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Amjad H, Roth DL, Sheehan OC, Lyketsos CG, Wolff JL, Samus QM. Underdiagnosis of Dementia: an Observational Study of Patterns in Diagnosis and Awareness in US Older Adults. J Gen Intern Med 2018; 33:1131-1138. [PMID: 29508259 PMCID: PMC6025653 DOI: 10.1007/s11606-018-4377-y] [Citation(s) in RCA: 211] [Impact Index Per Article: 35.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2017] [Revised: 12/28/2017] [Accepted: 02/08/2018] [Indexed: 10/17/2022]
Abstract
BACKGROUND Many older adults living with dementia have not been formally diagnosed. Even when clinicians document the diagnosis, patients and families may be unaware of the diagnosis. Knowledge of how individual characteristics affect detection and awareness of dementia is limited. OBJECTIVE To identify characteristics associated with dementia diagnosis and awareness of diagnosis. DESIGN Cross-sectional observational study. PARTICIPANTS Five hundred eighty-five adults aged ≥ 65 in the National Health and Aging Trends Study who met assessment-based study criteria for probable dementia in 2011 and had 3 years of continuous, fee-for-service Medicare claims prior to 2011. MAIN MEASURES Using multivariable logistic regression, we compared participants with undiagnosed versus diagnosed dementia (based on Medicare claims) on demographic, social/behavioral, functional, medical, and healthcare utilization characteristics. Among those diagnosed, we compared characteristics of participants unaware versus aware of the diagnosis (based on self or proxy report). KEY RESULTS Among older adults with probable dementia, 58.7% were either undiagnosed (39.5%) or unaware of the diagnosis (19.2%). In adjusted analyses, individuals who were Hispanic (OR 2.48, 95% CI 1.19, 5.14), had less than high school education (OR 0.54 for at least high school education, 95% CI 0.32, 0.91), attended medical visits alone (OR 1.98, 95% CI 1.11, 3.51), or had fewer functional impairments (OR 0.79 for each impairment, 95% CI 0.69, 0.90) were more likely to be undiagnosed. Similarly, among those diagnosed, having less education (OR 0.42), attending medical visits alone (OR 1.97), and fewer functional impairments (OR 0.72) were associated with unawareness of diagnosis (all ps < 0.05). CONCLUSIONS The majority of older adults with dementia are either undiagnosed or unaware of the diagnosis, suggesting shortcomings in detection and communication of dementia. Individuals who may benefit from targeted screening include racial/ethnic minorities and persons who have lower educational attainment, any functional impairment, or attend medical visits alone.
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Black BE, Johnston D, Reuland M, Lyketsos C, Samus QM. P1‐549: UNMET NEEDS OF COMMUNITY‐RESIDING PERSONS WITH DEMENTIA. Alzheimers Dement 2018. [DOI: 10.1016/j.jalz.2018.06.560] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Nieman CL, Plaat K, Johnston D, Black BE, Reuland M, Lyketsos C, Samus QM. O3‐08‐02: DEMENTIA AND HEARING CARE DISPARITIES: PREVALENCE OF PROXY‐RATED HEARING LOSS AND HEARING AID USE IN A COMMUNITY‐DWELLING COHORT OF DIVERSE OLDER ADULTS WITH DEMENTIA. Alzheimers Dement 2018. [DOI: 10.1016/j.jalz.2018.06.2813] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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Samus QM, Davis K, Willink A, Black BS, Reuland M, Leoutsakos J, Roth DL, Wolff J, Gitlin LN, Lyketsos CG, Johnston D. Comprehensive home-based care coordination for vulnerable elders with dementia: Maximizing Independence at Home-Plus-Study protocol. INTERNATIONAL JOURNAL OF CARE COORDINATION 2017; 20:123-134. [PMID: 29607051 PMCID: PMC5870897 DOI: 10.1177/2053434517744071] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
INTRODUCTION Despite availability of effective care strategies for dementia, most health care systems are not yet organized or equipped to provide comprehensive family-centered dementia care management. Maximizing Independence at Home-Plus is a promising new model of dementia care coordination being tested in the U.S. through a Health Care Innovation Award funded by the Centers for Medicare and Medicaid Services that may serve as a model to address these delivery gaps, improve outcomes, and lower costs. This report provides an overview of the Health Care Innovation Award aims, study design, and methodology. METHODS This is a prospective, quasi-experimental intervention study of 342 community-living Medicare-Medicaid dual eligibles and Medicare-only beneficiaries with dementia in Maryland. Primary analyses will assess the impact of Maximizing Independence at Home-Plus on risk of nursing home long-term care placement, hospitalization, and health care expenditures (Medicare, Medicaid) at 12, 18 (primary end point), and 24 months, compared to a propensity-matched comparison group. DISCUSSION The goals of the Maximizing Independence at Home-Plus model are to improve care coordination, ability to remain at home, and life quality for participants and caregivers, while reducing total costs of care for this vulnerable population. This Health Care Innovation Award project will provide timely information on the impact of Maximizing Independence at Home-Plus care coordination model on a variety of outcomes including effects on Medicaid and Medicare expenditures and service utilization. Participant characteristic data, cost savings, and program delivery costs will be analyzed to develop a risk-adjusted payment model to encourage sustainability and facilitate spread.
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Samus QM, Black BS, Bovenkamp D, Buckley M, Callahan C, Davis K, Gitlin LN, Hodgson N, Johnston D, Kales HC, Karel M, Kenney JJ, Ling SM, Panchal M, Reuland M, Willink A, Lyketsos CG. Home is where the future is: The BrightFocus Foundation consensus panel on dementia care. Alzheimers Dement 2017; 14:104-114. [PMID: 29161539 DOI: 10.1016/j.jalz.2017.10.006] [Citation(s) in RCA: 60] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2017] [Revised: 10/13/2017] [Accepted: 10/15/2017] [Indexed: 02/07/2023]
Abstract
INTRODUCTION A national consensus panel was convened to develop recommendations on future directions for home-based dementia care (HBDC). METHODS The panel summarized advantages and challenges of shifting to HBDC as the nexus of care and developed consensus-based recommendations. RESULTS The panel developed five core recommendations: (1) HBDC should be considered the nexus of new dementia models, from diagnosis to end of life in dementia; (2) new payment models are needed to support HBDC and reward integration of care; (3) a diverse new workforce that spans the care continuum should be prepared urgently; (4) new technologies to promote communication, monitoring/safety, and symptoms management must be tested, integrated, and deployed; and (5) targeted dissemination efforts for HBDC must be employed. DISCUSSION HBDC represents a promising paradigm shift to improve care for those living with dementia and their family caregivers: these recommendations provide a framework to chart a course forward for HBDC.
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Amjad H, Ahuja A, Lyketsos C, Roth DL, Samus QM. [P2–523]: PATTERNS IN FORMAL DEMENTIA DIAGNOSIS AND AWARENESS OF DIAGNOSIS. Alzheimers Dement 2017. [DOI: 10.1016/j.jalz.2017.06.1181] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Amjad H, Wong SK, Roth DL, Huang J, Willink A, Black BS, Johnston D, Rabins PV, Gitlin LN, Lyketsos CG, Samus QM. Health Services Utilization in Older Adults with Dementia Receiving Care Coordination: The MIND at Home Trial. Health Serv Res 2017; 53:556-579. [PMID: 28083879 DOI: 10.1111/1475-6773.12647] [Citation(s) in RCA: 36] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
OBJECTIVE To investigate effects of a novel dementia care coordination program on health services utilization. DATA SOURCES/STUDY SETTING A total of 303 community-dwelling adults aged ≥70 with a cognitive disorder in Baltimore, Maryland (2008-2011). STUDY DESIGN Single-blind RCT evaluating efficacy of an 18-month care coordination intervention delivered through community-based nonclinical care coordinators, supported by an interdisciplinary clinical team. DATA COLLECTION/EXTRACTION METHODS Study partners reported acute care/inpatient, outpatient, and home- and community-based service utilization at baseline, 9, and 18 months. PRINCIPAL FINDINGS From baseline to 18 months, there were no significant group differences in acute care/inpatient or total outpatient services use, although intervention participants had significantly increased outpatient dementia/mental health visits from 9 to 18 months (p = .04) relative to controls. Home and community-based support service use significantly increased from baseline to 18 months in the intervention compared to control (p = .005). CONCLUSIONS While this dementia care coordination program did not impact acute care/inpatient services utilization, it increased use of dementia-related outpatient medical care and nonmedical supportive community services, a combination that may have helped participants remain at home longer. Future care model modifications that emphasize delirium, falls prevention, and behavior management may be needed to influence inpatient service use.
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Amjad H, Roth DL, Samus QM, Yasar S, Wolff JL. Potentially Unsafe Activities and Living Conditions of Older Adults with Dementia. J Am Geriatr Soc 2016; 64:1223-32. [PMID: 27253366 PMCID: PMC4914464 DOI: 10.1111/jgs.14164] [Citation(s) in RCA: 56] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
OBJECTIVES To examine the prevalence of dementia in the absence of a reported dementia diagnosis and whether potentially unsafe activities and living conditions vary as a function of dementia diagnosis status in a nationally representative sample of older adults. DESIGN Observational cohort study. SETTING Community. PARTICIPANTS Medicare beneficiaries aged 65 and older enrolled in the National Health and Aging Trends Study (N = 7,609). MEASUREMENTS Participants were classified into four groups based on self-report of dementia diagnosis, proxy screening interview, and cognitive testing: probable dementia with reported dementia diagnosis (n = 457), probable dementia without reported dementia diagnosis (n = 581), possible dementia (n = 996), or no dementia (n = 5,575). Potentially unsafe activities (driving, preparing hot meals, managing finances or medications, attending doctor visits alone) and living conditions (falls, living alone, and unmet needs) were examined according to dementia status subgroups in stratified analyses and multivariate models, adjusting for sociodemographic factors, medical comorbidities, and physical capacity. RESULTS The prevalence of driving (22.9%), preparing hot meals (31.0%), managing finances (21.9%), managing medications (36.6%), and attending doctor visits alone (20.6%) was lowest in persons with probable dementia; however, but in persons with probable dementia, the covariate-adjusted rates of driving, preparing hot meals, managing finances, managing medications, and attending doctor visits alone were significantly higher in those without reported dementia diagnosis than in those with reported diagnosis (all odds ratios ≥2.00, all P < .01). CONCLUSION Older adults with probable dementia who are not aware of a dementia diagnosis are more likely to report engaging in potentially unsafe behaviors. Understanding the prevalence of potentially unsafe activities and living conditions can help clinicians focus safety screening and counseling in older adults with diagnosed or suspected dementia.
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Samus QM, Amjad H, Johnston D, Black BS, Bartels SJ, Lyketsos CG. A Multipronged, Adaptive Approach for the Recruitment of Diverse Community-Residing Elders with Memory Impairment: The MIND at Home Experience. Am J Geriatr Psychiatry 2015; 23:698-708. [PMID: 25771267 PMCID: PMC5226267 DOI: 10.1016/j.jagp.2015.01.005] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2014] [Revised: 01/21/2015] [Accepted: 01/27/2015] [Indexed: 10/24/2022]
Abstract
OBJECTIVE To provide a critical review of a multipronged recruitment approach used to identify, recruit, and enroll a diverse community-based sample of persons with memory disorders into an 18-month randomized, controlled dementia care coordination trial. METHODS Descriptive analysis of a recruitment approach comprised five strategies: community liaison ("gatekeepers") method, letters sent from trusted community organizations, display and distribution of study materials in the community, research registries, and general community outreach and engagement activities. Participants were 55 community organizations and 63 staff of community organizations in Baltimore, Maryland. Participant referral sources, eligibility, enrollment status, demographics, and loss to follow-up were tracked in a relational access database. RESULTS In total, 1,275 referrals were received and 303 socioeconomically, cognitively, and racially diverse community-dwelling persons with cognitive disorders were enrolled. Most referrals came from letters sent from community organizations directly to clients on the study's behalf (39%) and referrals from community liaison organizations (29%). African American/black enrollees were most likely to come from community liaison organizations. CONCLUSION A multipronged, adaptive approach led to the successful recruitment of diverse community-residing elders with memory impairment for an intervention trial. Key factors for success included using a range of evidence-supported outreach strategies, forming key strategic community partnerships, seeking regular stakeholder input through all research phases, and obtaining "buy-in" from community stakeholders by aligning study objectives with perceived unmet community needs.
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Davis K, Buttorff C, Leff B, Samus QM, Szanton S, Wolff JL, Bandeali F. Innovative care models for high-cost Medicare beneficiaries: delivery system and payment reform to accelerate adoption. THE AMERICAN JOURNAL OF MANAGED CARE 2015; 21:e349-e356. [PMID: 26167783] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
OBJECTIVES About a third of Medicare beneficiaries are covered by Medicare Advantage (MA) plans or accountable care organizations (ACOs). As a result of assuming financial risk for Medicare services and/or being eligible for shared savings, these organizations have an incentive to adopt models of delivering care that contribute to better care, improved health outcomes, and lower cost. This paper identifies innovative care models across the care continuum for high-cost Medicare beneficiaries that MA plans and ACOs could adopt to improve care while potentially achieving savings. It suggests policy changes that would accelerate testing and spread of promising care delivery model innovations. STUDY DESIGN AND METHODS Targeted review of the literature to identify care delivery models focused on high-cost or high-risk Medicare beneficiaries. RESULTS This paper presents select delivery models for high-risk Medicare beneficiaries across the care continuum that show promise of yielding better care at lower cost that could be considered for adoption by MA plans and ACOs. Common to these models are elements of the Wagner Chronic Care Model, including practice redesign to incorporate a team approach to care, the inclusion of nonmedical personnel, efforts to promote patient engagement, supporting provider education on innovations,and information systems allowing feedback of information to providers. The goal of these models is to slow the progression to long-term care, reduce health risks, and minimize adverse health impacts, all while achieving savings.These models attempt to maintain the ability of high-risk individuals to live in the home or a community-based setting, thereby avoiding costly institutional care. Identifying and implementing promising care delivery models will become increasingly important in launching successful population health initiatives. CONCLUSIONS MA plans and ACOs stand to benefit financially from adopting care delivery models for high-risk Medicare beneficiaries that reduce hospitalization. Spreading these models to other organizations will require provider payment policy changes. Integration of acute and long-term care would further spur adoption of effective strategies for reducing or delaying entry into long-term institutional care.
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Tanner JA, Black BS, Johnston D, Hess E, Leoutsakos JM, Gitlin LN, Rabins PV, Lyketsos C, Samus QM. A randomized controlled trial of a community-based dementia care coordination intervention: effects of MIND at Home on caregiver outcomes. Am J Geriatr Psychiatry 2015; 23:391-402. [PMID: 25260557 PMCID: PMC4355038 DOI: 10.1016/j.jagp.2014.08.002] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2014] [Revised: 07/23/2014] [Accepted: 08/06/2014] [Indexed: 10/24/2022]
Abstract
OBJECTIVE To assess whether MIND at Home, a community-based, multicomponent, care coordination intervention, reduces unmet caregiving needs and burden in informal caregivers of persons with memory disorders. METHODS An 18-month randomized controlled trial of 289 community-living care recipient (CR)-caregiver (informal caregivers, i.e., unpaid individuals who regularly assisted the CR) dyads from 28 postal code areas of Baltimore, Maryland was conducted. All dyads and the CR's primary care physician received the written needs assessment results and intervention recommendations. Intervention dyads then received an 18-month care coordination intervention delivered by nonclinical community workers to address unmet care needs through individualized care planning, referral and linkage to dementia services, provision of caregiver dementia education and skill-building strategies, and care progress monitoring by an interdisciplinary team. Primary outcome was total percent of unmet caregiver needs at 18 months. Secondary outcomes included objective and subjective caregiver burden measures, quality of life (QOL), and depression. RESULTS Total percent of unmet caregiver needs declined in both groups from baseline to 18 months, with no statistically significant between-group difference. No significant group differences occurred in most caregiver burden measures, depression, or QOL. There was a potentially clinically relevant reduction in self-reported number of hours caregivers spent with the CR for MIND participants compared with control subjects. CONCLUSION No statistically significant impacts on caregiver outcomes were found after multiple comparison adjustments. However, MIND at Home appeared to have had a modest and clinically meaningful impact on informal caregiver time spent with CRs.
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Black BS, Johnston D, Rabins PV, Morrison A, Lyketsos C, Samus QM. Unmet needs of community-residing persons with dementia and their informal caregivers: findings from the maximizing independence at home study. J Am Geriatr Soc 2014; 61:2087-2095. [PMID: 24479141 DOI: 10.1111/jgs.12549] [Citation(s) in RCA: 199] [Impact Index Per Article: 19.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
OBJECTIVES To determine the prevalence and correlates of unmet needs in a sample of community-residing persons with dementia (PWD) and their informal caregivers. DESIGN Analysis of cross-sectional, baseline participant characteristics before randomization in a care coordination intervention trial. SETTING Baltimore, Maryland. PARTICIPANTS Community-residing PWD (n=254) and their informal caregivers (n=246). MEASUREMENTS In-home assessments of dementia-related needs based on the Johns Hopkins Dementia Care Needs Assessment. Bivariate and multivariate regression analyses were conducted to identify demographic, socioeconomic, clinical, functional, and quality-of-life correlates of unmet needs. RESULTS The mean number of unmet needs was 7.7±4.8 in PWD and 4.6±2.3 in caregivers, with almost all PWD (99%) and caregivers (97%) having one or more unmet needs. Unmet needs in PWD were significantly greater in those with higher cognitive function. Ninety percent of PWD had unmet safety needs, more than half had unmet needs for meaningful activities, and almost one-third had not received a prior evaluation or diagnosis. Higher unmet needs in PWD was significantly associated with nonwhite race, lower income, less impairment in activities of daily living, and more symptoms of depression. For caregivers, more than 85% had unmet needs for resource referrals and caregiver education. Higher unmet caregiver needs was significantly associated with nonwhite race, less education, and more symptoms of depression. CONCLUSION Many community-residing PWD and their caregivers have unmet dementia-related needs for care, services, and support. Providers should be aware that unmet needs may be higher in minority and low-income community residents, caregivers with lower education, and individuals with early-stage dementia. Identifying and treating symptoms of depression in PWD and caregivers may enable them to address their other unmet needs.
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de Medeiros K, Rubinstein RL, Onyike CU, Johnston DM, Baker A, McNabney M, Lyketsos CG, Rosenblatt A, Samus QM. Childless Elders in Assisted Living: Findings from the Maryland Assisted Living Study. JOURNAL OF HOUSING FOR THE ELDERLY 2013; 27:206-220. [PMID: 24729653 DOI: 10.1080/02763893.2012.754823] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
We compared data drawn from a random sample of 399 current assisted living (AL) residents and a subsample of 222 newly admitted residents for two groups: childless AL residents and AL residents with children. The percentage of childless AL residents (26%) in our study was slightly higher than US population estimates of childless persons age 65 and over (20%). In the overall sample, the two groups differed significantly by age, race and women's years of education. The childless group was slightly younger, had a higher percentage of African American residents, and had more years of education than the group with children. In the subsample, we looked at demographic, functional, financial and social characteristics and found that compared to residents with children, fewer childless residents had a dementia diagnosis, received visits from a relative while more paid less money per month for AL and reported having private insurance. As childlessness among older adults continues to increase, it will become increasingly important to understand how child status affects the need for and experience of long-term care.
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Kozubal DE, Samus QM, Bakare AA, Trecker CC, Wong HW, Guo H, Cheng J, Allen PX, Mayer LS, Jamison KR, Kaplin AI. Separate may not be equal: a preliminary investigation of clinical correlates of electronic psychiatric record accessibility in academic medical centers. Int J Med Inform 2012; 82:260-7. [PMID: 23266060 DOI: 10.1016/j.ijmedinf.2012.11.007] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2011] [Revised: 11/01/2012] [Accepted: 11/08/2012] [Indexed: 10/27/2022]
Abstract
OBJECTIVES Electronic Medical Records (EMR) have the potential to improve the coordination of healthcare in this country, yet the field of psychiatry has lagged behind other medical disciplines in its adoption of EMR. METHODS Psychiatrists at 18 of the top US hospitals completed an electronic survey detailing whether their psychiatric records were stored electronically and accessible to non-psychiatric physicians. Electronic hospital records and accessibility statuses were correlated with patient care outcomes obtained from the University Health System Consortium Clinical Database available for 13 of the 18 top US hospitals. RESULTS 44% of hospitals surveyed maintained most or all of their psychiatric records electronically and 28% made psychiatric records accessible to non-psychiatric physicians; only 22% did both. Compared with hospitals where psychiatric records were not stored electronically, the average 7-day readmission rate of psychiatric patients was significantly lower at hospitals with psychiatric EMR (5.1% vs. 7.0%, p = .040). Similarly, the 14 and 30-day readmission rates at hospitals where psychiatric records were accessible to non-psychiatric physicians were lower than those of their counterparts with non-accessible records (5.8% vs. 9.5%, p = .019, 8.6% vs. 13.6%, p = .013, respectively). The 7, 14, and 30-day readmission rates were significantly lower in hospitals where psychiatric records were both stored electronically and made accessible than at hospitals where records were either not electronic or not accessible (4% vs 6.6%, 5.8% vs 9.1%, 8.9 vs 13%, respectively, all with p = 0.045). CONCLUSIONS Having psychiatric EMR that were accessible to non-psychiatric physicians correlated with improved clinical care as measured by lower readmission rates specific for psychiatric patients.
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Gross AL, Parisi JM, Spira AP, Kueider AM, Ko JY, Saczynski JS, Samus QM, Rebok GW. Memory training interventions for older adults: a meta-analysis. Aging Ment Health 2012; 16:722-34. [PMID: 22423647 PMCID: PMC3430800 DOI: 10.1080/13607863.2012.667783] [Citation(s) in RCA: 109] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
A systematic review and meta-analysis of memory training research was conducted to characterize the effect of memory strategies on memory performance among cognitively intact, community-dwelling older adults, and to identify characteristics of individuals and of programs associated with improved memory. The review identified 402 publications, of which 35 studies met criteria for inclusion. The overall effect size estimate, representing the mean standardized difference in pre-post change between memory-trained and control groups, was 0.31 standard deviations (SD; 95% confidence interval (CI): 0.22, 0.39). The pre-post training effect for memory-trained interventions was 0.43 SD (95% CI: 0.29, 0.57) and the practice effect for control groups was 0.06 SD (95% CI: 0.05, 0.16). Among 10 distinct memory strategies identified in studies, meta-analytic methods revealed that training multiple strategies was associated with larger training gains (p=0.04), although this association did not reach statistical significance after adjusting for multiple comparisons. Treatment gains among memory-trained individuals were not better after training in any particular strategy, or by the average age of participants, session length, or type of control condition. These findings can inform the design of future memory training programs for older adults.
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Black BS, Johnston D, Morrison A, Rabins PV, Lyketsos CG, Samus QM. Quality of life of community-residing persons with dementia based on self-rated and caregiver-rated measures. Qual Life Res 2011; 21:1379-89. [PMID: 22038392 DOI: 10.1007/s11136-011-0044-z] [Citation(s) in RCA: 66] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/07/2011] [Indexed: 11/26/2022]
Abstract
PURPOSE To identify correlates of self-rated and caregiver-rated quality of life (QOL) in community-residing persons with dementia (PWD) for intervention development. METHODS Cross-sectional data of 254 PWD and their caregivers participating in a clinical trial were derived from in-home assessments. Self-rated QOL was measured with the Quality of Life-Alzheimer Disease (QOL-AD) scale, and caregiver-rated QOL was measured using the QOL-AD and Alzheimer Disease-Related Quality of Life (ADRQL) scales. Multivariate modeling identified correlates of the PWD' QOL. RESULTS Self-rated QOL was related significantly to participant race, unmet needs, depression, and total medications. Caregiver-rated QOL-AD scores were significantly associated with participant function, unmet needs, depression, and health problems and with caregiver burden and self-rated health. Significant correlates of ADRQL scores included neuropsychiatric symptom severity, functional and cognitive impairment, and caregiver burden and depression. CONCLUSIONS Correlates of QOL in community-residing PWD depend on who rates the PWD's QOL and which measure is used. Addressing health problems, medication use, and dementia-related unmet needs, reducing functional dependency, and treating neuropsychiatric symptoms in PWD, while reducing caregiver burden and depression, may maximize QOL in those with dementia.
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Marquardt G, Johnston D, Black BS, Morrison A, Rosenblatt A, Lyketsos CG, Samus QM. A Descriptive Study of Home Modifications for People with Dementia and Barriers to Implementation. ACTA ACUST UNITED AC 2011; 25:258-273. [PMID: 21904419 DOI: 10.1080/02763893.2011.595612] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
This study describes home environmental features, safety issues, and health-related modifications in a community dwelling sample of 82 elderly people with dementia. Main barriers to the accessibility of the homes were steps, both inside and outside the house. The majority of the caregivers had made home modifications, which pertained mainly to physical limitations. Home modifications to support cognitive deficits were made to a lesser extent. The main barrier to the implementation of home modifications to accommodate the care recipient's memory loss was skepticism about their usefulness. Regarding the removal of physical barriers, financial constraints were most frequently mentioned.
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Johnston D, Samus QM, Morrison A, Leoutsakos JS, Hicks K, Handel S, Rye R, Robbins B, Rabins PV, Lyketsos CG, Black BS. Identification of community-residing individuals with dementia and their unmet needs for care. Int J Geriatr Psychiatry 2011; 26:292-8. [PMID: 20658473 PMCID: PMC3039061 DOI: 10.1002/gps.2527] [Citation(s) in RCA: 51] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2009] [Accepted: 03/05/2010] [Indexed: 11/10/2022]
Abstract
BACKGROUND Innovative approaches to the widespread delivery of evidence-based dementia care are needed. The aims of this study were to determine whether a telephone screening method could efficiently identify individuals in the community in need of care for dementia and to develop a multidimensional needs assessment tool for identifying the type and frequency of unmet needs related to memory disorders in the home setting. METHODS This was a cross-sectional evaluation of 292 community-residing individuals aged 70 and older in Maryland. Participants were given a brief cognitive telephone screen. A subsample (n=43) received a comprehensive in-home assessment for dementia and dementia-related needs. Cognitive, functional, behavioral, and clinical factors were assessed. The Johns Hopkins Dementia Care Needs Assessment (JHDCNA) was used to identify unmet needs related to dementia. RESULTS Telephone screening for the sample took 350 h, and 27% screened positive for dementia. Virtually all participants with dementia who received an in-home assessment had at least one unmet need, with the most frequent unmet needs being for a dementia workup, general medical care, environmental safety, assistance with ADL impairments, and access to meaningful activities. Caregivers, when present, also had a number of unmet needs, with the most common being caregiver education about dementia, knowledge of community resources, and caregiver mental health care. CONCLUSIONS Effective and efficient means for identifying community-residing individuals with dementia are needed so that dementia care interventions can be provided to address unmet care needs of patients and their caregivers.
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Marquardt G, Johnston D, Black BS, Morrison A, Rosenblatt A, Lyketsos CG, Samus QM. Association of the spatial layout of the home and ADL abilities among older adults with dementia. Am J Alzheimers Dis Other Demen 2011; 26:51-7. [PMID: 21282278 PMCID: PMC3143576 DOI: 10.1177/1533317510387584] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
We investigated the relationship between architectural space syntax measures describing the spatial layout of a home and activities of daily living (ADL) among people with dementia. We visited the homes of 82 participants in a dementia care comparative effectiveness clinical trial and measured the space syntax variables intelligibility and convexity along with several clinical variables, including ADLs. In regression models, we estimated the cross-sectional association between space syntax measures and ADLs. Higher convexity was associated with worse performance of basic but not instrumental ADLs (adjusted β =19.2, P = .02). Intelligibility was not associated with ADLs. These results imply that enclosed rooms with a clearly legible meaning and function might be better memorized and associated with the spatial layout of the home resulting in better basic ADL performance. These results warrant further research on space syntax measures in the home environment of people with dementia, including longitudinal study, which we are pursuing.
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Bicket MC, Samus QM, McNabney M, Onyike CU, Mayer LS, Brandt J, Rabins P, Lyketsos C, Rosenblatt A. The physical environment influences neuropsychiatric symptoms and other outcomes in assisted living residents. Int J Geriatr Psychiatry 2010; 25:1044-54. [PMID: 20077498 PMCID: PMC3143504 DOI: 10.1002/gps.2460] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
OBJECTIVE Although the number of elderly residents living in assisted living (AL) facilities is rising, few studies have examined the AL physical environment and its impact on resident well-being. We sought to quantify the relationship of AL physical environment with resident outcomes including neuropsychiatric symptoms (NPS), quality of life (QOL), and fall risk, and to compare the effects for demented and non-demented residents. METHODS Prospective cohort study of a stratified random sample of 326 AL residents living in 21 AL facilities. Measures included the Therapeutic Environmental Screening Scale for Nursing Homes and Residential Care (TESS-NH/RC) to rate facilities and in-person assessment of residents for diagnosis (and assessment of treatment) of dementia, ratings on standardized clinical, cognitive, and QOL measures. Regression models compared environmental measures with outcomes. TESS-NH/RC is modified into a scale for rating the AL physical environment AL-EQS. RESULTS The AL Environmental Quality Score (AL-EQS) was strongly negatively associated with Neuropsychiatric Inventory (NPI) total score (p < 0.001), positively associated with Alzheimer Disease Related Quality of Life (ADRQL) score (p = 0.010), and negatively correlated with fall risk (p = 0.042). Factor analysis revealed an excellent two-factor solution, Dignity and Sensory. Both were strongly associated with NPI and associated with ADRQL. CONCLUSION The physical environment of AL facilities likely affects NPS and QOL in AL residents, and the effect may be stronger for residents without dementia than for residents with dementia. Environmental manipulations that increase resident privacy, as well as implementing call buttons and telephones, may improve resident well-being.
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Smith M, Samus QM, Steele C, Baker A, Brandt J, Rabins PV, Lyketsos C, Rosenblatt A. Anxiety symptoms among assisted living residents: implications of the "no difference" finding for participants with and without dementia. Res Gerontol Nurs 2010; 1:97-104. [PMID: 20078022 DOI: 10.3928/19404921-20080401-06] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Anxiety is a distressing experience at any age but may be particularly disabling when coupled with dementia. Dementia-related anxiety is associated with a range of additional problems among community-dwelling older adults, but little is known about its occurrence in assisted living environments. The purpose of this article is to describe the prevalence of anxiety symptoms among older adults who participated in Phase I of the Maryland Assisted Living Study, a cross-sectional study of 198 participants who underwent comprehensive dementia evaluations. Participants with dementia diagnoses (n=134) were compared with those without dementia (n=64) using two measures of anxiety. Anxiety was common in both groups: 22% of each group were assessed to have one or more anxiety symptoms using proxyrated methods, and 45% had at least mild anxiety using direct observation and interview. Factors that contribute to variability in reports of dementia-related anxiety are reviewed.
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Samus QM, Mayer L, Onyike CU, Brandt J, Baker A, McNabney M, Rabins PV, Lyketsos CG, Rosenblatt A. Correlates of functional dependence among recently admitted assisted living residents with and without dementia. J Am Med Dir Assoc 2009; 10:323-9. [PMID: 19497544 DOI: 10.1016/j.jamda.2009.01.004] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2009] [Accepted: 01/15/2009] [Indexed: 11/30/2022]
Abstract
OBJECTIVES To describe and contrast functional dependency (FD) levels among recently admitted AL residents with and without dementia and to assess the differential contribution of cognitive, behavioral, medical, and social factors on FD within each group. DESIGN A cross-sectional study. SETTING A random sample of 28 AL facilities in the Central Maryland region. PARTICIPANTS Two hundred and sixty-two AL residents assessed less than 1 year after admission. MEASUREMENTS Participants were given comprehensive in-person dementia assessments. Cognitive, behavioral, medical, and social factors were also assessed. FD was operationalized as impairment in activities of daily living. RESULTS The 59% of residents with dementia had higher levels of FD (P < .001) and were more likely to require assistance in all assessed task-specific ADL domains (P < .001) except mobility (P = .653). In multivariate models, global cognition, medical health status, and presence of diabetes explained 43% of the variance in FD in the dementia group. Twenty-five percent of the variance in FD was explained by depression, neuropsychiatric symptoms, and global cognition in those without dementia. CONCLUSIONS Recently admitted AL residents have substantial levels of FD. FD is higher among residents with dementia compared with those without and the association of cognitive, mental health, and medical variables with FD differ as a function of dementia status. Future research should examine how these dimensions affect FD longitudinally and whether they may serve as targets for interventions and quality of care improvement initiatives.
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McNabney MK, Samus QM, Lyketsos CG, Brandt J, Onyike CU, Baker A, Rosenblatt A. The spectrum of medical illness and medication use among residents of assisted living facilities in central Maryland. J Am Med Dir Assoc 2009; 9:558-64. [PMID: 19083289 DOI: 10.1016/j.jamda.2008.03.003] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2008] [Revised: 03/05/2008] [Accepted: 03/10/2008] [Indexed: 10/21/2022]
Abstract
BACKGROUND Although increasing numbers of older adults are living in assisted living facilities, there is little information on the types and amount of chronic medical illness and the medications required by such residents. To better inform efforts to optimize care in this setting, we sought to quantify chronic medical illnesses and their treatment. METHODS Medical diagnoses and treatments were derived from chart reviews and interviews of 198 residents of 22 randomly selected assisted living facilities (AL) in central Maryland. To evaluate the burden of medical illnesses, chronic conditions were categorized and quantified according to general (organ system) diseases, as well as 7 specific long-term care Clinical Practice Guidelines (CPG). Using logistic regression, we calculated the associations between facility-level characteristics and those residents with a) conditions from 3 or more general disease categories and, b) 2 or more CPG conditions. To evaluate medical treatment complexity, we categorized oral and certain non-oral medications, as well medications that typically require additional monitoring. RESULTS Almost one-half (46%) of AL residents had chronic conditions in 3 or more different general disease categories and one-fourth (25.2%) had 2 or more specific Clinical Practice Guideline (CPG) conditions. Residents with chronic conditions in 3 or more different general disease groups were more likely to live in larger facilities; otherwise, no other facility-level characteristics that we assessed were associated with residents having conditions from 3 or more general disease categories or 2 or more CPG conditions. One-half of all residents were taking medications that typically require additional monitoring and 25% of residents were receiving treatments of respiratory inhalers, eye drops and/or injections. CONCLUSIONS Many AL residents have multiple medical illnesses of different types and complexity. Given the increasing role of AL providers in the management of such conditions, appropriate adjustments in care provision will be needed for facilities to meet the needs of these residents.
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Samus QM, Mayer L, Baker A, McNabney M, Brandt J, Onyike CU, Rabins PV, Lyketsos CG, Rosenblatt A. Characteristics and outcomes for assisted living residents with dementia: comparing dementia-specific care units with non-dementia-specific care units. J Am Geriatr Soc 2008; 56:1361-3. [PMID: 18774972 DOI: 10.1111/j.1532-5415.2008.01722.x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Rao V, Spiro J, Samus QM, Steele C, Baker A, Brandt J, Mayer L, Lyketsos CG, Rosenblatt A. Insomnia and daytime sleepiness in people with dementia residing in assisted living: findings from the Maryland Assisted Living Study. Int J Geriatr Psychiatry 2008; 23:199-206. [PMID: 17621378 DOI: 10.1002/gps.1863] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
OBJECTIVE To estimate the frequency and correlates of insomnia and daytime sleepiness among people with dementia in AL facilities. METHODS Participants were randomly selected from 22 different assisted living facilities in Maryland. A total of 124 dementia participants were included in the analysis. All participants were rated on an 11-item sleep questionnaire regarding insomnia and daytime sleepiness. RESULTS Sleep disturbance was present in 59.2% of people with dementia. Of the total sample, 21.8% had insomnia only (IN); 21.6% had excessive daytime sleepiness only (DS); and 16.8% had both IN and DS. 40.8% had no sleep disturbance. IN and DS scores were not significantly associated with each other (r=0.07, p=0.43). Of those in the IN group, the majority had mild and moderate dementia and of those in the DS only group the majority had severe dementia. Those with IN only performed the best and DS only performed the worst on both cognitive measures (the Mini Mental State Examination) (F=3.26, p=0.014), and on physical measures (the physical subscale of the psychogeraitric dependency rating scale) (F=6.09, p<0.001). There was no significant difference between the groups on the Cornell scale for depression in dementia. CONCLUSION The frequency of insomnia and daytime sleepiness in dementia subjects in AL is similar to that found in nursing homes. Daytime sleepiness is associated with poorer cognitive and day-to-day functioning. Effective management of DS may lead to improved functioning in the AL residents. Insomnia is associated with the best outcomes, even better than those with no sleep disturbance. This finding needs to be replicated.
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