0857 Factors Associated With Sleep Health Among Middle-aged And Older Adults

Introduction

The concept of Sleep Health (SH) was developed to provide a multidimensional framework consisting of characteristics of sleep that have been closely associated with physical and mental well-being. Identification of key factors associated with SH can identify targets for intervention for its improvement. This study aimed to identify factors related to SH among middle-aged and older adults.

Methods

A valid Sleep Health Composite Measure was recently developed from the data of the 2014 Core Survey of the Health and Retirement Survey and was used to assess overall SH in middle-aged and older adults. Spearman’s correlations, T-test, and Kruskal-Wallis tests were used to explore the association of SH with age, gender, self-rated health, chronic disease burden, disability, pain, and modifiable lifestyle behaviors (physical activity, smoking, alcohol, sleep medication).

Results

Our sample included 6,095 adults with mean age of 68 years (SD=10.1; range 50-99 years). The majority were female (59.7%) and white (77%). Correlations showed significant moderate associations between SH and self-rated health (r=.404), sleep medications (r=.390), pain (r=-.315). There were significant but small associations between vigorous activity (r=-.193), alcohol (r=.112), currently smoking (r=-.089) and SH. SH was significantly worse among women compared to men (t(6093)=6.996, p<0.001). Furthermore, SH scores were significantly different between middle-aged versus older adults (p<0.001); varying levels of self-rated health (p<0.001), number of chronic diseases (p<0.001), and degree of physical disability (p<0.001).

Conclusion

These findings provide evidence of factors related to SH among middle-aged and older adults, providing targets for intervention to improve health in this population. Age-related differences in relation to SH indicate intervention tailored for middle-aged adults may improve health outcomes as they age. Future studies are warranted to extend these findings using multivariable statistical approaches.

Support

This study was supported by the University at Buffalo Clinical and Translational Science Institute (CTSI) funded by the National Institutes of Health (Lorenz PI).

0854 Exploration Of Sleep Health Among Middle-aged And Older Adults

Introduction

Sleep health, a construct introduced to characterize the multidimensional attributes of sleep, has been explored in a variety of populations; however has not been adequately examined for middle-aged and older adults. As attributes of sleep may change with age, the dimensional structure of sleep health may differ in this population. This study aimed to validate a composite measure of sleep health among middle-aged and older adults using data from the Health and Retirement Survey (HRS).

Methods

Data from the 2014 Core survey of the HRS was used to create a composite measure of Sleep Health including sleep efficiency, duration, timing, satisfaction, and alertness. We standardized and averaged the original variables before transforming to T scores. Sleep Health T scores (ranging 0-100, higher scores indicating better sleep health) were examined using exploratory and confirmatory factor analysis (EFA; CFA).

Results

Our sample included 6,095 adults with mean age of 68 years (SD=10.1; range 50-99 years). The majority were female (59.7%), white (77%), with high school education (53.9%). Sleep Health T scores ranged from 27-61 (mean=50; SD=6.7). EFA identified one factor. Timing was removed due to low factor loading (<0.4). The revised four-dimension composite Sleep Health measure had acceptable reliability (Cronbach’s alpha 0.6). CFA showed a well-adjusted model (REMSA=0.097; NFI=0.964; RMR=0.035; GFI=0.990; AGFI=0.951).

Conclusion

These results suggest that the composite measure was valid for assessing sleep health among middle-aged and older adults. Limitations include the use of secondary data, as sleep health dimensions were based on variables not created specifically for our research question. Future research should further examine the role of sleep timing in overall sleep health among middle-aged and older adults.

Support

This study was supported by the University at Buffalo Clinical and Translational Science Institute (CTSI) funded by the National Institutes of Health (Lorenz, PI).

Premature pubarche in girls is associated with functional adrenal but not ovarian hyperandrogenism

OBJECTIVE

We hypothesized that there would be evidence of functional ovarian hyperandrogenism in girls with premature pubarche (PP) at diagnosis.

METHODS

White girls <8 years of age and black girls <6 years with PP (n = 15) were studied. Prepubertal girls (n = 13; 5.3-10.9 years) and early pubertal girls (n = 8) served as control subjects. The biochemical marker for functional ovarian hyperandrogenism was the 17-hydroxyprogesterone (17-OHP), androstenedione (AD), and estradiol (E2) response to subcutaneous leuprolide during adrenal suppression with dexamethasone. This was studied in girls with PP and in control subjects.

RESULTS

ACTH stimulated 17-hydroxypregnenolone (17-OH Preg), dehydroepiandrosterone (DHEA), and AD levels, and 17-OH Preg:17-OHP and DHEA:AD ratios were significantly higher in girls with PP than in prepubertal control subjects (n = 18) (P < or =.003). The ovarian response to leuprolide stimulation was comparable in girls with PP and prepubertal control subjects, but the response in prepubertal study subjects was significantly lower than in pubertal control subjects (P =.016 for Delta17-OHP, P =.001 for DeltaAD, and P =.026 for DeltaE2).

CONCLUSIONS

Contrary to the hypothesis, PP in girls was not associated with prepubertal evidence of ovarian hyperandrogenism but was associated with functional adrenal hyperandrogenism.

Long-term trends in childhood diabetes mortality: 1968-1998

OBJECTIVE

In the context of recent improvements in type 1 diabetes therapy, to describe longitudinal trends in mortality attributable to childhood diabetes and to investigate socioeconomic and health services correlates of mortality.

RESEARCH DESIGN AND METHODS

We extracted mortality data for 1968-1998 from National Center for Health Statistics files and covariates from the Bureau of Health Professions Area Resource File. Analytical techniques included linear and Poisson regression and standard descriptive statistics.

RESULTS

Childhood (defined as 0-19 years of age) age-adjusted mortality from diabetes declined from 9.5 (1968) to 3.0 (1984) deaths per 10 million but remained relatively constant subsequently. All-cause childhood mortality, however, continued to decline. Older children experienced higher mortality rates, as did those living in counties with higher levels of unemployment.

CONCLUSIONS

Despite recent improvements in therapy, diabetes-related mortality among children has not declined for 14 years. This finding may be partially attributable to sociodemographic factors influencing access to care, but the remaining mortality may defy available treatment methods. Reducing childhood diabetes mortality rates below the current apparent plateau may require new prevention and/or treatment strategies.

Diabetes training for dietitians: needs assessment, program description, and effects on knowledge and problem solving

Recent changes in management and medical nutrition therapy for diabetes mellitus have produced a need to retrain many practicing dietitians. To meet this need, a multidisciplinary group experienced in medical nutrition therapy and educational methods used a formal needs-assessment process to design a new training program. Sugar is Not a Poison (SNAP): The Dietitian's New Role in Diabetes Management is a 2 1/2-day program that uses written text, didactic presentation, and exercises that simulate patient encounters to accomplish 12 learning objectives. Program evaluations show high levels of participant satisfaction. Mean (+/- standard deviation) scores on pre- and postests of knowledge and problem solving were 69 +/- 13% and 86 +/- 9%, respectively (P < 0.01). The SNAP program needs assessment, training methods, and knowledge problem-solving test are relevant to all types of education programs in clinical dietetics.

Modern insulin therapy for type 1 diabetes mellitus

Modern insulin therapy for Type 1 diabetes is part of a comprehensive treatment program designed to achieve and maintain blood glucose levels as close to normal as possible. The insulin regimens most likely to be successful approximate physiologic insulin delivery by combining basal and meal doses. Several options are available, including constant infusion by external pump and multiple daily injection therapy. Modern therapy affords major health benefits through improved blood glucose control, as well as lifestyle benefits associated with increased flexibility and spontaneity.

Evaluation of a patient teaching skills course disseminated through staff developers

Effective Patient Teaching (EPT), a course designed to improve health professionals' and health professions students' teaching skills, reliably produces gains in participants' skills when presented by its developers. The objective of this dissemination research study was to investigate whether, using a 'training of trainers' approach, seven nurses with staff development responsibilities in five different sites could teach EPT with similar effectiveness. The evaluation included pre- and post-course analysis of audiotaped patient education sessions conducted by 48 health professional participants who took EPT from one of the trainers in their home institutions. Post-course participant satisfaction surveys were also administered. EPT resulted in teaching skill improvements in four of five sites, and overall teaching skills scores improved significantly (P < 0.01). EPT can improve participants' teaching skills when taught by health professional trainers with staff development responsibilities who have recently received EPT training.

Evaluation of a training program for improving adherence promotion skills

A workshop for improving the adherence counseling skills of health professionals was developed and evaluated. Target audiences have included medical students, nursing students, dietetic interns, and practising nurses and dietitians. Four categories of skills are taught: relationship building, interviewing, problem diagnosis, and behavioral intervention. Teaching methods include faculty demonstration, participant rehearsal, and group and individual feedback. The Adherence Promotion Training (APT) workshop has been offered as a 3- to 5-day intensive course and as a semester-long elective. A reliable coding system was developed to assess these skills from videotaped provider-patient interactions. A standardized patient task was given to 60 subjects before and after participation in the adherence counseling skills workshop. Videotapes were coded by trained raters, who were masked to whether the tape came from before or after the workshop. Significant short-term improvements were observed in all four core skills. This uncontrolled evaluation suggests that the Adherence Promotion Training program is a promising way to enhance the ability of health professionals to care for nonadherent patients.

Continuing education on teaching skills for health professionals. Evaluation of training the trainers

Effective Patient Teaching (EPT), a health professions continuing education course, improves educators' teaching skills when presented by its developers. This study aimed to determine whether others could teach EPT with similar effectiveness. Four nurse managers who provide staff training and supervision for multiple hospital diabetes care units presented EPT to health care professionals at seven such sites; another seven served as controls. The evaluation included observations of trainers conducting EPT programs in the field, teaching skills ratings of health professionals in both groups, and knowledge test administered to patients. Six months after training, teaching skills scores of health professional EPT participants were better (p < .05) than controls. The EPT program improves participants' teaching skills and maintains these effects in field settings, when presented by faculty not involved in its development.

Glomerular filtration rate measurements in clinical trials. Modification of Diet in Renal Disease Study Group and the Diabetes Control and Complications Trial Research Group

To assess the utility and precision of GFR measurements in multicenter trials, the test performance and variability of GFR were analyzed in 2,250 patients enrolled in 44 clinical centers participating in either the Modification of Diet in Renal Disease (MDRD) Study or the Diabetes Control and Complications Trial (DCCT). GRF was measured as the renal clearance of [125I]iothalamate after an sc injection without epinephrine. The studies used similar protocols for obtaining blood and urine, training clinical center staff, and processing specimens in central laboratories. The performance of GFR measurements, assessed from adherence to protocol and quality control analyses, was excellent. The variability among the four clearance periods (intratest coefficient of variation [CV]) was acceptable; the median intratest CV for GFR was 9.4% in the MDRD Study and 11.7% in the DCCT. The pattern of decline in serum counts was better approximated by an exponential rather than a linear relationship. The cause of the intratest variability in GFR measurements was explored by univariate and multivariate analysis. The intratest CV was highest at the extremes of GFR. Among patients with a high GFR (> 90 mL/min per 1.73 m2), most of whom were participants in the DCCT, the higher intratest GFR was due, in part, to a systematic decline in GFR during the test. Among patients with a very low GFR (< 13 mL/min per 1.73 m2), technical difficulties in urine collections contributed substantially to the higher intratest CV. Other patient characteristics, including age, gender, weight, serum glucose, renal diagnosis, and use of diuretics, were not strongly correlated with the intratest CV. The precision of GFR measurements was assessed from the variability from measurement to measurement (interest CV). Among MDRD Study subjects, in whom two measurements of GFR were performed over a 3-month interval, the median interest CV was relatively low (6.3%) and was only weakly related to the intratest CV. Thus, GFR measurements are reasonably precise, even if the intratest CV is high. Given the relatively high intratest CV that is characteristic of GFR measurements, the estimate of GFR in an individual is more precise if multiple clearance periods, rather than a single period, are included. Similarly, the estimate of mean GFR for a population is also more precise if multiple clearance periods are included. In conclusion, by the use of standardized methods, an acceptable precision of GFR results can be obtained in multicenter trials. The same methods can be applied in clinical practice.(ABSTRACT TRUNCATED AT 400 WORDS)

Improving dietitians' teaching skills

Many health professionals lack important teaching skills, perhaps adding to patient difficulties in understanding and adopting therapeutic diets. Research suggests that teaching skills improved after dietitians took a continuing education course entitled "Effective Patient Teaching." Our study tested whether dietitians' new skills would persist in the field and whether selected patient outcomes would differ as a result. Thirty staff dietitians from six urban hospitals were videotaped teaching patients, then randomly assigned to take the Effective Patient Teaching course or not (control group). Follow-up videotapes were made after 1 week, 1 month, and 3 months. After each teaching session, patient satisfaction and recall were assessed. Two judges rated 20 teaching skills, which were divided into four subsets for analysis. Repeated measures analyses of variance showed overall gains only for the group that took the Effective Patient Teaching course, which scored higher than the control group at 1 week and 1 month, but not at baseline or 3 months. Gains occurred in presentation skills and essential teaching functions. Throughout the study, interpersonal skills were high and adherence promotion skills were low for dietitians in both groups. Groups did not differ on patient satisfaction or recall. Improvements in dietitians' teaching skills translated to the field immediately after they completed the continuing education program, but not all gains were sustained after 3 months. We recommend that dietitians assess their teaching and adherence promotion skills, obtain training where warranted, and periodically reassess the application of those skills during patient teaching sessions.

Training health care professionals to enhance their patient teaching skills

Lack of training interferes with health-care professionals' ability to teach effectively. Nursing staff development educators are seeking strategies to overcome teaching-skill deficits. A 30-hour program was designed to improve teaching skills. Evaluation was based on operationally defined teaching skills. Sixty-six course participants' teaching skills improved from the beginning to the end of the course. Further research is needed to determine whether effects persist in practice, whether patients benefit, and whether "training of trainers" is feasible.

Evaluation of education program developments: illustration of the research and development cycle

The Research and Development (R and D) cycle is a program development model used to translate research findings into educational programs or products ready for use in the field. The R and D cycle is illustrated by describing its application to Effective Patient Teaching, a course on teaching skills for health professionals. Evaluation is a continuing part of program development. Evaluation methods need not follow a rigid formula; methods will generally change with the stages of program development and the evaluation purposes.

Teaching skills of health professionals

The purpose of this paper is to describe an analytic method that focuses on health professionals' teaching skills. The method involves comparing live or recorded teacher behaviors with operational definitions of 20 skills known to influence learning outcomes, and assigning numerical ratings on a four-point scale. The videotapes prepared for this symposium are rated and compared with other sessions recorded in health care settings. Virtually all patient educators could improve their teaching skills substantially. Although many questions about teaching skills and education process remain unanswered, available data clearly justify training to improve health professionals' teaching skills.

Impact of organizational interventions on the delivery of patient education in a diabetes clinic

Patient education is widely regarded as an essential component of chronic disease care and effective health promotion. Nevertheless, the patient education process is seldom the subject of systematic investigation. In a previous study we determined that only a minimal amount of patients' time was devoted to education in a multidisciplinary diabetes clinic. The present study was designed to assess whether organizational manipulations would influence the delivery of patient education. Nurses' responsibility for management of patient flow was reduced, and an education checklist was included in the medical record. These simple modifications of clinic operation to increase the availability of professional time for patient education and to stimulate educational interactions were successful in significantly increasing patient education time. Time spent in assessing patient need increased by about one half (P less than 0.05) and in instruction by about two thirds (P less than 0.05). The process of patient education can be facilitated at low cost to the facility through targeted attention to organizational issues other than providers' knowledge or interest.

Organ culture of isolated rat pancreatic islets with reference to A-cell function

Investigation of the control of glucagon secretion has suffered from the lack of suitable in vitro models. The present studies were initiated to further validate the use of organ cultured islets for such investigation and to develop methods for obtaining rat islets relatively depleted of B cells. Rat islets maintained in tissue culture for 1 week are shown to respond to glucose, epinephrine, acetylcholine, arginine, and somatostatin in a physiologic manner. High glucose concentration during culture is associated with increased glucagon secretion despite increased insulin secretion. Treatment of rats with diabetogenic agents just prior to islet isolation results in B-cell deterioration during culture and insulin content about 20% normal after 1 week of culture. B-cell depleted islets show no glucagon suppression by glucose despite the presence of insulin.

Diet-related knowledge, skill, and adherence among children with insulin-dependent diabetes mellitus

The dietary adherence of a sample of 97 patients with insulin-dependent diabetes mellitus has been quantitatively described. Now, in an effort to understand the poor dietary adherence found, diet-related knowledge and skill and their relationship to dietary adherence among 90 diabetic children have been studied. Diet-related competencies assessed were the ability to: (1) recall the personal diet plan, (2) correctly fill one's plate from a buffet, with the diet plan in hand, and (3) choose an appropriate meal from a restaurant menu. Adherence to the diet was assessed by unobtrusive observations at meals. Error rates on the three tests of knowledge and skill were .21, .28, and .51, respectively. The mean error rate at mealtime was .35, only slightly higher than the error rate for filling a plate when the children knew they were being tested. In a multiple regression analysis, age (r = .37) and sex (R = .48) were associated with adherence to the diet plan. Ability to choose correctly from a menu, duration of diabetes, and ability to correctly fill a plate from a buffet also entered the regression equation (R = .54). The data suggest that many children did not possess the knowledge and skill required for good dietary adherence, regardless of motivation. Health educators may underestimate the complexity of the behaviors expected of chronically ill patients.

Quantitative assessment of dietary adherence in patients with insulin-dependent diabetes mellitus

Research on the education of diabetic patients in diet management suffers from lack of an adequate method for describing patients' dietary behavior. In this report, a method is proposed for the quantitative assessment of dietary adherence in patients with IDDM. The method relies on comparisons between individualized diet plans and actual consumption as reflected by 24-h diet recalls. Data are presented that suggest this method has reliability and validity. In a sample of 97 patients with IDDM, nearly two-thirds adhered to the number and timing of planned feedings, while only about 10% of patients adhered to planned exchanges, 90% of the time. The average patient added or deleted one exchange for every four exchanges in the diet plan.

Diabetes-related goals, practices, and beliefs of practicing pediatricians

Practicing pediatricians were surveyed to assess their need for diabetes education programs. Pediatricians generally have fewer than five diabetic patients, frequently see them less than once every four months, prescribe single daily insulin injections, and do not include dietetic services in their treatment program. Among the pediatricians surveyed, practices correlated weakly with therapeutic goals for metabolic control, and goals correlated weakly with belief that hyperglycemia causes microvascular complications of diabetes. Belief in the importance of hyperglycemia did not correlate with actual care practices reported. The data support the idea that presentation of the latest advances in scientific rationale is an inadequate basis for physicians' continuing education.

Municipal waterborne giardiasis: an epidemilogic investigation. Beavers implicated as a possible reservoir

In March 1976, 128 persons in Camas, Washington, had laboratory-confirmed giardiasis. A questionnaire survey of 498 Camas residents revealed that 3.8% had clinical giardiasis, while none of 318 residents in a control town were ill. No associations between illness and sex, pet ownership, travel, time spent in wilderness areas, public gatherings, or food preference were found. Giardia cysts were recovered from raw water entering the city water treatment system via two streams and also from two storage reservoirs containing chlorinated and filtered stream water. Failure to remove Giardia cysts was attributed to the water plants' inadequate flocculation, coagulation, and sedimentation combined with deterioration of the filter media. Investigation of the watershed revealed no signs of human fecal contamination. Animal trapping in the watershed area yielded three beavers (Castor canadensis) infected with Giardia that were infective for specific pathogen-free beagle pups.