UT Southwestern Medical School
Permanent URI for this collectionhttps://hdl.handle.net/2152.5/6690
Welcome to the UT Southwestern Medical School’s electronic theses and dissertations (ETD) collection.
Most UT Southwestern ETDs are subject to a default embargo period of two (2) years from the date of degree conferral. These embargoed ETDs are unavailable until the embargo expires.
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Print theses and dissertations from 1943 to 2004 are located in the Library's Special Collections and Archives (Room E3.314) and are available by appointment. (Note: Former students may request a digitized copy of their work by email, but other users may submit an Interlibrary Loan request.) For more information, contact archives@utsouthwestern.edu.
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Browsing UT Southwestern Medical School by Subject "Aged, 80 and over"
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Item The Development and Preliminary Evaluation of MOTIVATE: Moving to Improve Chronic Back Pain and Depression in Older Adults(2021-03-10) Yang, Ailing Eileen; Makris, Una; Roche, Vivyenne; Saxon, LadonnaBACKGROUND: Chronic low back pain (cLBP) is the 2nd most common reason for physician visits; annual related costs exceed USD 100 billion and are expected to rise with the aging population. cLBP and depression often coexist, and current non-pharmacologic interventions have not focused on older adults with these challenging comorbidities. A feasible, effective non-pharmacologic intervention targeting cLBP and comorbid depressive symptoms in older adults is needed. MOTIVATE (Moving to Improve Chronic Back Pain and Depression in Older Adults) is a novel 8-session, 12-week, telephonic behavioral intervention targeting older adults with cLBP and comorbid depressive symptoms. A health coach utilizes motivational interviewing and value-concordant goal setting to capture individual motivations to increase physical activity. The ultimate goal is to improve back pain-related pain interference, disability, and depressive symptoms. OBJECTIVE: To develop a unique telephone-delivered behavioral intervention that is feasible, increases physical activity, and ultimately improves pain, function, and depressive symptoms among older Veterans. METHODS: In Phase 1, Dr. Makris' research team developed a telephone-delivered multicomponent behavioral intervention that targets older Veterans (>65 years old) with cLBP and comorbid depressive symptoms. Input from stakeholder groups [experts in pain, geriatrics, geriatric psychology, primary care, behavioral interventions, among others (n=8), patients (n=5), and key clinical leaders (n=6)] was used to inform and refine content for this unique population. In Phase 2, we conducted a single-arm rollout of MOTIVATE in older Veterans with cLBP and depressive symptoms to further refine future intervention content, procedures, and delivery based on stakeholder feedback. For qualitative interviews, the Promoting Action on Research Implementation in Health Services (PARIHS) framework was used to develop the discussion guide and facilitate individual interviews with the following key stakeholder groups: Veteran participants (n=4) over the age of 65 with comorbid cLBP and depressive symptoms who received MOTIVATE, primary care providers (PCP) (n=4), clinic director (n=1), and health coach (n=1). RESULTS: Informed by interviews with 14 experts and 5 Veterans, we developed and iteratively refined the MOTIVATE manual and study procedures for Phase 1. In the single-arm MOTIVATE rollout (Phase 2), we enrolled 7 Veterans, with a mean age of 69 years who were predominately white (71%), male (86%), married (57%), and had some education beyond high school (71%). The eligibility mean pain intensity score was 7.3/10; baseline cLBP Pain, Enjoyment of Life, and General (PEG-3) Activity Scale was 7.14/10, back pain-specific Roland Morris Disability Questionnaire (RMDQ) Scale was 16.5/24; and depression PHQ-9 score was 16.7/27, with higher scores indicating greater impairment. Two case studies are provided for additional context and to more fully articulate important MOTIVATE intervention concepts. Upon completion of the intervention, semi-structured interviews with Veterans and other stakeholders provided valuable feedback on how to modify MOTIVATE moving forward. Briefly, Veterans who completed MOTIVATE engaged well with the health coach, were motivated to walk with a pedometer, and felt that being more active reduced pain and depressive symptoms. Of the four PCPs interviewed, all attributed the success of the intervention to the skills and engagement of the health coach; we also learned about the variability in how PCPs would like results relating to patient-identified values and goals to be communicated with them. The health coach noted that Veterans were able to identify value-concordant goals and easily link these to physical activities. All stakeholders stated that the individual health coach plays a critical role in activating and motivating older Veterans with complex medical and psychiatric conditions. CONCLUSION: MOTIVATE content and procedures were developed in Phase 1. The Phase 2 rollout showed that we were able to effectively recruit older Veterans with cLBP and depressive symptoms and deliver MOTIVATE via telephone. Feedback from key stakeholders regarding the iterative refinement of recruitment, study procedures, and content will aid the future evaluation and implementation of MOTIVATE in a pilot randomized controlled trial.Item Is Nitrofurantoin Use Really Dangerous for Older Adults?: A Deeper Dive into Beers Criteria(2018-03-29) Claussen, Karin Rebekah; Reed, W. Gary; Rubin, Craig; Fish, JasonBACKGROUND: The use of nitrofurantoin (NF) has been quite controversial over the past several years. The Infectious Disease Society of America (IDSA) recommends NF as a first choice treatment for uncomplicated urinary tract infections (UTI's); yet, several quality indicators, specifically the Beers Criteria, include NF as a potentially inappropriate medication (PIM) for adults 65 and older due to a number of concerns, especially pulmonary and hepatic complications. However, many physicians and pharmacists question the Beers Criteria recommendation and believe the adverse event (AE) incidence is low enough to warrant using this antibiotic in the older population. OBJECTIVE: We sought to identify the pulmonary and hepatic adverse event rate associated with NF use in a cohort of patients 65 and older to determine if a restriction of the use of NF is needed. METHODS: A retrospective chart audit of patients 65 and older prescribed NF from January 1, 2010, to December 31, 2014 at an urban academic medical center was conducted. Additional inclusion criteria were diagnoses of dyspnea, pulmonary fibrosis, hepatotoxicity, cholestatic jaundice, and chronic hepatitis as documented in the patients' medical records. Two independent reviewers of the medical records assigned patients with the following categories: No Reaction, Allergy, Minor Side Effect, High Suspicion for AE, or Possible Suspicion for AE (A, B or C). If discordance occurred between the two reviewers, a third reviewer provided an additional review assigning the category based on the majority. RESULTS: Of 3,400 individuals aged 65 and older prescribed nitrofurantoin during the study period, 641 were identified as possibly having one of five targeted symptoms or disease complications (pulmonary and hepatic) associated with nitrofurantoin. After a detailed chart audit, 89% were deemed to have no adverse reaction, 7% had a minor side effect or allergy, and 3.9% (25 patients) met criteria for suspicion of a nitrofurantoin-induced AE, five of whom (0.8%) were rated as highly suspicious for nitrofurantoin toxicity; four of the five were identified with pulmonary toxicity and one with hepatotoxicity. Four of five of these individuals used nitrofurantoin chronically. CONCLUSION: Nitrofurantoin was prescribed for 3,400 individuals aged 65 and older during the 5-year study period. We found a low rate of nitrofurantoin-associated AEs. However, a judicious approach appears warranted with chronic use and in patients for whom toxicity could exacerbate underlying medical conditions (e.g. underlying interstitial disease). Avoiding NF in patients based on age alone should not be seen as a negative quality indicator based on our results. Through patient education and informed prescribers, NF can be used safely in most patients 65 and older.