Objectives: This article presents the results of an empirical test of a literature-based Patient-Centered Culturally Sensitive Health Care Model. The model was developed to explain and improve health care for ethnically diverse patients seen in community-based primary care clinics. Design: Samples of predominantly low-income African American (n = 110) and non-Hispanic White American (n = 119) patients were recruited to complete questionnaires about their perceived health care provider cultural sensitivity and adherence to their provider's treatment regimen recommendations. Main Outcome Measures: Patients completed written measures of their perceived provider cultural sensitivity, trust in provider, interpersonal control, satisfaction with their health care provider, physical stress, and adherence to provider-recommended treatment regimen variables (i.e., engagement in a health promoting lifestyle, and dietary and medication adherence). Results: Two-group path analyses revealed significant links between patient-perceived provider cultural sensitivity and adherence to provider treatment regimen recommendations, with some differences in associations emerging by race/ethnicity. Conclusion: The findings provide empirical support for the potential usefulness of the Patient-Centered Culturally Sensitive Health Care Model for explaining the linkage between the provision of patient-centered, culturally sensitive health care, and the health behaviors and outcomes of patients who experience such care. (PsycINFO Database Record (c) 2011 APA, all rights reserved)     

Catching patients: tuberculosis and detention in the 1990s

The resurgence of tuberculosis (TB) in the early 1990s, including multidrug-resistant strains, led health officials to recommend the use of involuntary detention for persistently nonadherent patients. Using a series of recently published articles on the subject, this paper offers some opinions on how detention programs have balanced protection of the public's health with patients' civil liberties. Detained persons are more likely than other TB patients to come from socially disadvantaged groups. Health departments have generally used coercion appropriately, detaining patients as a last resort and providing them with due process. Yet health officials still retain great authority to bypass "least restrictive alternatives" in certain cases and to detain noninfectious patients for months or years. Misbehavior within institutions may inappropriately be used as a marker of future nonadherence with medications. As rates of TB and attention to the disease again decline, forcible confinement of sick patients should be reserved for those persons who truly threaten the public's health.     

Compliance issues with the geriatric population: complexity with aging

Nonadherence with the prescribed treatment regimen is a major issue in health care. This article focuses specifically on adherence issues in the geriatric population. The strengths and weaknesses of measurement methods to assess nonadherence with medication regimens are discussed. Determinants of noncompliance with special emphasis on risk factors for geriatric patients are described. Finally, an overview of preventative and restorative compliance interventions is given.     

Chronic illness, pain and health behaviors of community behavioral health clients.

Persons with comorbid medical disorders, along with substance use disorders and mental illness, present complex treatment needs that are seldom addressed. Chronic physical illness negatively affects treatment participation and retention, decreasing effectiveness. Studies documenting higher medical morbidity and mortality in such persons have long been available. Less is known about their health behaviors. Respondents (n = 418) at a community behavioral health center were surveyed for prevalence of illness, pain, health behaviors, and interest in lifestyle change. A total of 73% reported at least one chronic health problem, and nearly half rated their health between fair and very poor. Most reported at least one negative health indicator or behavior (e.g., smoking). Encouragingly, nearly 50% desired lifestyle changes including smoking cessation, exercise, and stress management. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Health independence and developmental tasks of adulthood in cystic fibrosis.

Examined participation in health behaviors, health locus of control, and negotiation of developmental tasks of adulthood with 75 patients with cystic fibrosis (CF), aged 18–42 yrs old. Ss completed the Multidimensional Health Locus of Control Scale. Results indicate there were a number of health behaviors for which Ss had not yet assumed responsibility, such as managing their medical insurance correspondence and monitoring nutrition. Ss reported that they were more compliant with their medical regimen currently than when first assuming responsibility for their health as adolescents. Multidimensional health locus of control profiles were similar to those of other chronic illness populations. Most Ss appeared to have successfully mastered adult developmental tasks, such as living independently, getting married, and attaining educational or vocational goals. Ss who continued to live with their parents tended to be younger. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Does age make a difference? Predicting physical activity of South Koreans.

Social cognition models of health behavior are commonly understood as being universal, which implies that they are applicable to groups varying in age or cultural background, for example. Cultural uniqueness and characteristics of life-span development, however, necessitate the study of differential effects. Accordingly, the health action process approach (HAPA) was examined in younger and middle-aged/older adults from South Korea (N = 697) who participated in a longitudinal health screening study with a 6-month time lag. The HAPA model had a good fit within the middle-aged/older adult sample. Physical activity was predicted by planning, coping self-efficacy, and intention, which were, in turn, predicted by action self-efficacy, outcome expectancies, and risk perceptions. Conversely, the results indicated a poor model fit in the younger adult sample. The results suggest a different motivation for the involvement in physical activity as a function of age. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

The impact of minority stress on mental health and substance use among sexual minority women.

Objective: We examined the direct and indirect impact of minority stress on mental health and substance use among sexual minority women. Method: A combination of snowball and targeted sampling strategies was used to recruit lesbian and bisexual women (N = 1,381) for a cross-sectional, online survey. Participants (M age = 33.54 years; 74% White) completed a questionnaire assessing gender expression, minority stressors (i.e., victimization, internalized homophobia, and concealment), social–psychological resources (i.e., social support, spirituality), and health-related outcomes. We used structural equation modeling to test associations among these factors, with gender expression as an antecedent and social–psychological resources as a mediator between minority stress and health. Results: The final model demonstrated acceptable fit, χ2(79) = 414.00, p confirmatory fit index = .93, Tucker–Lewis index = .91, standardized root-mean-square residual = .05, root-mean-square error of approximation = .06, accounting for significant portions of the variance in mental health problems (56%) and substance use (14%), as well as the mediator social–psychological resources (24%). Beyond indirect effects of minority stress on health outcomes, direct links emerged between victimization and substance use and between internalized homophobia and substance use. Conclusions: Findings indicate a significant impact of minority stressors and social–psychological resources on mental health and substance use among sexual minority women. The results improve understanding of the distinct role of various minority stressors and their mechanisms on health outcomes. Health care professionals should assess for minority stress and coping resources and refer for evidence-based psychosocial treatments. (PsycINFO Database Record (c) 2011 APA, all rights reserved)     

Body adaptation to the action of ecological factors at the cellular and subcellular levels

While poor drug compliance is a significant impediment to the effective treatment of hypertension, knowledge of what patients wish to know about their medications in order to improve compliance is very limited. To develop a preliminary understanding of patients' medication requirements and expectations, a simple 30-item questionnaire was developed and administered to 66 patients who were either taking antihypertensive drugs, or about to commence antihypertensive drug treatment. Ninety percent of patients wanted to know about all possible side effects of medications as well as the most likely side effects. Ninety-six percent wanted to know if their drug treatment would keep them well. In addition, most patients wanted to avoid multiple medications, were concerned about the prospect of life-long treatment, and were worried about potential drug interactions. Effects of the drugs on their lifestyles as well as any lifestyle changes required to augment drug therapy were other issues of concern. The elderly were less interested in many of these issues. A strong desire for further knowledge about their disease was noted in most subjects (82%). If compliance with medication therapy is to be improved, a better understanding of patients' concerns and fears about medications is required, particularly in a relatively asymptomatic disease like hypertension.     

Polyethylene wear of the Optifix cementless acetabular component after 5 years

We describe seven patients who developed symptoms including severe headache, circumoral paresthesia, and facial flushing during high-dose carmustine (BCNU) infusion as part of the preparative regimen for autologous peripheral blood stem cell (PBSC) transplantation for metastatic breast cancer. Five patients responded to pain medications, including partial and complete opiate receptor agonists. Premedication of subsequent doses of BCNU with corticosteroids, pain medications, or benzodiazepines lessened, but did not prevent the same symptoms from recurring. The incidence and mechanism of this toxicity are unknown, but this adverse syndrome should be considered when administering high-dose BCNU infusions.     

Sleeping problems and health behaviors as mediators between organizational justice and health.

The aim of this longitudinal cohort study was to investigate whether sleeping problems and health behaviors (smoking, alcohol consumption, and sedentary lifestyle) mediate the association between organizational justice and employee health. Health indicators were minor psychiatric morbidity, as assessed by the General Health Questionnaire (U. Werneke, D. P. Goldberg, 1. Yalcin, & B. T. Ustun, 2000), and poor self-rated health status. The results of logistic regression analysis of data for 416 male and 3,357 female hospital employees working during the 1998-2000 period in 10 Finnish hospitals suggest that sleeping problems are one of the underlying factors causing the adverse health effects of low organizational justice at work. No support for a mediating role of health behaviors between low organizational justice and health problems was obtained. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Job characteristics and off-job activities as predictors of need for recovery, well-being, and fatigue.

Two empirical studies examined need for recovery (i.e., a person's desire to be temporarily relieved from demands in order to restore his or her resources) as a mediator in the relationship between poor job characteristics (high job demands, low job control) and high off-job demands, on the one hand, and fatigue and poor individual well-being, on the other hand. Multilevel data from a daily survey study in the health service sector (Study 1) showed that high job demands, low job control, and unfavorable off-job activities predicted a high need for recovery. Need for recovery in turn was negatively related to individual well-being. A large-scale survey with a representative sample of the Dutch working population (Study 2) confirmed these findings for fatigue. In both studies, need for recovery mediated the effects of job characteristics and off-job activities on fatigue and poor well-being, respectively. (PsycINFO Database Record (c) 2011 APA, all rights reserved)     

Integrating health care: The clear advantage for underserved diverse populations.

Integrating health care into primary and specialty physician practices and clinics has potential benefits for women; racial/ethnic minorities; and lesbian, gay, bisexual, transgendered populations, thus making a major contribution to the health disparities in America. Mounting evidence suggests that physical illnesses are accompanied and exacerbated by emotional, social, and cultural factors. Many of the chronic diseases, cardiovascular disease, HIV-AIDS, diabetes, and some cancers can be prevented and altered by behavioral changes and are thus considered behavioral diseases. In addition, nonadherence to medication is a significant factor in less-than-optimal treatment of any illness. Thus, medical treatment without coordinated attempts to also treat the behavioral and social factors compromises its effectiveness. Treatment is often complicated by the lack of timely diagnoses of issues such as domestic violence, substance abuse, and eating disorders. Furthermore, helping patients negotiate medical visits, treatment options, and disease prevention and management can be effectively addressed within an integrated primary care system of health delivery with better outcomes for minorities. (PsycINFO Database Record (c) 2011 APA, all rights reserved)     

The molecular biology of chitin digestion

A beneficial effect in blood pressure control is presumed for patients on an intensive preoperative antihypertensive regimen who undergo empiric renal revascularization. Nonetheless, a noticeable decline in surgical cure rates for hypertension has been recently observed in patients with generalized atherosclerosis. The outcome of patients on multiple preoperative antihypertensive agents who underwent combined aortic and renal artery reconstruction was reviewed. The study population comprised 43 patients who underwent concomitant renal artery and aortic reconstruction for atherosclerotic disease between 1983 and 1995 and who were taking two or more antihypertensive medications and had a serum creatinine of less than or equal to 1.7 mg/dL. Operative management included an aortic reconstruction with either unilateral (n = 22) or bilateral (n = 19) aortorenal bypass or renal endarterectomy (n = 2). Operative mortality was 4.7% (2 of 43). The estimated 5-yr probability of survival was 83% (95% C.I. 0.70, 0.99). Late follow-up data on blood pressure control were available for review in 32 patients at a median follow-up of 37 months. Hypertension was cured in 1 (3%) and improved in an additional 15 (47%) patients. The numbers of antihypertensive medications taken preoperatively (mean = 2.7) declined at late follow-up (mean = 1.6). Notably, the largest reduction was observed with beta blockers (p = 0.006), central sympatholytics (p = 0.041), and angiotensin converting enzyme (ACE) inhibitors (p = 0.052). The number of preoperative antihypertensive medications was not significantly related to survival or to blood pressure improvement. However, uncontrolled preoperative hypertension despite antihypertensive therapy was associated with a favorable blood pressure response to operation (p < 0.001). Patients on an intensive antihypertensive regimen can safely undergo concomitant renal artery and aortic reconstruction for the empiric management of hypertension. Poorly controlled preoperative hypertension in the presence of multiple antihypertensive agents is a favorable marker for improved postoperative blood pressure control.     

Health patterns of cardiac surgery clients using home health care nursing services

The purpose of this study was to examine the health patterns of cardiac surgical patients in the home health care population and their relationships to outcomes and duration of home health care using Gordon's Functional Health Pattern framework. Home health care records of 96 cardiac surgical clients were reviewed. Admission health pattern data, reasons for admission, duration and outcomes of home care services, characteristics of hospital experience, and demographic data were analyzed. Dysfunctional health patterns were primarily in the area of activity/exercise. The most common reasons for admission were monitoring of cardiopulmonary status, wound care, and instruction on diet, medications, and cardiac regimen. The mean duration of home care was 28.8 days. Thirty percent of the sample were readmitted to the hospital. Duration of home care was shorter for those who were married and for those who reported weakness, tiredness, or fatigue as a chief complaint. Readmission to the hospital was more likely for those who had complications during their initial hospital stay and those who required at least partial assistance with bathing, dressing, feeding, or toileting. Implications for practice and research are discussed.     

Internalized heterosexism among HIV-positive, gay-identified men: Implications for HIV prevention and care.

Internalized heterosexism (IH), or the internalization of societal antihomosexual attitudes, has been consistently linked to depression and low self-esteem among gay men, and it has been inconclusively associated with substance use and sexual risk in gay and bisexual men. Using structural equation modeling, the authors tested a model framed in social action theory (C. K. Ewart, 1991, 2004) in which IH is associated with HIV transmission risk and poor adherence to HIV antiretroviral therapy (ART) through the mechanisms of negative affect and stimulant use. Data from a sample of 465 gay-identified men interviewed as part of an HIV risk reduction behavioral trial were used to test the fit of the model. Results support the hypothesized model in which IH was associated with unprotected receptive (but not insertive) anal intercourse with HIV-negative or unknown HIV status partners, and with ART nonadherence indirectly via increased negative affect and more regular stimulant use. The model accounted for 15% of the variance in unprotected receptive anal intercourse and 17% of the variance in ART nonadherence. Findings support the potential utility of addressing IH in HIV prevention and treatment with HIV-positive gay men. (PsycINFO Database Record (c) 2010 APA, all rights reserved)