Emergency Department Visits in African Americans with Mild Cognitive Impairment and Diabetes

Abstract

Aims:

Dementia, diabetes, and African American race are three factors that are independently associated with emergency department (ED) use. This study tested the hypothesis that ED use is associated with worse cognitive function in African Americans with Mild Cognitive Impairment (MCI) and poorly controlled diabetes.

Methods:

This study examined differences in ED use among African Americans with MCI and diabetes in a secondary data analysis of baseline data from a one-year randomized controlled trial (N = 101).

Results:

Over one year, 49/92 participants (53.3%) had at least one ED visit. At baseline, participants who had an incident ED visit had significantly fewer years of education; lower scores on neuropsychological tests assessing working memory, psychomotor speed, and complex scanning; higher diabetes-related interpersonal distress scores; lower adherence to a diabetes medication; and higher hemoglobin A1c levels compared to participants with no ED visits (p ≤ 0.05 for all comparisons).

Conclusions:

This study identified multiple risk factors for ED visits in older African Americans with MCI and diabetes. Targeted interventions may be necessary to reduce the need for ED care in high risk populations.

Introduction

Dementia, diabetes, and African American race are three factors that are independently associated with greater emergency department (ED) use. Almost 10% of all ED visits in the United States are diabetes-related; dementia increases the odds of an ED visit 1.7 times; and African Americans have twice the rate of ED visits as whites.^1–5 Multiple socioeconomic (e.g., education, literacy, income), individual (e.g., health beliefs, mistrust), and medical (e.g., access to care, glycemic control) factors may contribute to ED use in African Americans.^6–11 For many African Americans, EDs serve as “the safety net of the safety net,” meeting both unmet medical and social needs.¹² In fact, recent increases in ED visits are in part attributed to a disproportionate rise in use by African Americans.¹³

African Americans are also more likely than whites to develop Mild Cognitive Impairment (MCI), which is a transition state between normal cognition and dementia that is often characterized by deficits in memory and executive function.^{2, 14} These cognitive deficits can compromise diabetes self-care and glycemic control and potentially necessitate ED care^{15, 16}

To learn more about risk factors for ED use, we examined incident ED use over one year in a cohort of older African Americans with MCI and diabetes who enrolled in a randomized controlled trial (RCT) that compared the efficacy of two behavioral interventions to improve glycemic control in this high risk population.¹⁷

Materials and Methods

Institutional Review Board approval was obtained for all study procedures, and all participants provided informed consent in accordance with the Code of Ethics of the World Medical Association. Participants (N = 101) were recruited from primary care practices at Thomas Jefferson University (Philadelphia, Pennsylvania) from March 2015 to October 2017, and enrolled in the RCT (clinicaltrials.gov NCT02174562). The RCT compared the efficacy of in-home occupational therapist (OT)-delivered behavioral activation versus in-home community health worker (CHW)-delivered diabetes education to improve glycemic control over one year in African Americans with MCI and diabetes.¹⁷ The OT intervention was delivered by two white OTs who provided diabetes education using culturally relevant educational materials (e.g., “4 Steps to Control your Diabetes for Life”) and used activity simplification, environmental modification, adaptive device use, and behavioral activation (i.e., defining a goal and taking steps to achieve it) to increase adherence to diabetes self-care activities to improve glycemic control.¹⁸ The in-home diabetes education intervention was delivered by a black CHW who used supportive techniques (e.g., encouraging personal expression, conveying empathy) to create an accepting treatment environment, and delivered an accurate understanding of diabetes that accorded with the American Association of Diabetes Educators’ position statement on CHWs.¹⁹ This education-only intervention was designed to match the OT intervention in visit frequency and duration (i.e., five 90-minute treatment sessions over the first three months, and three 90-minute booster sessions over the next nine months), educational materials, and delivery characteristics (i.e., in-home) but did not include behavioral interventions to increase adherence to diabetes self-care activities. The Health Belief Model guided this research.²⁰ The Health Belief Model holds that perceived disease susceptibility and severity, along with perceived benefits and barriers to treatment, influence health behaviors, and contribute to racial health disparities.

Eligibility criteria were: age 60 years and older; African American race; type 2 diabetes; hemoglobin A1c ≥ 7.5%; MCI (based on cognitive testing conducted for this RCT and current diagnostic criteria);²¹ and ≤ 80% adherence to a diabetes medication. The cognitive tests included the Mini-Mental Status Examination; Logical Memory, immediate and delayed recall; Trail-Making Tests Parts A and B; and Digit Symbol Coding. The Diabetes Self-Care Inventory-Revised was used to assess diabetes self-care, and the Diabetes Distress Scale was used to assess diabetes-related distress.^{22, 23} Information on ED visits was obtained from medical chart reviews and self-report. Two emergency medicine physicians independently reviewed the medical records to identify the principal medical cause for the ED visit. For discrepant determinations, a third emergency medicine physician rendered the final determination. ED diagnoses were categorized as: infections (e.g., urinary tract infection, abscess); non-infectious disease (e.g., diabetic ketoacidosis, CHF, stroke); and symptom only (e.g., pain, dizziness).

For statistical analyses, continuous demographic and clinical characteristics were summarized using means and standard deviations and, for categorical variables, using counts and percentages. Chi square analyses were conducted to compare rates for categorical variables, and one-way analyses of variance were used for continuous variables.

Results

Participants were randomized to the OT intervention (n = 50) or the diabetes education intervention (n = 51). Participants in the two treatment groups had similar baseline demographic, clinical, and neuropsychological characteristics (data not shown). At 12 months, 42/50 (84.0%) of OT participants and 50/51 (98.0%) diabetes education participants provided follow-up data on ED use (p = 0.014). Participants with no follow-up data had higher diabetes-related interpersonal distress scores at baseline than retained participants (3.5 [1.8] vs. 2.3 [1.8]; F=5.2, df 1,100; p = 0.016); otherwise, there were no statistically significant differences.

Over one year, 49/92 participants (53.3%) had at least one ED visit (mean 2.1; SD 1.2). Of the 71 total ED visits, 34 (47.9%) were categorized as symptom-related; 22 (31.0%) as non-infection-related; and 15 (21.1%) as infection-related. The Table shows the demographic and clinical characteristics and treatment assignments of participants with and without ED visits. Twenty-five of 42 OT participants (59.5%) and 24 of 50 diabetes education participants (48.0%) had ED visits. There was no statistically significant difference in ED use by treatment group (p = 0.230).

Table:

Baseline Demographic and Clinical Characteristics of Participants with and without Emergency Department Visits over 12 Months

	ED Visit (n = 49)		No ED visit (n = 43)		p
Age (mean years, SD)	67.7	6.5	68.9	6.4	.353
Female (n, %)	31	63.3	25	58.1	.615
Married (n, %)	13	26.5	14	32.6	.694
Education, years (mean, SD)	11.9	2.1	12.8	2.1	.042a
Had Difficulty Paying for Basics (n, %)	28	57.1	28	65.1	.722
Treatment Group (n, %)
Occupational Therapy	25	51.0	17	39.5	.270
Diabetes Education	24	49.0	26	61.0
Chronic Medical Conditions (mean, SD)	4.9	2.3	4.3	2.3	.233
Number of Medications (mean, SD)	9.5	4.3	9.0	4.4	.608
Cognitive Tests
Mini-Mental State Exam (mean, SD)b	25.4	2.6	25.3	2.6	.779
Digit Symbol Substitution (mean, SD)c	30.1	13.9	36.4	13.1	.032d
Trail Making Test-Part A (mean, SD)e	67.1	34.3	68.4	31.9	.861
Trail Making Test-Part B (mean, SD)f	219.4	79.5	217.8	84.2	.926
Logical Memory Immediate (mean, SD)g	8.1	2.5	9.4	3.4	.035h
Logical Memory Delayed (mean, SD)i	6.0	2.9	6.7	3.5	.288
Hemoglobin A1c (mean, SD)	9.7	1.5	8.9	1.6	.024j
Diabetes Self-Care Inventory (mean, SD)k	57.0	13.6	56.9	15.4	.964
Percent Days Adherent to Diabetes Medication (mean, SD)l	30.6	27.8	43.6	31.5	.038m
Diabetes Distress Scale:
Emotional Burdenn (mean, SD)	3.1	1.6	2.7	1.5	.319
Regimen Distressn (mean, SD)	3.4	.7	3.4	.8	.989
Physician Distressn (mean, SD)	1.6	1.1	1.6	1.1	.991
Interpersonal Distressn (mean, SD)	2.6	1.8	1.9	1.1	.027o

^aED visit vs No ED visit; F_(1,91) = 4.3.

^bRange 0 to 30; higher score indicates better global cognition.

^cRange 0 to 140; higher score indicates better performance.

^dED visit vs No ED visit; F_(1,89) = 4.7.

^eRange 0 to 150 seconds; lower score indicates better performance.

^fRange 0 to 300 seconds; lower score indicates better performance.

^gRange 0 to 25; higher score indicates better performance.

^hED visit vs No ED visit; F_(1,91) = 4.6

ⁱRange 0 to 25; higher score indicates better performance.

^jED visit vs No ED visit; F_(1,91) = 5.3

^kRange 1 to 100; higher score indicates better diabetes self-management.

^lPercent of days that a diabetes medication was taken correctly.

^mED visit vs No ED visit; F_(1,91) = 4.4.

ⁿRange 1 to 6; higher scores indicate greater distress.

^oED visit vs No ED visit; F_(1,91) = 5.0.

Compared to participants with no ED visits, participants with ED visits had significantly fewer years of education; lower scores on Digit Symbol Coding and Logical Memory-Immediate Recall; higher diabetes-related interpersonal distress scores (2.6 [moderate distress] vs. 1.9 [little or no distress]); lower adherence to a diabetes medication; and higher hemoglobin A1c levels.

Discussion

This study identified specific cognitive, emotional, behavioral, and medical factors that increase the risk of ED visits in African Americans with MCI and diabetes. Compared to participants with no ED visits, participants with ED visits had fewer years of education and lower scores on Digit Symbol Coding (working memory, psychomotor speed, and complex scanning) and Logical Memory-Immediate Recall (working memory). These educational and cognitive limitations may increase the risk for ED visits by compromising the ability to quickly comprehend and later adhere to physician instructions, possibly resulting in suboptimal diabetes self-care. Participants with ED visits also had a higher level of diabetes-related interpersonal distress (i.e., feeling that family members failed to appreciate the difficulties of living with diabetes), which too may compromise diabetes self-care.²⁴ Together, these emotional and cognitive factors likely contributed to the lower medication adherence and worse glycemic control that we observed in the participants with ED visits.

Bazargan et al (2003) demonstrated that African Americans with diabetes had unique predisposing (e.g., low education) and need-for-care characteristics (e.g., insulin use) that predicted ED use.²⁵ Together with our findings, these empirical data support the Health Belief Model, which highlights the role of predisposing and precipitating factors and health care utilization, and which provides theoretical support for culturally relevant interventions.²⁰ Notably, we found that participants who received CHW-delivered diabetes education were less likely numerically, albeit not statistically, to have ED visits than participants who received the OT intervention. Although both interventions had treatment features that conferred cultural relevance (i.e., in-home delivery to increase access, referral to social service agencies as needed, and educational materials that African Americans find acceptable), a black CHW delivered the diabetes education intervention whereas white OTs delivered the OT intervention. This racial difference may have influenced retention rates (higher in the CHW intervention) and subsequent ED use. This study was not designed to disentangle this effect but it requires additional study. Also, this study is limited by the small sample size, uncertain generalizability, the lack of comparable data on ED use among other racial and ethnic groups with diabetes and MCI, and the unknown mechanisms by which the identified risk characteristics interacted with intervening medical events to lead to ED visits. Study strengths include recruitment of an understudied minority population, the prospective design, and low attrition. To our knowledge, there have been no previous studies of ED use in older African Americans with MCI and diabetes.

The results of this study are best understood in the context of the clinical realities of treating diabetes in older African Americans with impaired cognition. Besides the possible adverse effects of impaired memory on diabetes self-care, the ability of African Americans to effectively manage diabetes is also reduced by competing social, financial, and health demands; health beliefs about diabetes and its treatment; and difficulty accessing healthy foods, walking safely in one’s neighborhood, and affording medications, all of which can increase risk for emergency care.^6–10 Additional investigation is needed in larger and broader populations, but this study suggests that targeted interventions may be necessary to reduce the need for ED care in high risk populations.

Highlights.

• Minority race, diabetes, and poor cognition increase risk of emergency room use

• Worse cognition and poor glycemia predicted emergency room use in African Americans.

• Screening for impaired cognition may reduce emergency room care.