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Gombault‐Datzenko E, Gallini A, Carcaillon‐Bentata L, Fabre D, Nourhashemi F, Andrieu S, Rachas A, Gardette V. Alzheimer’s disease and related syndromes and hospitalization: a nationwide 5‐year longitudinal study. Eur J Neurol 2020; 27:1436-1447. [DOI: 10.1111/ene.14256] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2019] [Revised: 11/01/2019] [Accepted: 04/02/2020] [Indexed: 12/25/2022]
Affiliation(s)
| | - A. Gallini
- Department of Epidemiology University Hospital of Toulouse Toulouse France
- UMR1027 Epidemiology and Analyses in Public Health INSERM Toulouse France
- Faculty of Medicine Department of Epidemiology and Public Health Université de Toulouse III Toulouse France
| | | | - D. Fabre
- Department of Medical Information University Hospital of Toulouse Toulouse France
| | - F. Nourhashemi
- Faculty of Medicine Department of Epidemiology and Public Health Université de Toulouse III Toulouse France
- Gérontopole Cité de la Santé University Hospital of Toulouse Toulouse France
| | - S. Andrieu
- Department of Epidemiology University Hospital of Toulouse Toulouse France
- UMR1027 Epidemiology and Analyses in Public Health INSERM Toulouse France
- Faculty of Medicine Department of Epidemiology and Public Health Université de Toulouse III Toulouse France
| | | | - V. Gardette
- Department of Epidemiology University Hospital of Toulouse Toulouse France
- UMR1027 Epidemiology and Analyses in Public Health INSERM Toulouse France
- Faculty of Medicine Department of Epidemiology and Public Health Université de Toulouse III Toulouse France
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152
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Tong C, Huang C, Wu J, Xu M, Cao H. The Prevalence and Impact of Undiagnosed Mild Cognitive Impairment in Elderly Patients Undergoing Thoracic Surgery: A Prospective Cohort Study. J Cardiothorac Vasc Anesth 2020; 34:2413-2418. [PMID: 32381306 DOI: 10.1053/j.jvca.2020.03.011] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2020] [Revised: 03/06/2020] [Accepted: 03/09/2020] [Indexed: 11/11/2022]
Abstract
OBJECTIVES The objective of this study was to explore the prevalence of undiagnosed mild cognitive impairment (MCI) and its association with adverse outcomes in elderly patients undergoing thoracic surgery. DESIGN A prospective cohort study. SETTING Large tertiary medical center. PARTICIPANTS The authors enrolled 170 patients aged 65 years or older who were scheduled for thoracic surgery between November 7, 2018, and April 1, 2019, at the Shanghai Chest Hospital. Patients with a history of schizophrenia or dementia disease, uncorrected vision or hearing impairment, and refusal to participate were excluded. INTERVENTIONS A total of 154 elderly patients completed the Chinese version of the Montreal Cognitive Assessment (MoCA) test preoperatively and were included in the final analysis. They were categorized into a normal group (MoCA ≥ 26 scores, group N) and an abnormal group (MoCA < 26 scores, group AN) based on test results. Delirium was assessed with the Confusion Assessment Method twice daily during the first 3 postoperative days. MEASUREMENTS AND MAIN RESULTS The primary outcome was the incidence of postoperative delirium (POD). Secondary outcomes included the incidence of postoperative pulmonary complications (PPCs), cardiovascular complications, other complications, intensive care unit (ICU) stay, and the hospital length of stay (LOS). The incidence of MCI before thoracic surgery in elderly patients was 49.4% (76 of 154). Compared with group N, MCI could increase the incidence of POD (14.1% v 30.3%, p = 0.016) and median LOS (4 d v 5 d, p = 0.016). However, the differences in pulmonary complications, cardiovascular and other complications, and ICU stay were not significant. Multivariable logistic regression analysis showed preoperative MCI (OR = 2.573, 95% CI =1.092 to 6.060, p = 0.031) as an independent risk factor of POD. Compared with the elderly patients without POD, POD could increase the risk of PPCs (17.5% v 35.3%, p = 0.026) and median LOS (4 d v 5 d, p < 0.001). CONCLUSIONS The incidence of MCI before thoracic surgery in elderly patients was higher and associated with a higher rate of adverse postoperative outcomes. The findings may be important for preoperative patient counseling, operative planning, and eventually reducing potential risk exposure and related outcomes.
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Affiliation(s)
- Chaoyang Tong
- Department of Anesthesiology, Shanghai Chest Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Chengya Huang
- Department of Anesthesiology, Shanghai Chest Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Jingxiang Wu
- Department of Anesthesiology, Shanghai Chest Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Meiying Xu
- Department of Anesthesiology, Shanghai Chest Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Hui Cao
- Department of Anesthesiology, Shanghai Chest Hospital, Shanghai Jiao Tong University, Shanghai, China.
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153
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Jazzar U, Shan Y, Klaassen Z, Freedland SJ, Kamat AM, Raji MA, Masel T, Tyler DS, Baillargeon J, Kuo YF, Mehta HB, Bergerot CD, Williams SB. Impact of Alzheimer's disease and related dementia diagnosis following treatment for bladder cancer. J Geriatr Oncol 2020; 11:1118-1124. [PMID: 32354675 DOI: 10.1016/j.jgo.2020.04.009] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2020] [Revised: 04/14/2020] [Accepted: 04/18/2020] [Indexed: 10/24/2022]
Abstract
OBJECTIVES Our objective was to assess the incidence of Alzheimer's Disease and related dementia diagnosis following treatment for muscle-invasive bladder cancer and impact on survival outcomes. MATERIALS AND METHODS A total of 4814 patients diagnosed with clinical stage T2-T4a, N0, M0 bladder cancer between January 1, 2002 to December 31, 2011 using the Surveillance, Epidemiology, and End Results (SEER)-Medicare database were identified. Alzheimer's disease and related dementia diagnosis was identified using International Statistical Classification of Disease-Ninth Edition outpatient and inpatient codes. Incidence of dementia following treatment were calculated and reported as dementia cases per 10,000 person-years. Cox proportional hazards models were used to assess the impact of dementia on survival outcomes. RESULTS Of the 4814 patients, 2403 (49.9%) underwent radical cystectomy (RC) and 2411 (50.1%) underwent radiotherapy (RTX) and/or chemotherapy (CTX). Overall, 837 (17.4%) patients developed Alzheimer's disease and related dementia following bladder cancer treatment. There was no significant difference in the incidence of Alzheimer's disease and related dementia following either treatment. Patients diagnosed with Alzheimer's disease and related dementia had worse overall (Hazard Ratio (HR), 2.64; 95% Confidence Interval (CI), 2.41-2.89) and cancer-specific (HR, 2.45; 95% CI, 2.18-2.76) survival than those without a dementia diagnosis following treatment. CONCLUSION While we observed no difference in new-onset Alzheimer's disease and related dementia diagnosis following RC or RTX and/or CTX, patients with a Alzheimer's and related dementia diagnosis was associated with worse overall and cancer-specific survival. These findings have important implications for screening and the development of targeted interventions for improving outcomes in older adults following complex cancer treatments, as observed in this bladder cancer population.
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Affiliation(s)
- Usama Jazzar
- Division of Urology, The University of Texas Medical Branch at Galveston, Galveston, TX, United States of America
| | - Yong Shan
- Division of Urology, The University of Texas Medical Branch at Galveston, Galveston, TX, United States of America
| | - Zachary Klaassen
- Department of Surgery, Section of Urology, Medical College of Georgia, Georgia Regents University, Augusta, GA, United States of America
| | - Stephen J Freedland
- Department of Urology, Cedars Sinai Medical Center, Los Angeles, CA, United States of America
| | - Ashish M Kamat
- Department of Urology, The University of Texas MD Anderson Cancer Center, Houston, TX, United States of America
| | - Mukaila A Raji
- Department of Preventive Medicine and Community Health, Sealy Center of Aging, The University of Texas Medical Branch, Galveston, TX, United States of America
| | - Todd Masel
- Department of Neurology, The University of Texas Medical Branch, Galveston, TX, United States of America
| | - Douglas S Tyler
- Department of Surgery, The University of Texas Medical Branch at Galveston, Galveston, TX, United States of America
| | - Jacques Baillargeon
- Department of Preventive Medicine and Community Health, Sealy Center of Aging, The University of Texas Medical Branch, Galveston, TX, United States of America
| | - Yong-Fang Kuo
- Department of Preventive Medicine and Community Health, Sealy Center of Aging, The University of Texas Medical Branch, Galveston, TX, United States of America
| | - Hemalkumar B Mehta
- Department of Surgery, The University of Texas Medical Branch at Galveston, Galveston, TX, United States of America
| | - Cristiane D Bergerot
- Department of Medical Oncology, City of Hope Comprehensive Cancer Center, Duarte, CA, United States of America
| | - Stephen B Williams
- Division of Urology, The University of Texas Medical Branch at Galveston, Galveston, TX, United States of America.
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154
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Islam MM, Parkinson A, Burns K, Woods M, Yen L. A training program for primary health care nurses on timely diagnosis and management of dementia in general practice: An evaluation study. Int J Nurs Stud 2020; 105:103550. [PMID: 32145467 DOI: 10.1016/j.ijnurstu.2020.103550] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2019] [Revised: 02/06/2020] [Accepted: 02/12/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND Primary health care nurses can play an important role in assisting the diagnosis and management of dementia. This study describes the evaluation outcome of a training program developed on the 'Four Steps to Building Dementia Practice in Primary Care'. OBJECTIVE To evaluate a training program for primary health care nurses by assessing change in current practice and future intention; and their knowledge, confidence, and perceived importance about dementia diagnosis and management. DESIGN A longitudinal survey. Participants were surveyed at three time points: pre-training, immediately post-training and six months (+/- 3 months) following their training. SETTING All states and territories in Australia. PARTICIPANTS Primary health care nurses (n = 1,290). METHODS A face-to-face and online training program on timely diagnosis and management of dementia was offered to primary health care nurses. A questionnaire was administered face-to-face and online to assess whether certain processes and services were 'currently in practice', 'working towards', or 'not in current practice' in their primary care facility. Three 10-point Likert scales were created to assess self-perceived levels of importance, knowledge and confidence about the diagnosis and management of dementia. A paired t-test was used to examine the differences between (a) post and pre-scores, and (b) follow-up and post scores. Linear regressions were used to identify the significant factors associated with pre-training scores for importance, confidence and knowledge. RESULTS Of 1290 primary health care nurses who participated in the training, 471 attended face-to-face and 819 participated online. Participants demonstrated improvements in all items in all four steps of the survey, with considerably higher improvement in the face-to-face mode. The average post-training score was significantly higher than the pre-training score for perceived importance, knowledge and confidence. The average follow-up score was significantly higher than the post-training score for perceived knowledge and confidence but not for perceived importance. Primary health care nurses who had 20 or more years of experience reported significantly more knowledge in attending patients with dementia than those with less than five years of experience (0.56, 95% CI: 0.11-1.01). CONCLUSIONS With a growing ageing population, the demand for dementia care is rising. Primary health care nurses can lead practice change and promote the timely diagnosis and management of dementia in general practice. Training programs of this kind that build knowledge, confidence, awareness and skills should be made available to the primary care nursing workforce. Further research is recommended to examine the translation of this training outcome into practice.
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Affiliation(s)
- M Mofizul Islam
- Department of Public Health, La Trobe University, Melbourne Australia.
| | - Anne Parkinson
- Department of Health Services Research and Policy, Research School of Population Health, The Australian National University, Canberra, Australia
| | - Kelly Burns
- Centre for Dementia Learning, Dementia Australia, Melbourne, Australia
| | - Murphy Woods
- Australian Primary Health Care Nurses Association (APNA), Melbourne, Australia
| | - Laurann Yen
- Department of Health Services Research and Policy, Research School of Population Health, The Australian National University, Canberra, Australia
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155
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Schulte PJ, Warner DO, Martin DP, Deljou A, Mielke MM, Knopman DS, Petersen RC, Weingarten TN, Warner MA, Rabinstein AA, Hanson AC, Schroeder DR, Sprung J. Association Between Critical Care Admissions and Cognitive Trajectories in Older Adults. Crit Care Med 2020; 47:1116-1124. [PMID: 31107280 DOI: 10.1097/ccm.0000000000003829] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVES Patients requiring admission to an ICU may subsequently experience cognitive decline. Our objective was to investigate longitudinal cognitive trajectories in older adults hospitalized in ICUs. We hypothesized that individuals hospitalized for critical illness develop greater cognitive decline compared with those who do not require ICU admission. DESIGN A retrospective cohort study using prospectively collected cognitive scores of participants enrolled in the Mayo Clinic Study of Aging and ICU admissions retrospectively ascertained from electronic medical records. A covariate-adjusted linear mixed effects model with random intercepts and slopes assessed the relationship between ICU admissions and the slope of global cognitive z scores and domains scores (memory, attention/executive, visuospatial, and language). SETTING ICU admissions and cognitive scores in the Mayo Clinic Study of Aging from October 1, 2004, to September 11, 2017. PATIENTS Nondemented participants age 50 through 91 at enrollment in the Mayo Clinic Study of Aging with an initial cognitive assessment and at least one follow-up visit. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Of 3,673 participants, 372 had at least one ICU admission with median (25-75th percentile) follow-up after first ICU admission of 2.5 years (1.2-4.4 yr). For global cognitive z score, admission to an ICU was associated with greater decline in scores over time compared with participants not requiring ICU admission (difference in annual slope = -0.028; 95% CI, -0.044 to -0.012; p < 0.001). ICU admission was associated with greater declines in memory (-0.029; 95% CI, -0.047 to -0.011; p = 0.002), attention/executive (-0.020; 95% CI, -0.037 to -0.004; p = 0.016), and visuospatial (-0.013; 95% CI, -0.026 to -0.001; p = 0.041) domains. ICU admissions with delirium were associated with greater declines in memory (interaction p = 0.006) and language (interaction p = 0.002) domains than ICU admissions without delirium. CONCLUSIONS In older adults, ICU admission was associated with greater long-term cognitive decline compared with patients without ICU admission. These findings were more pronounced in those who develop delirium while in the ICU.
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Affiliation(s)
- Phillip J Schulte
- Department of Health Sciences Research, Division of Biomedical Statistics and Informatics, Mayo Clinic College of Medicine and Science, Mayo Clinic, Rochester, MN
| | - David O Warner
- Department of Anesthesiology, Mayo Clinic College of Medicine and Science, Mayo Clinic, Rochester, MN
| | - David P Martin
- Department of Anesthesiology, Mayo Clinic College of Medicine and Science, Mayo Clinic, Rochester, MN
| | - Atousa Deljou
- Department of Anesthesiology, Mayo Clinic College of Medicine and Science, Mayo Clinic, Rochester, MN
| | - Michelle M Mielke
- Department of Health Sciences Research, Division of Epidemiology, Mayo Clinic College of Medicine and Science, Mayo Clinic, Rochester, MN.,Department of Neurology, Mayo Clinic College of Medicine and Science, Mayo Clinic, Rochester, MN
| | - David S Knopman
- Department of Neurology, Mayo Clinic College of Medicine and Science, Mayo Clinic, Rochester, MN
| | - Ronald C Petersen
- Department of Health Sciences Research, Division of Epidemiology, Mayo Clinic College of Medicine and Science, Mayo Clinic, Rochester, MN.,Department of Neurology, Mayo Clinic College of Medicine and Science, Mayo Clinic, Rochester, MN
| | - Toby N Weingarten
- Department of Anesthesiology, Mayo Clinic College of Medicine and Science, Mayo Clinic, Rochester, MN
| | - Matthew A Warner
- Department of Anesthesiology, Mayo Clinic College of Medicine and Science, Mayo Clinic, Rochester, MN
| | - Alejandro A Rabinstein
- Department of Neurology, Mayo Clinic College of Medicine and Science, Mayo Clinic, Rochester, MN
| | - Andrew C Hanson
- Department of Health Sciences Research, Division of Biomedical Statistics and Informatics, Mayo Clinic College of Medicine and Science, Mayo Clinic, Rochester, MN
| | - Darrell R Schroeder
- Department of Health Sciences Research, Division of Biomedical Statistics and Informatics, Mayo Clinic College of Medicine and Science, Mayo Clinic, Rochester, MN
| | - Juraj Sprung
- Department of Anesthesiology, Mayo Clinic College of Medicine and Science, Mayo Clinic, Rochester, MN
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156
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Gungabissoon U, Perera G, Galwey NW, Stewart R. The association between dementia severity and hospitalisation profile in a newly assessed clinical cohort: the South London and Maudsley case register. BMJ Open 2020; 10:e035779. [PMID: 32284392 PMCID: PMC7200045 DOI: 10.1136/bmjopen-2019-035779] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2019] [Revised: 02/07/2020] [Accepted: 03/20/2020] [Indexed: 11/18/2022] Open
Abstract
OBJECTIVES To evaluate the risk and common causes of hospitalisation in patients with newly diagnosed dementia and variation by severity of cognitive impairment. SETTING We used data from a large London mental healthcare case register linked to a national hospitalisation database. PARTICIPANTS Individuals aged ≥65 years with newly diagnosed dementia with recorded cognitive function and the catchment population within the same geography. OUTCOME MEASURES We evaluated the risk and duration of hospitalisation in the year following a dementia diagnosis. In addition we identified the most common causes of hospitalisation and calculated age-standardised and gender-standardised admission ratios by dementia severity (mild/moderate/severe) relative to the catchment population. RESULTS Of the 5218 patients with dementia, 2596 (49.8%) were hospitalised in the year following diagnosis. The proportion of individuals with mild, moderate and severe dementia who had a hospital admission was 47.9%, 50.8% and 51.7%, respectively (p= 0.097). Duration of hospital stay increased with dementia severity (median 2 days in mild to 4 days in severe dementia, p 0.0001). After excluding readmissions for the same cause, the most common primary hospitalisation discharge diagnoses among patients with dementia were urinary system disorders, pneumonia and fracture of femur, accounting for 15%, 10% and 6% of admissions, respectively. Overall, patients with dementia were hospitalised 30% more than the catchment population, and this trend was observed for most of the discharge diagnoses evaluated. Standardised admission ratios for urinary and respiratory disorders were higher in those with more severe dementia at diagnosis. CONCLUSIONS Individuals with a dementia diagnosis were more likely to be hospitalised than individuals in the catchment population. The length of hospital stay increased with dementia severity. Most of the common causes of hospitalisation were more common than expected relative to the catchment population, but standardised admission ratios only varied by dementia stage for certain groups of conditions.
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Affiliation(s)
- Usha Gungabissoon
- Epidemiology (Value Evidence and Outcomes), GSK, Brentford, London, UK
- Department of Psychological Medicine, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
| | - Gayan Perera
- Department of Psychological Medicine, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
| | | | - Robert Stewart
- Department of Psychological Medicine, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
- NIHR Maudsley Biomedical Research Centre, South London and Maudsley NHS Foundation Trust, London, UK
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157
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Abstract
Among adults ages 65 and older, dementia doubles the risk of hospitalization. Roughly one in four hospitalized patients has dementia, and the prevalence of dementia in the United States is rising rapidly. Patients with dementia have significantly higher rates of hospital-acquired complications, including urinary tract infections, pressure injuries, pneumonia, and delirium, which when unrecognized and untreated can accelerate physical and cognitive decline, precipitating nursing home placement and death. The authors discuss the unique needs of patients with dementia who require acute care, highlighting evidence-based strategies for nurses to incorporate into practice.
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158
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Fox A, MacAndrew M, Ramis MA. Health outcomes of patients with dementia in acute care settings-A systematic review. Int J Older People Nurs 2020; 15:e12315. [PMID: 32207886 DOI: 10.1111/opn.12315] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2019] [Revised: 02/06/2020] [Accepted: 03/04/2020] [Indexed: 01/29/2023]
Abstract
BACKGROUND An ageing population has resulted in increased numbers of people with dementia attending acute care services; however, the impact of hospitalisation on this population is uncertain. PURPOSE This systematic review aimed to synthesise the available evidence on adverse health outcomes for people with dementia in acute care settings. METHODS A systematic search of CINAHL, PubMed, MEDLINE, EMBASE and Scopus databases for primary research articles in English language, published from 2000 to 2017, was conducted. A protocol for the review was registered on the PROSPERO database. RESULTS The initial search identified 5,520 records. Following removal of duplicates and assessment against inclusion criteria, 13 studies were included in the final review. Findings identify associations between patients with dementia, longer length of hospital stay and higher mortality in some situations. Heterogeneity across studies in data reporting and outcomes prevented meta-analysis; therefore, results are presented narratively. CONCLUSIONS Certainty of findings from this review is impacted by variation in patient condition and data reporting. Additional rigorous studies on health outcomes for people with dementia during acute hospitalisation will contribute to the evidence. IMPLICATIONS FOR PRACTICE These findings along with further research examining outcomes for patients with dementia in acute care settings will inform provision of safer, quality care and optimal health outcomes for this vulnerable population.
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Affiliation(s)
- Amanda Fox
- Institute of Health and Biomedical Innovation, School of Nursing, Queensland University of Technology, Brisbane, Qld, Australia
| | - Margaret MacAndrew
- Institute of Health and Biomedical Innovation, School of Nursing, Queensland University of Technology, Brisbane, Qld, Australia
| | - Mary-Anne Ramis
- Evidence in Practice Unit, Queensland Centre for Evidence Based Nursing and Midwifery, Mater Health, South Brisbane, Qld, Australia
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159
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Chuakhamfoo NN, Phanthunane P, Chansirikarn S, Pannarunothai S. Health and long-term care of the elderly with dementia in rural Thailand: a cross-sectional survey through their caregivers. BMJ Open 2020; 10:e032637. [PMID: 32209620 PMCID: PMC7202699 DOI: 10.1136/bmjopen-2019-032637] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
OBJECTIVE To describe the circumstances of the elderly with dementia and their caregivers' characteristics in order to examine factors related to activities of daily living (ADL) and household income to propose a long-term care policy for rural areas of Thailand. SETTING A cross-sectional study at the household level in three rural regions of Thailand where there were initiatives relating to community care for people with dementia. PARTICIPANTS Caregivers of 140 people with dementia were recruited for the study. PRIMARY AND SECONDARY OUTCOME MEASURES Socioeconomic characteristics including data from assessment of ADL and instrumental ADL and the Thai version of Resource Utilisation in Dementia were collected. Descriptive statistics were used to explain the characteristics of the elderly with dementia and the caregivers while inferential statistics were used to examine the associations between different factors of elderly patients with dementia with their dependency level and household socioeconomic status. RESULTS Eighty-six per cent of the dementia caregivers were household informal caregivers as half of them also had to work outside the home. Half of the primary caregivers had no support and no minor caregivers. The elderly with dementia with high dependency levels were found to have a significant association with age, dementia severity, chance of hospitalisation and number of hospitalisations. Though most of these rural samples had low household incomes, the patients in the lower-income households had significantly lower dementia severity, but, with the health benefit coverage had significantly higher chances of hospitalisation. CONCLUSION As the informal caregivers are the principal human resources for dementia care and services in rural area, policymakers should consider informal care for the Thai elderly with dementia and promote it as the dominant pattern of dementia care in Thailand.
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Affiliation(s)
- Nalinee N Chuakhamfoo
- Department of Community Medicine, Faculty of Medicine, Naresuan University, Phitsanulok, Thailand
| | - Pudtan Phanthunane
- Department of Economics, Faculty of Business, Economics and Communications, Naresuan University, Phitsanulok, Thailand
| | - Sirintorn Chansirikarn
- Department of Medicine, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Supasit Pannarunothai
- Research unit, Centre for Health Equity Monitoring Foundation, Phitsanulok, Thailand
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160
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Park S, White L, Fishman P, Larson EB, Coe NB. Health Care Utilization, Care Satisfaction, and Health Status for Medicare Advantage and Traditional Medicare Beneficiaries With and Without Alzheimer Disease and Related Dementias. JAMA Netw Open 2020; 3:e201809. [PMID: 32227181 PMCID: PMC7485599 DOI: 10.1001/jamanetworkopen.2020.1809] [Citation(s) in RCA: 40] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Importance Compared with traditional Medicare (TM) fee-for-service plans, Medicare Advantage (MA) plans may provide more-efficient care for beneficiaries with Alzheimer disease and related dementias (ADRD) without compromising care quality. Objective To determine differences in health care utilization, care satisfaction, and health status for MA and TM beneficiaries with and without ADRD. Design, Setting, and Participants A cohort study was conducted of MA and TM beneficiaries with and without ADRD from all publicly available years of the Medicare Current Beneficiary Survey between 2010 and 2016. To address advantageous selection into MA plans, county-level MA enrollment rate was used as an instrument. Data were analyzed between July 2019 and December 2019. Exposures Enrollment in MA. Main Outcomes and Measures Self-reported health care utilization, care satisfaction, and health status. Results The sample included 47 100 Medicare beneficiaries (25 900 women [54.9%]; mean [SD] age, 72.2 [11.4] years). Compared with TM beneficiaries with ADRD, MA beneficiaries with ADRD had lower utilization across the board, including a mean of -22.3 medical practitioner visits (95% CI, -24.9 to -19.8 medical practitioner visits), -2.3 outpatient hospital visits (95% CI, -3.6 to -1.1 outpatient hospital visits), -0.2 inpatient hospital admissions (95% CI, -0.3 to -0.1 inpatient hospital admissions), and -0.1 long-term care facility stays (95% CI, -0.2 to -0.1 long-term care facility stays). A similar trend was observed among beneficiaries without ADRD, but the difference was greater between MA and TM beneficiaries with ADRD than between MA and TM beneficiaries without ADRD (mean, -15.0 medical practitioner visits [95% CI, -18.7 to -11.3 medical practitioner visits], -1.7 outpatient hospital visits [95% CI, -3.0 to -0.3 outpatient hospital visits], and -0.1 inpatient hospital admissions [95% CI, -1.0 to 0.0 inpatient hospital admissions]). Overall, no or negligible differences were detected in care satisfaction and health status between MA and TM beneficiaries with and without ADRD. Conclusions and Relevance Compared with TM beneficiaries, MA beneficiaries had lower health care utilization without compromising care satisfaction and health status. This difference was more pronounced among beneficiaries with ADRD. These findings suggest that MA plans may be delivering health care more efficiently than TM, especially for beneficiaries with ADRD.
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Affiliation(s)
- Sungchul Park
- Department of Health Management and Policy, Dornsife School of Public Health, Drexel University, Philadelphia, Pennsylvania
| | - Lindsay White
- RTI International, Research Triangle Park, North Carolina
| | - Paul Fishman
- Department of Health Services, School of Public Health, University of Washington, Seattle
| | - Eric B Larson
- Kaiser Permanent Washington Health Research Institute, Seattle, Washington
| | - Norma B Coe
- Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia
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161
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Cappetta K, Lago L, Potter J, Phillipson L. Under-coding of dementia and other conditions indicates scope for improved patient management: A longitudinal retrospective study of dementia patients in Australia. Health Inf Manag 2020; 51:32-44. [PMID: 31971019 DOI: 10.1177/1833358319897928] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Under-coding of dementia during hospitalisation results in an inability to identify all patients with dementia using hospital administrative data. Clinical coding can be viewed as a proxy for management; therefore, under-coding indicates dementia was not considered in the patient's management. While under-coding of dementia is well established, there is sparse evidence on whether dementia is coded in subsequent hospitalisations among patients with a known diagnosis. OBJECTIVE (a) To describe patterns of dementia coding over 5 years after a first-coded (i.e. index) admission for dementia; (b) to identify factors associated with clinical coding of dementia; and (c) to identify patient subgroups at risk of not being coded to inform future interventions to improve hospital identification and management of dementia. METHOD Retrospective study of longitudinal hospital data from 1 July 2006 to 30 June 2015 for 7919 patients hospitalised during the 5 years' post-index admission for dementia in a regional local health district of New South Wales, Australia. RESULTS Dementia was coded in 63.9% of admissions in the 12 months following index admission for dementia; this decreased to 53.7% after 5 years. Patients were 20% more likely to have dementia actively managed when it co-occurred with delirium. Under-coding varied across conditions, with dementia more likely to be coded in admissions for falls and pneumonitis, and less likely for heart failure, pneumonia and urinary tract infection (UTI). CONCLUSION The frequency with which dementia was not coded highlights opportunities to improve identification and management of dementia through dementia-specific care, enhanced clinical protocols, and interventions focused around heart failure, pneumonia and UTI admissions.
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Affiliation(s)
| | | | - Jan Potter
- University of Wollongong, Australia.,Illawarra Shoalhaven Local Health District, Australia
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Steiner V, Pierce L, Bryan C, Trowbridge S. Feasibility of online educational CARREs modules for family caregivers of persons with cognitive deficits about potentially avoidable hospitalizations. Appl Nurs Res 2020; 52:151233. [PMID: 31954607 DOI: 10.1016/j.apnr.2020.151233] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2019] [Revised: 01/08/2020] [Accepted: 01/08/2020] [Indexed: 12/01/2022]
Affiliation(s)
- Victoria Steiner
- University of Toledo, College of Health and Human Services, M.S. 1027, 3000 Arlington Ave., Toledo, OH 43614, United States of America.
| | - Linda Pierce
- University of Toledo, College of Nursing, United States of America.
| | - Carol Bryan
- University of Toledo, College of Nursing, United States of America.
| | - Stephanie Trowbridge
- University of Toledo, College of Health and Human Services, M.S. 1027, 3000 Arlington Ave., Toledo, OH 43614, United States of America.
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163
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MacNeil-Vroomen JL, Nagurney JM, Allore HG. Comorbid conditions and emergency department treat and release utilization in multimorbid persons with cognitive impairment. Am J Emerg Med 2020; 38:127-131. [PMID: 31337598 PMCID: PMC6917961 DOI: 10.1016/j.ajem.2019.07.023] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2019] [Revised: 07/02/2019] [Accepted: 07/16/2019] [Indexed: 02/09/2023] Open
Abstract
BACKGROUND There is an increasing focus in the emergency department (ED) on addressing the needs of persons with cognitive impairment, most of whom have multiple chronic conditions. We investigated which common comorbidities among multimorbid persons with cognitive impairment conferred increased risk for ED treat and release utilization. METHODS We examined the association of 16 chronic conditions on use of ED treat and release visit utilization among 1006 adults with cognitive impairment and ≥ 2 comorbidities using the nationally-representative National Health and Aging Trends Study merged with Fee-For-Service Medicare claims data, 2011-2015. RESULTS At baseline, 28.5% had ≥6 conditions and 35.4% were ≥ 85 years old. After controlling for sex, age, race, education, urban-living, number of disabled activities of daily living, and sampling strata, we found significantly increased adjusted risk ratios (aRR) of ED treat and release visits for persons with depression (aRR 1.38 95% CI 1.15-1.65) representing 78/100 person-years, and osteoarthritis or rheumatoid arthritis (aRR 1.32 95% CI 1.12-1.57) representing 71/100 person-years. At baseline 93.9% had ≥1 informal caregiver and 69.7% had a caregiver that helped with medications or attended physician visits. CONCLUSION These results show that multimorbid cognitively impaired older adults with depression or osteoarthritis or rheumatoid arthritis are at higher risk of ED treat and release visits. Future ED research with multimorbid cognitively impaired persons may explore behavioral aspects of depression and/or pain and flairs associated with osteoarthritis or rheumatoid arthritis, as well as the role of informal caregivers in the care of these conditions.
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Affiliation(s)
- Janet L MacNeil-Vroomen
- Section of Geriatrics, Department of Internal Medicine, School of Medicine, Yale University, New Haven 06511, CT, United States of America; Section of Geriatric Medicine, Department of Internal Medicine, Amsterdam Public Health Research Institute, Amsterdam UMC, University of Amsterdam, Amsterdam 110Z AZ, the Netherlands.
| | - Justine M Nagurney
- Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston 02215-5321, MA, United States of America
| | - Heather G Allore
- Section of Geriatrics, Department of Internal Medicine, School of Medicine, Yale University, New Haven 06511, CT, United States of America; Department of Biostatistics, Yale School of Public Health, New Haven 06511, CT, United States of America
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164
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Chan HY, Tien SC, Chen JJ. A retrospective study of chart review for the use of benzodiazepines and related drugs among patients with dementia. TAIWANESE JOURNAL OF PSYCHIATRY 2020. [DOI: 10.4103/tpsy.tpsy_20_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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165
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Muzambi R, Bhaskaran K, Brayne C, Davidson JA, Smeeth L, Warren-Gash C. Common Bacterial Infections and Risk of Dementia or Cognitive Decline: A Systematic Review. J Alzheimers Dis 2020; 76:1609-1626. [PMID: 32651320 PMCID: PMC7504996 DOI: 10.3233/jad-200303] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/29/2020] [Indexed: 12/11/2022]
Abstract
BACKGROUND Bacterial infections may be associated with dementia, but the temporality of any relationship remains unclear. OBJECTIVES To summarize existing literature on the association between common bacterial infections and the risk of dementia and cognitive decline in longitudinal studies. METHODS We performed a comprehensive search of 10 databases of published and grey literature from inception to 18 March 2019 using search terms for common bacterial infections, dementia, cognitive decline, and longitudinal study designs. Two reviewers independently performed the study selection, data extraction, risk of bias and overall quality assessment. Data were summarized through a narrative synthesis as high heterogeneity precluded a meta-analysis. RESULTS We identified 3,488 studies. 9 met the eligibility criteria; 6 were conducted in the United States and 3 in Taiwan. 7 studies reported on dementia and 2 investigated cognitive decline. Multiple infections were assessed in two studies. All studies found sepsis (n = 6), pneumonia (n = 3), urinary tract infection (n = 1), and cellulitis (n = 1) increased dementia risk (HR 1.10; 95% CI 1.02-1.19) to (OR 2.60; 95% CI 1.84-3.66). The range of effect estimates was similar when limited to three studies with no domains at high risk of bias. However, the overall quality of evidence was rated very low. Studies on cognitive decline found no association with infection but had low power. CONCLUSION Our review suggests common bacterial infections may be associated with an increased risk of subsequent dementia, after adjustment for multiple confounders, but further high-quality, large-scale longitudinal studies, across different healthcare settings, are recommended to further explore this association.
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Affiliation(s)
- Rutendo Muzambi
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK
| | - Krishnan Bhaskaran
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK
| | - Carol Brayne
- Cambridge Institute of Public Health, Cambridge University, Cambridge, UK
| | - Jennifer A. Davidson
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK
| | - Liam Smeeth
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK
| | - Charlotte Warren-Gash
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK
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166
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Tahami Monfared AA, Meier G, Perry R, Joe D. Burden of Disease and Current Management of Dementia with Lewy Bodies: A Literature Review. Neurol Ther 2019; 8:289-305. [PMID: 31512165 PMCID: PMC6858913 DOI: 10.1007/s40120-019-00154-7] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2019] [Indexed: 11/12/2022] Open
Abstract
INTRODUCTION A significant proportion of dementia is concretely estimated to be attributable to dementia with Lewy bodies (DLB)-one of the most common types of progressive dementia; however, there is a paucity of literature on this disease. We aimed to examine available evidence to gain a better understanding of its treatment landscape, clinical management, and disease burden. METHODS A systematic literature review captured any DLB studies that report on randomised controlled trials (RCTs), epidemiology, disease progression, and economic data. An additional targeted literature review captured studies reporting on clinical management and quality of life (QoL) in this disease. Publication date was limited to 1 January 2007-26 March 2018, with the exception for RCTs, where no time restrictions were applied. FINDINGS Of the 3486 studies initially identified, 55 studies were eligible for inclusion. The studies were mainly from Europe (n = 29), the USA (n = 9), and Japan (n = 8). Mini-Mental State Examination and Neuropsychiatric Inventory scores were the most commonly reported clinical outcomes in RCTs (n = 14). The most frequently identified interventions reported in RCTs were donepezil and memantine. Patients with DLB typically reported worse outcomes in relation to efficacy and safety, cognitive impairment, survival, and QoL compared with those with Alzheimer's disease (AD). Additionally, patients with DLB were associated with higher hospitalisation rates and cost of care. Furthermore, there is a reliance on a small number of consensus guidelines. Of these, only one set of guidelines (DLB Consortium) was developed specifically for DLB. CONCLUSION The paucity of data indicates an unmet need in this therapy area. Although several studies look into the clinical and pathological aspects of DLB, consensus guidelines and studies on healthcare utilisation in patients with dementia have largely focused on AD. Additionally, most of the findings were made in comparison with AD. FUNDING Eisai Inc.
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Affiliation(s)
- Amir Abbas Tahami Monfared
- Eisai Inc., Woodcliff Lake, USA.
- Epidemiology, Biostatistics, and Occupational Health, McGill University, Montreal, Canada.
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Desai U, Kirson NY, Ye W, Mehta NR, Wen J, Andrews JS. Trends in health service use and potentially avoidable hospitalizations before Alzheimer's disease diagnosis: A matched, retrospective study of US Medicare beneficiaries. ALZHEIMER'S & DEMENTIA (AMSTERDAM, NETHERLANDS) 2019; 11:125-135. [PMID: 30788409 PMCID: PMC6369145 DOI: 10.1016/j.dadm.2018.12.005] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
INTRODUCTION This study evaluates rates of all-cause emergency department visits, all-cause hospitalizations, potentially avoidable hospitalizations, and falls in 3 years preceding Alzheimer's disease (AD) diagnosis. METHODS Patients with AD and controls with no cognitive impairment were identified from the Medicare claims data. Patients were required to be aged ≥ 65 years and have continuous Medicare enrollment for ≥4 years before the index date (AD cohort: first AD diagnosis in 2012-2014; controls: randomly selected medical claim). Outcomes for each preindex year were compared among propensity score-matched cohorts. RESULTS Each year, before index, patients with AD were more likely to have all-cause emergency department visits, all-cause hospitalizations, potentially avoidable hospitalizations, and falls (P < .05 for all comparisons) than matched controls (N = 19,679 pairs). Increasing absolute and relative risks over time were observed for all outcomes. DISCUSSION The study findings highlight the growing burden of illness before AD diagnosis and emphasize the need for timely recognition and management of patients with AD.
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Affiliation(s)
| | | | - Wenyu Ye
- Eli Lilly and Company, Lilly Corporate Center, Indianapolis, IN, USA
| | | | - Jody Wen
- Analysis Group, Inc., Boston, MA, USA
| | - J. Scott Andrews
- Eli Lilly and Company, Lilly Corporate Center, Indianapolis, IN, USA
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168
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[Dementia sensitivity in acute care hospitals : Why the implementation is so difficult, and how it can nevertheless succeed]. Z Gerontol Geriatr 2019; 52:291-296. [PMID: 31628614 DOI: 10.1007/s00391-019-01631-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2019] [Accepted: 09/17/2019] [Indexed: 10/25/2022]
Abstract
BACKGROUND In Germany, the question arises as to why the dementia sensitivity of acute care hospitals is still so uncommon even though the first concepts were successfully tested more than 20 years ago. OBJECTIVE The aim of this article is to describe implementation barriers in an overview and to show ways to a better practice. MATERIAL AND METHODS The results presented are based on a document analysis, the evaluation of focus groups and network meetings as well as on interviews with experts within the framework of a study for the Robert Bosch Foundation. In addition, the results of an earlier investigation of the iso institut for the German Alzheimer Society are included. RESULTS Based on the experience gained in model projects, typical barriers for a dementia-sensitive orientation on individual, work organizational and superordinate levels are described. The systematization of the barriers provides a starting point for overcoming these hurdles. In addition, a number of success factors for the implementation of good practice can be worked out from the projects. It has been found to be crucial to work on the attitude of staff towards people with cognitive impairments and to adapt processes to the special needs of this patient group. In this context, management and a professionally sound structuring of change processes play a key role. DISCUSSION In the future, managers and employees in acute care hospitals will be able to find a wide range of suggestions in comprehensive guidelines from the iso-Institute on the modular implementation of dementia-sensitive hospitals, which is backed up by tried and tested and effective aids to action, instruments, process descriptions, etc. The guidelines will also be available in the form of a comprehensive list of recommendations.
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Evans CS, Self W, Ginde AA, Chandrasekhar R, Ely EW, Han JH. Vitamin D Deficiency and Long-Term Cognitive Impairment Among Older Adult Emergency Department Patients. West J Emerg Med 2019; 20:926-930. [PMID: 31738720 PMCID: PMC6860383 DOI: 10.5811/westjem.2019.8.43312] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2019] [Accepted: 08/16/2019] [Indexed: 11/11/2022] Open
Abstract
INTRODUCTION Approximately 16% of acutely ill older adults develop new, long-term cognitive impairment (LTCI), many of whom initially seek care in the emergency department (ED). Currently, no effective interventions exist to prevent LTCI after an acute illness. Identifying early and modifiable risk factors for LTCI is the first step toward effective therapy. We hypothesized that Vitamin D deficiency at ED presentation was associated with LTCI in older adults. METHODS This was an observational analysis of a prospective cohort study that enrolled ED patients ≥ 65 years old who were admitted to the hospital for an acute illness. All patients were enrolled within four hours of ED presentation. Serum Vitamin D was measured at enrollment and Vitamin D deficiency was defined as serum concentrations <20 mg/dL. We measured pre-illness and six-month cognition using the short form Informant Questionnaire on Cognitive Decline in the Elderly (IQCODE), which ranges from 1 to 5 (severe cognitive impairment). Multiple linear regression was performed to determine whether Vitamin D deficiency was associated with poorer six-month cognition adjusted for pre-illness IQCODE and other confounders. We incorporated a two-factor interaction into the regression model to determine whether the relationship between Vitamin D deficiency and six-month cognition was modified by pre-illness cognition. RESULTS We included a total of 134 older ED patients; the median (interquartile range [IQR]) age was 74 (69, 81) years old, 61 (46%) were female, and 14 (10%) were nonwhite race. The median (IQR) vitamin D level at enrollment was 25 (18, 33) milligrams per deciliter and 41 (31%) of enrolled patients met criteria for vitamin D deficiency. Seventy-seven patients survived and had a six-month IQCODE. In patients with intact pre-illness cognition (IQCODE of 3.13), Vitamin D deficiency was significantly associated with worsening six-month cognition (β-coefficient: 0.43, 95% CI, 0.07 to 0.78, p = 0.02) after adjusting for pre-illness IQCODE and other confounders. Among patients with pre-illness dementia (IQCODE of 4.31), no association with Vitamin D deficiency was observed (β-coefficient: -0.1;, 95% CI, [-0.50-0.27], p = 0.56). CONCLUSION Vitamin D deficiency was associated with poorer six-month cognition in acutely ill older adult ED patients who were cognitively intact at baseline. Future studies should determine whether early Vitamin D repletion in the ED improves cognitive outcomes in acutely ill older patients.
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Affiliation(s)
- Christopher S Evans
- Vanderbilt University Medical Center, Department of Emergency Medicine, Nashville, Tennessee
| | - Wesley Self
- Vanderbilt University Medical Center, Department of Emergency Medicine, Nashville, Tennessee
| | - Adit A Ginde
- University of Colorado School of Medicine, Department of Emergency Medicine, Aurora, Colorado
| | | | - E Wesley Ely
- Vanderbilt University Medical Center, Department of Medicine, Division of Allergy Pulmonary, and Critical Care Medicine, Nashville, Tennessee
| | - Jin H Han
- Vanderbilt University Medical Center, Department of Emergency Medicine and Geriatric Research, Education, and Clinical Center, Tennessee Valley Healthcare System, Nashville, Tennessee
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170
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Guterman EL, Allen IE, Josephson SA, Merrilees JJ, Dulaney S, Chiong W, Lee K, Bonasera SJ, Miller BL, Possin KL. Association Between Caregiver Depression and Emergency Department Use Among Patients With Dementia. JAMA Neurol 2019; 76:1166-1173. [PMID: 31282955 DOI: 10.1001/jamaneurol.2019.1820] [Citation(s) in RCA: 39] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Importance Current attempts to gauge the acute care needs of patients with dementia have not effectively addressed the role of caregivers, despite their extensive involvement in decisions about acute care management. Objective To determine whether caregiver depression is associated with increased use of the emergency department (ED) among patients with dementia. Design, Setting, and Participants This longitudinal cohort study used data from the Care Ecosystem study, a randomized clinical trial examining telephone-based supportive care for patients with dementia and their caregivers. Patients were 45 years or older with any type of dementia. A total of 780 caregiver-patient dyads were enrolled from March 20, 2015, until February 28, 2017, and 663 dyads contributed baseline and 6-month data and were included in the analysis. Exposures Caregiver depression (9-item Patient Health Questionnaire score of ≥10). Secondary analyses examined caregiver burden and self-efficacy. Main Outcomes and Measures The primary outcome was the number of ED visits in a 6-month period. Results Among the 663 caregivers (467 women and 196 men; mean [SD] age, 64.9 [11.8] years), 84 caregivers (12.7%) had depression at baseline. The mean incidence rate of ED visits was 0.9 per person-year. Rates of ED presentation were higher among dyads whose caregiver did vs did not have depression (1.5 vs 0.8 ED visits per person-year). In a Poisson regression model adjusting for patient age, sex, severity of dementia, number of comorbidities, and baseline ED use, as well as caregiver age and sex, caregiver depression continued to be associated with ED use, with a 73% increase in rates of ED use among dyads with caregivers with depression (adjusted incident rate ratio, 1.73; 95% CI, 1.30-2.30). Caregiver burden was associated with higher ED use in the unadjusted model, but this association did not reach statistical significance after adjustment (incident rate ratio, 1.19; 95% CI, 0.93-1.52). Caregiver self-efficacy was inversely proportional to the number of ED visits in the unadjusted and adjusted models (adjusted incident rate ratio, 0.96; 95% CI, 0.92-0.99). Conclusions and Relevance Among patients with dementia, caregiver depression appears to be significantly associated with increased ED use, revealing a key caregiver vulnerability, which, if addressed with patient- and caregiver-centered dementia care, could improve health outcomes and lower costs for this high-risk population.
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Affiliation(s)
- Elan L Guterman
- Department of Neurology, University of California, San Francisco.,Weill Institute for Neurosciences, University of California, San Francisco
| | - I Elaine Allen
- Department of Epidemiology and Biostatistics, University of California, San Francisco
| | - S Andrew Josephson
- Department of Neurology, University of California, San Francisco.,Weill Institute for Neurosciences, University of California, San Francisco.,Editor, JAMA Neurology
| | - Jennifer J Merrilees
- Department of Neurology, University of California, San Francisco.,Weill Institute for Neurosciences, University of California, San Francisco
| | - Sarah Dulaney
- Department of Neurology, University of California, San Francisco.,Weill Institute for Neurosciences, University of California, San Francisco
| | - Winston Chiong
- Department of Neurology, University of California, San Francisco.,Weill Institute for Neurosciences, University of California, San Francisco
| | - Kirby Lee
- Department of Clinical Pharmacy, University of California, San Francisco
| | - Stephen J Bonasera
- Department of Geriatrics, Gerontology, and Palliative Medicine, University of Nebraska Medical Center, Omaha.,Department of Internal Medicine, University of Nebraska Medical Center, Omaha
| | - Bruce L Miller
- Department of Neurology, University of California, San Francisco.,Weill Institute for Neurosciences, University of California, San Francisco
| | - Katherine L Possin
- Department of Neurology, University of California, San Francisco.,Weill Institute for Neurosciences, University of California, San Francisco
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171
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Leggett A, Connell C, Dubin L, Dunkle R, Langa KM, Maust DT, Roberts JS, Spencer B, Kales HC. Dementia Care Across a Tertiary Care Health System: What Exists Now and What Needs to Change. J Am Med Dir Assoc 2019; 20:1307-1312.e1. [PMID: 31147289 PMCID: PMC6768732 DOI: 10.1016/j.jamda.2019.04.006] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2019] [Revised: 04/08/2019] [Accepted: 04/09/2019] [Indexed: 10/26/2022]
Abstract
OBJECTIVES This study explored the process of care for persons living with dementia (PLWDs) in various care settings across a tertiary care system and considers challenges and opportunities for change. DESIGN Aimed at quality improvement, qualitative interviews were conducted with key stakeholders in dementia care across geriatric outpatient clinics, medical and psychiatric emergency departments, and the main hospital in 2016. SETTING AND PARTICIPANTS Forty-nine interactive interviews were conducted with a purposive and snowball sampling of health care professionals (physicians, nurses, social workers, administrators) and families in a large, academic health care system. MEASURES Qualitative interview guides were developed by the study team to assess the process of care for PLWDs and strengths and challenges to delivering that care. RESULTS Key themes emerging from the interviews in each care setting are presented. The outpatient setting offers expertise, a multidisciplinary clinic, and research opportunities, but needs to respond to long waitlists, space limitations, and lack of consensus about who owns dementia care. The emergency department offers a low nurse/patient ratio and expertise in acute medical problems, but experiences competing demands and staff turnover; additionally, dementia does not appear on medical records, which can impede care. The hospital offers consultative services and resources, yet the physical space is confined and chaotic; sitters and antipsychotics can be overused, and placement outside of the hospital for PLWDs can be a challenge. CONCLUSIONS AND IMPLICATIONS Five key recommendations are provided to help health systems proactively prepare for the coming boom of PLWD and their caregivers, including outpatient education, a dementia care management program to link services, Internet-based training for providers, and repurposing sitters as Elder Life specialists.
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Affiliation(s)
- Amanda Leggett
- Program for Positive Aging and Department of Psychiatry, University of Michigan, Ann Arbor, MI.
| | - Cathleen Connell
- Department of Health Behavior & Health Education, School of Public Health, University of Michigan, Ann Arbor, MI
| | - Leslie Dubin
- School of Social Work, University of Michigan, Ann Arbor, MI; Michigan Medicine, University of Michigan, Ann Arbor, MI
| | - Ruth Dunkle
- School of Social Work, University of Michigan, Ann Arbor, MI
| | - Kenneth M Langa
- Department of Internal Medicine, Institute for Social Research, Veterans Affairs Center for Clinical Management Research, Ann Arbor, MI
| | - Donovan T Maust
- Program for Positive Aging and Department of Psychiatry, University of Michigan, Ann Arbor, MI
| | - J Scott Roberts
- Department of Health Behavior & Health Education, School of Public Health, University of Michigan, Ann Arbor, MI
| | - Beth Spencer
- School of Social Work, University of Michigan, Ann Arbor, MI
| | - Helen C Kales
- Program for Positive Aging and Department of Psychiatry, University of Michigan, Ann Arbor, MI
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172
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Maust DT, Kim HM, Chiang C, Langa KM, Kales HC. Predicting Risk of Potentially Preventable Hospitalization in Older Adults with Dementia. J Am Geriatr Soc 2019; 67:2077-2084. [PMID: 31211418 PMCID: PMC6896207 DOI: 10.1111/jgs.16030] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2019] [Revised: 05/20/2019] [Accepted: 05/21/2019] [Indexed: 01/01/2023]
Abstract
OBJECTIVES Reducing potentially preventable hospitalization (PPH) among older adults with dementia is a goal of Healthy People 2020, yet no tools specifically identify patients with dementia at highest risk. The objective was to develop a risk prediction model to identify older adults with dementia at high imminent risk of PPH. DESIGN A 30-day risk prediction model was developed using multivariable logistic regression. Patients from fiscal years (FY) 2009 to 2011 were split into development and validation cohorts; FY2012 was used for prediction. SETTING Community-dwelling older adults (≥65 years of age) with dementia who received care through the Veterans Health Administration. PARTICIPANTS There were 1 793 783 participants. MEASUREMENTS Characteristics associated with hospitalization risk were (1) age and other demographic factors; (2) outpatient, emergency department, and inpatient utilization; (3) medical and psychiatric diagnoses; and (4) prescribed medication use including changes to psychotropic medications (eg, initiation or dosage increase). Model discrimination was determined by the C statistic for each of the three cohorts. Finally, to determine whether predicted 30-day risk strata were stable over time, the observed PPH rate was calculated out to 1 year. RESULTS In the development cohort, .6% of patients experienced PPH within 30 days. The C statistic for the development cohort was .83 (95% confidence interval [CI] = .83-.84) and .83 in the prediction cohort (95% CI = .82-.84). Patients in the top 10% of predicted 30-day PPH risk accounted for more than 50% of 30-day PPH admissions in all three cohorts. In addition, those predicted to be at elevated 30-day risk remained at higher risk throughout a year of follow-up. CONCLUSION It is possible to identify older adults with dementia at high risk of imminent PPH, and their risk remains elevated for an entire year. Given the negative outcomes associated with acute hospitalization for those with dementia, healthcare systems and providers may be able to engage these high-risk patients proactively to avoid unnecessary hospitalization. J Am Geriatr Soc 67:2077-2084, 2019.
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Affiliation(s)
- Donovan T. Maust
- Department of Psychiatry, University of Michigan, Ann Arbor, MI
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI
- Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI
| | - H. Myra Kim
- Department of Psychiatry, University of Michigan, Ann Arbor, MI
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI
- Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI
| | - Claire Chiang
- Department of Psychiatry, University of Michigan, Ann Arbor, MI
- Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI
| | - Kenneth M. Langa
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI
- Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI
- Department of Internal Medicine, University of Michigan, Ann Arbor, MI
- Institute for Social Research, University of Michigan, Ann Arbor, MI
| | - Helen C. Kales
- Department of Psychiatry, University of Michigan, Ann Arbor, MI
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI
- Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI
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Zhang W, Liu S, Sun F, Dong X. Neighborhood social cohesion and cognitive function in U.S. Chinese older adults-findings from the PINE study. Aging Ment Health 2019; 23:1113-1121. [PMID: 30518241 DOI: 10.1080/13607863.2018.1480705] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Objectives: The projected increase in the population of older adults in the United States entails a pressing need to examine risk and protective factors associated with cognitive function. This study aims to examine the association between neighborhood social cohesion and cognitive function among older Chinese adults in the United States. Method: Using the first epidemiological survey of older Chinese Americans and applying ordinary least squares and quantile regressions, this study examines the association between neighborhood social cohesion and various domains of cognitive function. Results: Results show that neighborhood social cohesion is independently associated with most domains of cognitive function (i.e. global cognition score, and its components such as the Chinese Mini-Mental State Examination and executive function and episodic memory measures). Conclusion: This study represents one of a few initial efforts that examined the association between neighborhood social cohesion and cognitive function for Chinese older adults in the United States. Our findings suggest that socially cohesive neighborhoods can provide enriched environments where active lifestyles can be encouraged, and cognitive skills and abilities can be stimulated, practiced, and preserved for older adults.
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Affiliation(s)
- Wei Zhang
- a Department of Sociology , University of Hawaii at Mānoa , Honolulu , Hawaii
| | - Sizhe Liu
- b Department of Sociology , University of Hawaii at Mānoa , Honolulu , Hawaii , USA
| | - Fei Sun
- c School of Social Work , Michigan State University , East Lansing , Michigan
| | - XinQi Dong
- d Institute for Health, Health Care Policy and Aging Research , Rutgers University, The State University of New Jersey , New Brunswick , New Jersey
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Deardorff WJ, Liu PL, Sloane R, Van Houtven C, Pieper CF, Hastings SN, Cohen HJ, Whitson HE. Association of Sensory and Cognitive Impairment With Healthcare Utilization and Cost in Older Adults. J Am Geriatr Soc 2019; 67:1617-1624. [PMID: 30924932 PMCID: PMC6684393 DOI: 10.1111/jgs.15891] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2018] [Revised: 02/22/2019] [Accepted: 02/22/2019] [Indexed: 01/08/2023]
Abstract
OBJECTIVES To examine the association between self-reported vision impairment (VI), hearing impairment (HI), and dual-sensory impairment (DSI), stratified by dementia status, on hospital admissions, hospice use, and healthcare costs. DESIGN Retrospective analysis. SETTING Medicare Current Beneficiary Survey from 1999 to 2006. PARTICIPANTS Rotating panel of community-dwelling Medicare beneficiaries, aged 65 years and older (N = 24 009). MEASUREMENTS VI and HI were ascertained by self-report. Dementia status was determined by self-report or diagnosis codes in claims data. Primary outcomes included any inpatient admission over a 2-year period, hospice use over a 2-year period, annual Medicare fee-for-service costs, and total healthcare costs (which included information from Medicare claims data and other self-reported payments). RESULTS Self-reported DSI was present in 30.2% (n = 263/871) of participants with dementia and 17.8% (n = 4112/23 138) of participants without dementia. In multivariable logistic regression models, HI, VI, or DSI was generally associated with increased odds of hospitalization and hospice use regardless of dementia status. In a generalized linear model adjusted for demographics, annual total healthcare costs were greater for those with DSI and dementia compared to those with DSI without dementia ($28 875 vs $3340, respectively). Presence of any sensory impairment was generally associated with higher healthcare costs. In a model adjusted for demographics, Medicaid status, and chronic medical conditions, DSI compared with no sensory impairment was associated with a small, but statistically significant, difference in total healthcare spending in those without dementia ($1151 vs $1056; P < .001) but not in those with dementia ($11 303 vs $10 466; P = .395). CONCLUSION Older adults with sensory and cognitive impairments constitute a particularly prevalent and vulnerable population who are at increased risk of hospitalization and contribute to higher healthcare spending. J Am Geriatr Soc 67:1617-1624, 2019.
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Affiliation(s)
| | - Phillip L. Liu
- Department of Medicine, Duke University School of Medicine, Durham, NC
| | - Richard Sloane
- Center for the Study of Aging and Human Development, Duke University Medical Center, Durham, NC
| | - Courtney Van Houtven
- Durham Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Health Care System, Durham, NC
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC
| | - Carl F. Pieper
- Center for the Study of Aging and Human Development, Duke University Medical Center, Durham, NC
| | - Susan Nicole Hastings
- Department of Medicine, Duke University School of Medicine, Durham, NC
- Center for the Study of Aging and Human Development, Duke University Medical Center, Durham, NC
- Durham Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Health Care System, Durham, NC
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC
- Geriatrics Research Education and Clinical Center, Durham VA Health Care System, Durham, NC
| | - Harvey J. Cohen
- Department of Medicine, Duke University School of Medicine, Durham, NC
- Center for the Study of Aging and Human Development, Duke University Medical Center, Durham, NC
| | - Heather E. Whitson
- Department of Medicine, Duke University School of Medicine, Durham, NC
- Center for the Study of Aging and Human Development, Duke University Medical Center, Durham, NC
- Geriatrics Research Education and Clinical Center, Durham VA Health Care System, Durham, NC
- Department of Ophthalmology, Duke University School of Medicine, Durham, NC
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175
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Richardson A, Blenkinsopp A, Downs M, Lord K. Stakeholder perspectives of care for people living with dementia moving from hospital to care facilities in the community: a systematic review. BMC Geriatr 2019; 19:202. [PMID: 31366373 PMCID: PMC6668086 DOI: 10.1186/s12877-019-1220-1] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2018] [Accepted: 07/22/2019] [Indexed: 11/23/2022] Open
Abstract
Background People living with dementia in care homes are regularly admitted to hospital. The transition between hospitals and care homes is an area of documented poor care leading to adverse outcomes including costly re-hospitalisation. This review aims to understand the experiences and outcomes of care for people living with dementia who undergo this transition from the perspectives of key stakeholders; people living with dementia, their families and health care professionals. Methods A systematic search was conducted on the CINAHL, ASSIA, EMBASE, MEDLINE, PsychINFO, and Scopus databases without any date restrictions. We hand searched reference lists of included papers. Papers were included if they focused on people living with dementia moving from hospital to a short or long term care setting in the community including sub-acute, rehabilitation, skilled nursing facilities or care homes. Titles, abstracts and full texts were screened. Two authors independently evaluated study quality using a checklist. Themes were identified and discussed to reach consensus. Results In total, nine papers reporting eight studies met the inclusion criteria for the systematic review. A total of 257 stakeholders participated; 37 people living with dementia, 95 family members, and 125 health and social care professionals. Studies took place in Australia, Canada, United Kingdom (UK), and the United States of America (US). Four themes were identified as factors influencing the experience and outcomes of the transition from the perspectives of stakeholders; preparing for transition; quality of communication; the quality of care; family engagement and roles. Conclusion This systematic review presents a compelling case for the need for robust evidence to guide best practice in this important area of multi-disciplinary clinical practice. The evidence suggests this transition is challenging for all stakeholders and that people with dementia have specific needs which need attention during this period. Trial registration PROSPERO Registration Number: CRD42017082041.
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176
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Parke B, Hunter KF. The dementia-friendly emergency department: An innovation to reducing incompatibilities at the local level. Healthc Manage Forum 2019; 30:26-31. [PMID: 28929901 DOI: 10.1177/0840470416664532] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Emergency Departments (EDs) are an integral part of the Canadian healthcare system. Older people living with dementia challenge EDs. They have complex health profiles that pose multiple challenges for staff. The current one-size-fits-all approach that aids efficiency in a technologically dependent hospital setting may not always serve older people living with dementia, their caregivers, or staff well. The premise that older people living with dementia are a problem for Canadian EDs must be reconsidered. Understanding the complexity of the situation is aided by the dementia-friendly ED framework. We propose one way to enhance communication between those living with dementia who receive ED services and those providing the service.
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Affiliation(s)
- Belinda Parke
- 1 Faculty of Nursing, Edmonton Clinic Health Academy, University of Alberta, Edmonton, Alberta, Canada
| | - Kathleen F Hunter
- 1 Faculty of Nursing, Edmonton Clinic Health Academy, University of Alberta, Edmonton, Alberta, Canada
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177
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Gillespie SM, Wasserman EB, Wood NE, Wang H, Dozier A, Nelson D, McConnochie KM, Shah MN. High-Intensity Telemedicine Reduces Emergency Department Use by Older Adults With Dementia in Senior Living Communities. J Am Med Dir Assoc 2019; 20:942-946. [PMID: 31315813 DOI: 10.1016/j.jamda.2019.03.024] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2019] [Revised: 03/17/2019] [Accepted: 03/22/2019] [Indexed: 10/26/2022]
Abstract
OBJECTIVES Individuals with dementia have high rates of emergency department (ED) use for acute illnesses. We evaluated the effect of a high-intensity telemedicine program that delivers care for acute illnesses on ED use rates for individuals with dementia who reside in senior living communities (SLCs; independent and assisted living). DESIGN We performed a secondary analysis of data for patients with dementia from a prospective cohort study over 3.5 years that evaluated the effectiveness of high-intensity telemedicine for acute illnesses among SLC residents. SETTING AND PARTICIPANTS We studied patients cared for by a primary care geriatrics practice at 22 SLCs in a northeastern city. Six SLCs were selected as intervention facilities and had access to patient-to-provider high-intensity telemedicine services to diagnose and treat illnesses. Patients at the remaining 15 SLCs served as controls. Participants were considered to have dementia if they had a diagnosis of dementia on their medical record problem list, were receiving medications for the indication of dementia, or had cognitive testing consistent with dementia. MEASURES We compared the rate of ED use among participants with dementia and access to high-intensity telemedicine services to control participants with dementia but without access to services. RESULTS Intervention group participants had 201 telemedicine visits. In participants with dementia, it is estimated that 1 year of access to telemedicine services is associated with a 24% decrease in ED visits (rate ratio 0.76, 95% confidence interval 0.61, 0.96). CONCLUSIONS/IMPLICATIONS Telemedicine in SLCs can effectively decrease ED use by individuals with dementia, but further research is needed to confirm this secondary analysis and to understand how to best implement and optimize telemedicine for patients with dementia suffering from acute illnesses.
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Affiliation(s)
- Suzanne M Gillespie
- Geriatrics and Extended Care, Canandaigua VA Medical Center, Canandaigua, NY; Department of Medicine, Division of Geriatrics & Aging, University of Rochester School of Medicine and Dentistry, Rochester, NY; Department of Emergency Medicine, University of Rochester School of Medicine and Dentistry, Rochester, NY.
| | - Erin B Wasserman
- Department of Emergency Medicine, University of Rochester School of Medicine and Dentistry, Rochester, NY
| | - Nancy E Wood
- Datalys Center for Sports Injury Research and Prevention, Inc, Indianapolis, IN
| | - Hongyue Wang
- Department of Biostatistics, University of Rochester School of Medicine and Dentistry, Rochester, NY
| | - Ann Dozier
- Department of Public Health Sciences, University of Rochester School of Medicine and Dentistry, Rochester, NY
| | - Dallas Nelson
- Department of Medicine, Division of Geriatrics & Aging, University of Rochester School of Medicine and Dentistry, Rochester, NY
| | - Kenneth M McConnochie
- Department of Pediatrics, University of Rochester School of Medicine and Dentistry, Rochester, NY
| | - Manish N Shah
- Department of Emergency Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI; Department of Medicine (Geriatrics & Gerontology), University of Wisconsin School of Medicine and Public Health, Madison, WI; Department of Population Health Sciences, University of Wisconsin School of Medicine and Public Health, Madison, WI
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178
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Järvinen H, Taipale H, Koponen M, Tanskanen A, Tiihonen J, Tolppanen AM, Hartikainen S. Hospitalization after Oral Antibiotic Initiation in Finnish Community Dwellers with and without Alzheimer's Disease: Retrospective Register-Based Cohort Study. J Alzheimers Dis 2019; 64:437-445. [PMID: 29914029 DOI: 10.3233/jad-180125] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
BACKGROUND Persons with Alzheimer's disease (AD) are frequently hospitalized from infection-related causes. There are no previous studies investigating hospitalization associated with antibiotic initiation in persons with AD. OBJECTIVE To investigate the frequency and risk of hospitalization associated with oral antibiotic initiation among community dwellers with and without AD. METHODS We performed a retrospective register-based study utilizing register-based Medication Use and Alzheimer's disease (MEDALZ) cohort. It includes all community dwellers diagnosed with AD during 2005-2011 in Finland and their matched comparison persons without AD. Antibiotic use was initiated by 34,785 persons with and 36,428 without AD. Drug use data were collected from Prescription Register and comorbidities from Special Reimbursement and Hospital Care Registers. Infection diagnoses were collected from the Hospital Care Register. Factors associated with hospitalization were estimated utilizing logistic regression models. RESULTS Risk of hospitalization following antibiotic initiation was higher among antibiotic initiators with AD than without AD (adjusted odds ratio, aOR, 1.37, 95% Cl 1.28-1.46).Strongest association with hospitalization was found for oral glucocorticoid use, aOR 1.41 (1.25-1.59); epilepsy, aOR 1.33 (1.10-1.63); and active cancer, aOR 1.30 (1.14-1.49). Among initiators of cephalexin, pivmecillinam, amoxicillin/amoxicillin, and enzyme inhibitor and doxycycline, persons with AD were more frequently hospitalized than persons without AD. A quarter of hospitalized antibiotic initiators had infection diagnosis in their hospital care records. CONCLUSIONS Persons with AD initiating an antibiotic had a higher risk for hospitalization than antibiotic initiators without AD. Further research is needed to determine whether infection-related hospitalization could be reduced.
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Affiliation(s)
- Heli Järvinen
- School of Pharmacy, University of Eastern Finland, Kuopio, Finland.,Kuopio Research Centre of Geriatric Care, University of Eastern Finland, Kuopio, Finland
| | - Heidi Taipale
- School of Pharmacy, University of Eastern Finland, Kuopio, Finland.,Kuopio Research Centre of Geriatric Care, University of Eastern Finland, Kuopio, Finland.,Department of Clinical Neuroscience, Karolinska Institute, Stockholm, Sweden
| | - Marjaana Koponen
- School of Pharmacy, University of Eastern Finland, Kuopio, Finland.,Kuopio Research Centre of Geriatric Care, University of Eastern Finland, Kuopio, Finland
| | - Antti Tanskanen
- Department of Clinical Neuroscience, Karolinska Institute, Stockholm, Sweden.,Department of Forensic Psychiatry, Niuvanniemi Hospital, University of Eastern Finland, Kuopio, Finland
| | - Jari Tiihonen
- Department of Clinical Neuroscience, Karolinska Institute, Stockholm, Sweden.,Department of Forensic Psychiatry, Niuvanniemi Hospital, University of Eastern Finland, Kuopio, Finland
| | | | - Sirpa Hartikainen
- School of Pharmacy, University of Eastern Finland, Kuopio, Finland.,Kuopio Research Centre of Geriatric Care, University of Eastern Finland, Kuopio, Finland
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179
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Lehmann J, Michalowsky B, Kaczynski A, Thyrian JR, Schenk NS, Esser A, Zwingmann I, Hoffmann W. The Impact of Hospitalization on Readmission, Institutionalization, and Mortality of People with Dementia: A Systematic Review and Meta-Analysis. J Alzheimers Dis 2019; 64:735-749. [PMID: 29966191 DOI: 10.3233/jad-171128] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND People with dementia (PwD) are at a high risk of hospitalization. Hospitals are often not adequately equipped for PwD and discharges often come unexpected. Therefore, PwD are at a risk of adverse outcomes. However, information about those outcomes is rare but crucial for the development of preventive strategies. OBJECTIVES To conduct a quantitative systematic review and meta-analyses on the impact of a hospitalization on readmission, institutionalization, and mortality in PwD. To identify factors associated with these outcomes. METHODS PubMed, CENTRAL, and ScienceDirect were searched for studies including terms for dementia, hospital, readmission, institutionalization, and mortality. Relevant were assessed by a quality criteria sheet. Results were summarized in a table. Meta-analysis was conducted with Review Manager 5.3. RESULTS The search yielded 1,108 studies; 20 fulfilled the inclusion criteria and 10 studies were eligible for meta-analyses. The incidence and relative risk (RR) of mortality (RR 1.74 CI95 % 1.50, 2.05) and institutionalization (RR: 2.16 CI95 % 1.31, 3.56) of PwD was significantly higher when compared to people without dementia. Results according to readmission rate were inconsistent. Factors significantly associated with the examined adverse outcomes were severity of dementia, number of medications, and deficits in daily living activities. CONCLUSION Hospitalization of PwD lead to adverse outcomes. An improvement in the identification of and care for PwD in the acute setting as well as in after care in the community setting, especially in the interface between both settings, is required to prevent adverse outcomes in hospitalized PwD.
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180
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Shepherd H, Livingston G, Chan J, Sommerlad A. Hospitalisation rates and predictors in people with dementia: a systematic review and meta-analysis. BMC Med 2019; 17:130. [PMID: 31303173 PMCID: PMC6628507 DOI: 10.1186/s12916-019-1369-7] [Citation(s) in RCA: 111] [Impact Index Per Article: 22.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2019] [Accepted: 06/14/2019] [Indexed: 01/10/2023] Open
Abstract
BACKGROUND Hospitalisation is often harmful for people with dementia and results in high societal costs, so avoidance of unnecessary admissions is a global priority. However, no intervention has yet reduced admissions of community-dwelling people with dementia. We therefore aimed to examine hospitalisation rates of people with dementia and whether these differ from people without dementia and to identify socio-demographic and clinical predictors of hospitalisation. METHODS We searched MEDLINE, Embase, and PsycINFO from inception to 9 May 2019. We included observational studies which (1) examined community-dwelling people with dementia of any age or dementia subtype, (2) diagnosed dementia using validated diagnostic criteria, and (3) examined all-cause general (i.e. non-psychiatric) hospital admissions. Two authors screened abstracts for inclusion and independently extracted data and assessed included studies for risk of bias. Three authors graded evidence strength using Cochrane's GRADE approach, including assessing for evidence of publication bias using Begg's test. We used random effects meta-analysis to pool estimates for hospitalisation risk in people with and without dementia. RESULTS We included 34 studies of 277,432 people with dementia: 17 from the USA, 15 from Europe, and 2 from Asia. The pooled relative risk of hospitalisation for people with dementia compared to those without was 1.42 (95% confidence interval 1.21, 1.66) in studies adjusted for age, sex, and physical comorbidity. Hospitalisation rates in people with dementia were between 0.37 and 1.26/person-year in high-quality studies. There was strong evidence that admission is associated with older age, and moderately strong evidence that multimorbidity, polypharmacy, and lower functional ability are associated with admission. There was strong evidence that dementia severity alone is not associated. CONCLUSIONS People with dementia are more frequently admitted to hospital than those without dementia, independent of physical comorbidities. Future interventions to reduce unnecessary hospitalisations should target potentially modifiable factors, such as polypharmacy and functional ability, in high-risk populations.
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Affiliation(s)
- Hilary Shepherd
- Division of Psychiatry, University College London, 6th Floor, Maple House, 149 Tottenham Court Road, London, W1T 7NF, UK
| | - Gill Livingston
- Division of Psychiatry, University College London, 6th Floor, Maple House, 149 Tottenham Court Road, London, W1T 7NF, UK
- Camden and Islington NHS Foundation Trust, 4 St Pancras Way, London, NW1 0PE, UK
| | - Justin Chan
- Division of Psychiatry, University College London, 6th Floor, Maple House, 149 Tottenham Court Road, London, W1T 7NF, UK
| | - Andrew Sommerlad
- Division of Psychiatry, University College London, 6th Floor, Maple House, 149 Tottenham Court Road, London, W1T 7NF, UK.
- Camden and Islington NHS Foundation Trust, 4 St Pancras Way, London, NW1 0PE, UK.
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181
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Associations among hearing loss, hospitalization, readmission and mortality in older adults: A systematic review. Geriatr Nurs 2019; 40:367-379. [DOI: 10.1016/j.gerinurse.2018.12.013] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2018] [Revised: 12/20/2018] [Accepted: 12/21/2018] [Indexed: 12/26/2022]
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182
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Maxwell CJ, Mondor L, Hogan DB, Campitelli MA, Bronskill SE, Seitz DP, Wodchis WP. Joint impact of dementia and frailty on healthcare utilisation and outcomes: a retrospective cohort study of long-stay home care recipients. BMJ Open 2019; 9:e029523. [PMID: 31230032 PMCID: PMC6596979 DOI: 10.1136/bmjopen-2019-029523] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES To examine the associations between dementia and 1-year health outcomes (urgent hospitalisation, long-term care (LTC) admission, mortality) among long-stay home care recipients and the extent to which these associations vary by clients' frailty level. DESIGN A retrospective cohort study using linked clinical and health administrative databases. SETTING Home care in Ontario, Canada. PARTICIPANTS Long-stay (≥60 days) care clients (n=153 125) aged ≥50 years assessed between April 2014 and March 2015. MAIN OUTCOME MEASURES Dementia was ascertained with a validated administrative data algorithm and frailty with a 66-item frailty index (FI) based on a previously validated FI derived from the clinical assessment. We examined associations between dementia, FI and their interactions, with 1-year outcomes using multivariable Fine-Gray competing risk (urgent hospitalisation and LTC admission) and Cox proportional hazards (mortality) models. RESULTS Clients with dementia (vs without) were older (mean±SD, 83.3±7.9 vs 78.9±11.3 years, p<0.001) and more likely to be frail (30.3% vs 24.2%, p<0.001). In models adjusted for FI (as a continuous variable) and other confounders, clients with dementia showed a lower incidence of urgent hospitalisation (adjusted subdistribution HR (sHR)=0.84, 95% CI: 0.83 to 0.86) and mortality rate (adjusted HR=0.87, 95% CI: 0.84 to 0.89) but higher incidence of LTC admission (adjusted sHR=2.60, 95% CI: 2.53 to 2.67). The impact of dementia on LTC admission and mortality was significantly modified by clients' FI (p<0.001 interaction terms), showing a lower magnitude of association (ie, attenuated positive (for LTC admission) and negative (for mortality) association) with increasing frailty. CONCLUSIONS The strength of associations between dementia and LTC admission and death (but not urgent hospitalisation) among home care recipients was significantly modified by their frailty status. Understanding the public health impact of dementia requires consideration of frailty levels among older populations, including those with and without dementia and varying degrees of multimorbidity.
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Affiliation(s)
- Colleen J Maxwell
- School of Pharmacy, University of Waterloo, Waterlo, Ontario, Canada
- ICES, Toronto, Ontario, Canada
| | - Luke Mondor
- ICES, Toronto, Ontario, Canada
- Health System Performance Research Network, Toronto, Ontario, Canada
| | - David B Hogan
- Division of Geriatric Medicine, University of Calgary, Calgary, Alberta, Canada
| | | | - Susan E Bronskill
- ICES, Toronto, Ontario, Canada
- Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Dallas P Seitz
- Division of Geriatric Psychiatry, Queen's University, Kingston, Ontario, Canada
- ICES-Queen's, Queen's University, Kingston, Ontario, Canada
| | - Walter P Wodchis
- Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, Ontario, Canada
- Institute for Better Health, Trillium Health Partners, Mississauga, Ontario, Canada
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183
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Impact of health service interventions on acute hospital use in community-dwelling persons with dementia: A systematic literature review and meta-analysis. PLoS One 2019; 14:e0218426. [PMID: 31226138 PMCID: PMC6588225 DOI: 10.1371/journal.pone.0218426] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2018] [Accepted: 06/03/2019] [Indexed: 11/19/2022] Open
Abstract
Background Persons with dementia have twice the acute hospital use as older persons without dementia. In addition to straining overburdened healthcare systems, acute hospital use impacts patient and caregiver quality of life and is associated with increased risk of adverse outcomes including death. Reducing avoidable acute hospital use in persons with dementia is thus a global healthcare priority. However, evidence regarding the impact of health service interventions as defined by the Effective Practice and Organization of Care Cochrane Group on acute hospital use is scant and inconclusive. The aim of this systematic review and meta-analysis was to synthesize available evidence on the impact of health service interventions on acute hospital use in community-dwelling persons with dementia compared to usual care. Methods Data Sources: MEDLINE, EMBASE, CINAHL and Cochrane CENTRAL (from 01/1995 to 08/2017). Study eligibility criteria: Randomised controlled trials measuring the impact of health service interventions on acute hospital use (proportion and mean number of emergency department visits and hospitalisations, mean number of hospital days, measured at 12 months, and at longest follow-up) in community-dwelling persons with dementia, compared to usual care. Study selection, appraisal and synthesis methods: Reviewers independently identified studies, extracted data, and assessed the risk of bias, with the Cochrane risk of bias tool. Authors of relevant trials were queried about unpublished data. Random effects model was used for meta-analyses. Effect heterogeneity was assessed through prediction intervals, and explored using sub-group analyses. Findings Seventeen trials provided data on 4,549 persons. Unpublished data were obtained for 13 trials, representing 65% of synthesized data. Most interventions included a case management or a self-management component. None of the outcome comparisons provided conclusive evidence supporting the hypothesis that these interventions would lead to a decrease in acute hospital use. Furthermore, prediction intervals indicated possible and important increased service use associated with these interventions, such as emergency department visits, hospital admissions, and hospital days. Subgroup analyses did not favour any type of intervention. A limitation of this study is the inclusion of any type of health service intervention, which may have increased the observed heterogeneity. Conclusion Despite a comprehensive systematic review and meta-analysis, including predominantly unpublished data, no health service intervention beyond usual care was found to reduce acute hospital use in community-dwelling persons with dementia. An important increase in service use may be associated with these interventions. Further research is urgently needed to identify effective interventions for this vulnerable population to limit rising acute hospital use, associated costs and adverse outcomes. Systematic review registration PROSPERO CRD42016046444.
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184
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Reinold J, Palese F, Romanese F, Logroscino G, Riedel O, Pisa FE. Anticholinergic burden before and after hospitalization in older adults with dementia: Increase due to antipsychotic medications. Int J Geriatr Psychiatry 2019; 34:868-880. [PMID: 30761624 DOI: 10.1002/gps.5084] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2018] [Accepted: 02/03/2019] [Indexed: 11/08/2022]
Abstract
OBJECTIVES To evaluate changes in the use of antipsychotics and medications with anticholinergic activity (MACs) during hospitalization in older adults with dementia and factors associated with antipsychotic prescriptions and increased anticholinergic burden (ACB). METHODS AND DESIGN This retrospective cohort study included all patients aged 65 years or older with a discharge diagnosis of dementia hospitalized at the university hospital of Udine, Italy, from 2012 to 2014. Medications dispensed within 3 months before and after hospitalization were identified in community-pharmacy dispensations while those prescribed at discharge were collected from Hospital Electronic Medical Records (EMR). ACB was assessed using the Anticholinergic Cognitive Burden score. RESULTS Among 1908 patients included, at discharge, 37.0% used one or more antipsychotic (9.4% before and 12.6% after hospitalization), 68.6% used one or more MAC (49.1% and 45.7%, respectively), and ACB of 38.4% of patients increased at discharge mainly because of a higher use of antipsychotics with anticholinergic activity (33% at discharge vs 12% before hospitalization). Prescription of antipsychotics at discharge was associated with prior treatment with antipsychotics (adjusted odds ratio [aOR] 4.85; 95%CI, 3.37-6.97), psychiatric conditions, (4.39; 3.47-5.54) and discharge from surgical department (2.17; 1.32-3.55). An increased ACB was associated with psychiatric conditions (1.91; 1.52-2.39), discharge from surgical (1.75; 1.09-2.80) or medical department (1.50; 1.04-2.17), and with cardiac insufficiency (1.41; 1.00-1.99). CONCLUSIONS ACB was higher at discharge, and antipsychotics were the main drivers of this increase. Clinicians treating older adults with dementia should be aware of the risks associated with antipsychotics and that some of these medications may increase the risk of anticholinergic effects.
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Affiliation(s)
- Jonas Reinold
- Department of Clinical Epidemiology, Leibniz Institute for Prevention Research and Epidemiology BIPS, Bremen, Germany
| | | | | | - Giancarlo Logroscino
- Neurodegenerative Diseases Unit, Department of Basic Medicine Neuroscience and Sense Organs, Department of Clinical Research in Neurology of the University of Bari at "Pia Fondazione Card. G.Panico" Hospital Tricase, University of Bari, Lecce, Italy
| | - Oliver Riedel
- Department of Clinical Epidemiology, Leibniz Institute for Prevention Research and Epidemiology BIPS, Bremen, Germany
| | - Federica E Pisa
- Department of Clinical Epidemiology, Leibniz Institute for Prevention Research and Epidemiology BIPS, Bremen, Germany
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185
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Sommerlad A, Perera G, Mueller C, Singh-Manoux A, Lewis G, Stewart R, Livingston G. Hospitalisation of people with dementia: evidence from English electronic health records from 2008 to 2016. Eur J Epidemiol 2019; 34:567-577. [PMID: 30649705 PMCID: PMC6497615 DOI: 10.1007/s10654-019-00481-x] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2018] [Accepted: 01/05/2019] [Indexed: 01/11/2023]
Abstract
Hospitalisation of people with dementia is associated with adverse outcomes and high costs. We aimed to examine general, i.e. non-psychiatric, hospitalisation rates, changes since 2008 and factors associated with admission. We also aimed to compare admission rates of people with dementia with age-matched people without dementia. We conducted a cohort study of adults ≥ 65 years, with dementia diagnosed during the 2008-2016 study window, derived from a large secondary mental healthcare database in South London, UK. We used national general hospital records to identify emergency and elective hospitalisations. We calculated the cumulative incidence and rate of hospitalisation and examined predictors of hospitalisation using negative binomial regression, with multiple imputation for missing covariate data. We calculated age-standardised admission ratio for people with dementia compared to those without. Of 10,137 people, 50.6% were admitted to hospital in the year following dementia diagnosis and 75.9% were admitted during median 2.5 years follow-up. Annual admission rate was 1.26/person-year of which 0.90/person-year were in emergency. Emergency hospitalisation rate increased throughout the study period. Compared to controls without diagnosed dementia in the catchment area, the age-standardised emergency admission ratio for people with dementia was 2.06 (95% CI 1.95, 2.18). Male, older, white and socio-economically deprived people and those with clinically significant comorbid physical illness, depressed mood, activity of daily living or living condition problems had more hospitalisations. Emergency hospitalisations of people with dementia are higher than those without, and increasing. Many factors associated with admission are social and psychological, and may be targets for future interventions that aim to reduce avoidable admissions.
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Affiliation(s)
- Andrew Sommerlad
- Division of Psychiatry, University College London, 6th Floor, Maple House, 149 Tottenham Court Road, London, W1T 7NF UK
- Camden and Islington NHS Foundation Trust, London, UK
| | - Gayan Perera
- Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, UK
- South London and Maudsley NHS Foundation Trust, London, UK
| | - Christoph Mueller
- Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, UK
- South London and Maudsley NHS Foundation Trust, London, UK
| | - Archana Singh-Manoux
- INSERM U 1018, Epidemiology of Ageing and Age-related diseases, Villejuif, France
- Department of Epidemiology and Public Health, University College London, London, UK
| | - Glyn Lewis
- Division of Psychiatry, University College London, 6th Floor, Maple House, 149 Tottenham Court Road, London, W1T 7NF UK
- Camden and Islington NHS Foundation Trust, London, UK
| | - Robert Stewart
- Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, UK
- South London and Maudsley NHS Foundation Trust, London, UK
| | - Gill Livingston
- Division of Psychiatry, University College London, 6th Floor, Maple House, 149 Tottenham Court Road, London, W1T 7NF UK
- Camden and Islington NHS Foundation Trust, London, UK
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186
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Sinvani L, Strunk A, Patel V, Shah S, Mulvany C, Kozikowski A, Boltz M, Pekmezaris R, Wolf-Klein G. Constant Observation Practices for Hospitalized Persons With Dementia: A Survey Study. Am J Alzheimers Dis Other Demen 2019; 34:223-230. [PMID: 30704268 PMCID: PMC10852488 DOI: 10.1177/1533317519826272] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Despite substantial staffing and cost implications, the use of constant observation (CO) has been poorly described in the acute care setting. The purpose of this cross-sectional, multicenter, survey study was to assess hospital provider practices regarding the use of CO. Of the 543 surveys distributed, 231 were completed across 5 sites. Most respondents worked on medical units (67.5%), as nurses (49.1%); 44.8% were white; and 75.6% were female. The majority (84.2%) reported at least 1 patient/wk requiring CO. Most frequent indication for CO was dementia with agitation (60.7%), in patients older than 70 (62.3%) and predominantly by nurse assistants (93.9%). Almost half (47.3%) stated they felt pressured to discontinue CO, despite a strong perceived benefit (76%). Enhanced observation (92.6%) was most frequently used to decrease CO. Finally, 77.9% perceived that those performing CO lacked training. Our study highlights the widespread use of CO for hospitalized older adults with dementia.
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Affiliation(s)
- Liron Sinvani
- Department of Medicine, Division of Hospital Medicine, Northwell Health, New York, NY, USA
- Center of Health Innovation and Outcomes Research (CHIOR), The Feinstein Institute for Medical Research, Northwell Health, New York, NY, USA
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Northwell Health, New York, NY, USA
| | - Andrew Strunk
- Department of Dermatology, Northwell Health, New York, NY, USA
| | - Vidhi Patel
- Center of Health Innovation and Outcomes Research (CHIOR), The Feinstein Institute for Medical Research, Northwell Health, New York, NY, USA
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Northwell Health, New York, NY, USA
| | - Shalin Shah
- Department of Medicine, Division of Hospital Medicine, Northwell Health, New York, NY, USA
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Northwell Health, New York, NY, USA
| | - Colm Mulvany
- Center of Health Innovation and Outcomes Research (CHIOR), The Feinstein Institute for Medical Research, Northwell Health, New York, NY, USA
| | - Andrzej Kozikowski
- Center of Health Innovation and Outcomes Research (CHIOR), The Feinstein Institute for Medical Research, Northwell Health, New York, NY, USA
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Northwell Health, New York, NY, USA
| | - Marie Boltz
- College of Nursing, Penn State, University Park, PA, USA
| | - Renee Pekmezaris
- Center of Health Innovation and Outcomes Research (CHIOR), The Feinstein Institute for Medical Research, Northwell Health, New York, NY, USA
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Northwell Health, New York, NY, USA
| | - Gisele Wolf-Klein
- Department of Medicine, Division of Geriatrics and Palliative Medicine, Northwell Health, New York, NY, USA
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187
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Abreu W, Tolson D, Jackson GA, Staines H, Costa N. The relationship between frailty, functional dependence, and healthcare needs among community-dwelling people with moderate to severe dementia. HEALTH & SOCIAL CARE IN THE COMMUNITY 2019; 27:642-653. [PMID: 30402986 DOI: 10.1111/hsc.12678] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/30/2018] [Revised: 08/16/2018] [Accepted: 10/08/2018] [Indexed: 06/08/2023]
Abstract
This paper examines the healthcare needs of community-dwelling older people living in Porto, Portugal, diagnosed with moderate or severe dementia, linked to functional dependency, cognitive decline, limitations in the activities of daily life, and frailty levels. A sample of 83 participants was recruited. Data were collected between 2013 and 2017. A sociodemographic questionnaire, the Clinical Dementia Rating (CDR), the Barthel Index (BI), the Lawton and Brody Instrumental Activities of Daily Living (IADL) Scale, and the Edmonton Frail Scale (EFS) were used. A set of 26 healthcare needs was defined to support the assessment. The Pearson chi-square or Fisher's exact test (as appropriate) was used to examine the association of the needs (unmet and met) with the levels of dementia and frailty. Participants were diagnosed previously with moderate or severe dementia and benefited from a structured home-care program. There was a high number rated as "severe dementia," "fully dependent," "severely or fully dependent in the activities of daily living (ADL)," and "severe frailty." There were statistically significant differences among needs identified in people with moderate or severe dementia and moderate or severe frailty. The most prevalent healthcare needs in the sample were food preparation, medication/taking pills, looking after their home, toilet use, sensory problems, communication/interaction, bladder, bowels, eating and drinking, memory, sleeping, and falls prevention. In particular, the study identifies a set of needs that are present simultaneously in both frailty and dementia stages. This study underlines that despite well-structured home-care programs for people with dementia, unmet health needs remain. Timely healthcare needs assessment may help professionals to avoid fragmented care and to tailor quality-integrated interventions, including the emotional and psychological balance of the caregiver.
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Affiliation(s)
- Wilson Abreu
- Porto School of Nursing/CINTESIS (Center for Research in Health Technologies and Services), Porto, Portugal
| | - Debbie Tolson
- Alzheimer Scotland Centre for Policy and Practice, The University of the West of Scotland, Hamilton, UK
| | - Graham A Jackson
- Alzheimer Scotland Centre for Policy and Practice, The University of the West of Scotland, Hamilton, UK
| | - Harry Staines
- The University of the West of Scotland, Hamilton, UK
| | - Nilza Costa
- University of Aveiro - Campus Universitário de Santiago, Aveiro, Portugal
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188
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Abley C, Dickinson C, Andrews Z, Prato L, Lindley L, Robinson L. Training interventions to improve general hospital care for older people with cognitive impairment: systematic review. Br J Psychiatry 2019; 214:201-212. [PMID: 30784394 DOI: 10.1192/bjp.2019.29] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
BACKGROUND In response to increasing numbers of older people in general hospitals who have cognitive impairment such as dementia and delirium, many hospitals have developed education and training programmes to prepare staff for this area of clinical practice.AimsTo review the evidence on educational interventions on hospital care for older people with cognitive impairment. METHOD A mixed methods systematic review and narrative synthesis was undertaken. The following electronic databases were searched: Medline, Embase, CINAHL, PsycINFO, EBM Reviews, ASSIA and Scopus, as well as Health Management Information Consortium (HMIC), ProQuest, PubMed and SCIE: Social Care Online. Initial searches were run in August 2014 (update search September 2016). Titles and abstracts of studies retrieved were screened independently. The full text of eligible studies were then independently assessed by two review team members. All included studies were assessed using a standard quality appraisal tool. RESULTS Eight studies relating to delirium, six on dementia and two on delirium and dementia were included, each testing the use of a different educational intervention. Overall, the quality of the studies was low. In relation to delirium, all studies reported a significant increase in participants' knowledge immediately post-intervention. Two of the dementia studies reported an increase in dementia knowledge and dementia confidence immediately post-intervention. CONCLUSIONS The variety of outcomes measured makes it difficult to summarise the findings. Although studies found increases in staff knowledge, there is insufficient evidence to conclude that educational interventions for staff lead to improved patient outcomes.Declaration of interestNone.
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Affiliation(s)
- Clare Abley
- Nurse Consultant and Clinical Senior Lecturer,The Newcastle upon Tyne Hospitals NHS Foundation Trust,Institute of Health and Society and Newcastle Institute for Ageing,Newcastle University,UK
| | - Claire Dickinson
- Research Associate,Institute of Health and Society,Newcastle University,UK
| | - Zoe Andrews
- Student Intern,Institute of Health and Society,Newcastle University,UK
| | - Laura Prato
- Research Assistant,Institute of Health and Society,Newcastle University,UK
| | - Lyndsay Lindley
- Research Assistant,Institute of Health and Society,Newcastle University,UK
| | - Louise Robinson
- Professor of Primary Care and Ageing,Institute of Health and Society; andDirector,Newcastle Institute for Ageing,Newcastle University,UK
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189
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White L, Fishman P, Basu A, Crane PK, Larson EB, Coe NB. Medicare expenditures attributable to dementia. Health Serv Res 2019; 54:773-781. [PMID: 30868557 DOI: 10.1111/1475-6773.13134] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
OBJECTIVE To estimate dementia's incremental cost to the traditional Medicare program. DATA SOURCES Health and Retirement Study (HRS) survey-linked Medicare part A and B claims from 1991 to 2012. STUDY DESIGN We compared Medicare expenditures for 60 months following a claims-based dementia diagnosis to those for a randomly selected, matched comparison group. DATA COLLECTION/EXTRACTION METHODS We used a cost estimator that accounts for differential survival between individuals with and without dementia and decomposes incremental costs into survival and cost intensity components. PRINCIPAL FINDINGS Dementia's five-year incremental cost to the traditional Medicare program is approximately $15 700 per patient, nearly half of which is incurred in the first year after diagnosis. Shorter survival with dementia mitigates the incremental cost by about $2650. Increased costs for individuals with dementia were driven by more intensive use of Medicare part A covered services. The incremental cost of dementia was about $7850 higher for females than for males because of sex-specific differential mortality associated with dementia. CONCLUSIONS Dementia's cost to the traditional Medicare program is significant. Interventions that target early identification of dementia and preventable inpatient and post-acute care services could produce substantial savings.
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Affiliation(s)
- Lindsay White
- Department of Health Services, School of Public Health, University of Washington, Seattle, Washington
| | - Paul Fishman
- Department of Health Services, School of Public Health, University of Washington, Seattle, Washington
| | - Anirban Basu
- Department of Health Services, School of Public Health, University of Washington, Seattle, Washington.,Department of Pharmacy, School of Pharmacy, University of Washington, Seattle, Washington.,National Bureau of Economic Research, Cambridge, Massachusetts
| | - Paul K Crane
- Division of General Internal Medicine, School of Medicine, University of Washington, Seattle, Washington
| | - Eric B Larson
- Kaiser Permanente Washington Health Research Institute, Kaiser Permanente Washington, Seattle, Washington
| | - Norma B Coe
- National Bureau of Economic Research, Cambridge, Massachusetts.,Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
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190
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Tsang G, Xie X, Zhou SM. Harnessing the Power of Machine Learning in Dementia Informatics Research: Issues, Opportunities, and Challenges. IEEE Rev Biomed Eng 2019; 13:113-129. [PMID: 30872241 DOI: 10.1109/rbme.2019.2904488] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Dementia is a chronic and degenerative condition affecting millions globally. The care of patients with dementia presents an ever-continuing challenge to healthcare systems in the 21st century. Medical and health sciences have generated unprecedented volumes of data related to health and wellbeing for patients with dementia due to advances in information technology, such as genetics, neuroimaging, cognitive assessment, free texts, routine electronic health records, etc. Making the best use of these diverse and strategic resources will lead to high-quality care of patients with dementia. As such, machine learning becomes a crucial factor in achieving this objective. The aim of this paper is to provide a state-of-the-art review of machine learning methods applied to health informatics for dementia care. We collate and review the existing scientific methodologies and identify the relevant issues and challenges when faced with big health data. Machine learning has demonstrated promising applications to neuroimaging data analysis for dementia care, while relatively less effort has been made to make use of integrated heterogeneous data via advanced machine learning approaches. We further indicate future potential and research directions in applying advanced machine learning, such as deep learning, to dementia informatics.
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191
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A community health case for psychiatric care: A cross-sectional study of county health rankings. Gen Hosp Psychiatry 2019; 57:1-6. [PMID: 30616094 DOI: 10.1016/j.genhosppsych.2018.10.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2018] [Revised: 10/25/2018] [Accepted: 10/31/2018] [Indexed: 11/24/2022]
Abstract
OBJECTIVES To determine if there is an association between the provision of mental health services and county health rankings in the United States. METHODS We used retrospective population-based, 2016 U.S. county level cross-sectional analysis to determine the association of mental health services provision on U.S. counties health rankings. The key dependent variables in this study were the county health factor rankings (CHR). The presence of inpatient, outpatient and other facilities which may provide mental health services are identified for each county. Multilevel mixed effects ordinal logistic regression models were used to account for nesting effects utilizing two levels of data which include hospital- and county-level data. RESULTS Better county health rankings were associated with the presence of Outpatient services (OR = 0.69, 95% CI: 0.55-0.85) and Psychiatric hospital (OR = 0.55, 95% CI: 0.40-0.74). CONCLUSION These findings suggest a significant association between psychiatric care and community health. Access to psychiatric services is associated with improved population health.
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192
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Featherstone K, Northcott A, Harden J, Harrison Denning K, Tope R, Bale S, Bridges J. Refusal and resistance to care by people living with dementia being cared for within acute hospital wards: an ethnographic study. HEALTH SERVICES AND DELIVERY RESEARCH 2019. [DOI: 10.3310/hsdr07110] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Background
The acute hospital setting has become a key site of care for people living with dementia. The Department of Health and Social Care recognises that as many as one in four acute hospital beds in the UK will be occupied by a person living with dementia at any given time. However, people living with dementia are a highly vulnerable group within the hospital setting. Following an acute admission, their functional abilities can deteriorate quickly and significantly. Detailed research is required to understand the role and needs of health-care staff caring for this patient population and to explore what constitutes ‘good care’ for people living with dementia within the acute setting.
Objectives
The focus of this study was a common but poorly understood phenomenon within the acute setting: refusal and resistance to care. Our research questions were ‘How do ward staff respond to resistance to everyday care by people living with dementia being cared for on acute hospital wards?’ and ‘What is the perspective of patients and their carers?’.
Design
This ethnography was informed by the symbolic interactionist research tradition, focusing on understanding how action and meaning are constructed within a setting. In-depth evidence-based analysis of everyday care enabled us to understand how ward staff responded to the care needs of people living with dementia and to follow the consequences of their actions.
Setting
This ethnography was carried out on 155 days (over 18 months) in 10 wards within five hospitals across England and Wales, which were purposefully selected to represent a range of hospital types, geographies and socioeconomic catchments.
Participants
In addition to general observations, 155 participants took part directly in this study, contributing to 436 ethnographic interviews. Ten detailed case studies were also undertaken with people living with dementia.
Results
We identified high levels of resistance to care among people living with dementia within acute hospital wards. Every person living with dementia observed within an acute hospital ward resisted care at some point during their admission.
Limitations
Limitations identified included the potential for the Hawthorne or researcher effect to influence data collection and establishing the generalisability of findings.
Conclusions
Ward staff typically interpreted resistance as a feature of a dementia diagnosis, which overshadowed the person. However, resistance to care was typically a response to ward organisation and delivery of care and was typically rational to that person’s present ontology and perceptions. In response, nurses and health-care assistants used multiple interactional approaches that combined highly repetitive language with a focus on completing essential care on the body, which itself had a focus on the containment and restraint of the person in their bed or at their bedside. These approaches to patient care were a response to resistance but also a trigger for resistance, creating cycles of stress for patients, families and ward staff. The findings have informed the development of simple, no-cost innovations at the interactional and organisational level. A further study is examining continence care for people living with dementia in acute hospital settings.
Funding
The National Institute for Health Research Health Services and Delivery Research programme.
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Affiliation(s)
| | - Andy Northcott
- School of Allied Health Sciences, De Montfort University, Leicester, UK
| | - Jane Harden
- School of Healthcare Sciences, Cardiff University, Cardiff, UK
| | | | | | - Sue Bale
- Aneurin Bevan University Health Board, Newport, UK
| | - Jackie Bridges
- School of Health Sciences, University of Southampton, Southampton, UK
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193
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Resnick B, Boltz M. Optimizing Function and Physical Activity in Hospitalized Older Adults to Prevent Functional Decline and Falls. Clin Geriatr Med 2019; 35:237-251. [PMID: 30929885 DOI: 10.1016/j.cger.2019.01.003] [Citation(s) in RCA: 46] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Physical activity, defined as bodily movement that expends energy including such things as bed mobility, transfers, bathing, dressing, and walking, has a positive impact on physical and psychosocial outcomes among older adults during their hospitalization and the post hospitalization recovery period. Despite benefits, physical activity is not the focus of care in the acute care setting. Further there are many barriers to engaging patients in physical activity and fall prevention activities including patient, family and provider beliefs, environmental challenges and limitations, hospital policies, and medical and nursing interventions. This paper provides an overview of falls and physical activity prevalence among acute care patients, challenges to engaging patients in physical activity and falls prevention activities and innovative approaches to increase physical activity and prevent falls among older hospitalized patients.
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Affiliation(s)
- Barbara Resnick
- University of Maryland School of Nursing, 655 West Lombard Street, Baltimore, MD 21201, USA.
| | - Marie Boltz
- Pennsylvania State University, College of Nursing, 201 Nursing Sciences Building, University Park, PA 16802, USA
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194
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Abstract
UNLABELLED ABSTRACTObjectives:Dementia and cognitive impairment are associated with higher rates of complications and mortality during hospitalization in older patients. Moreover, length of hospital stay and costs are increased. In this prospective cohort study, we investigated the frequency of hospitalizations caused by ambulatory care-sensitive conditions (ACSCs), for which proactive ambulatory care might prevent the need for a hospital stay, in older patients with and without cognitive impairments. DESIGN Prospective cohort study. SETTING Eight hospitals in Germany. PARTICIPANTS A total of 1,320 patients aged 70 years and older. MEASUREMENTS The Mini-Cog test has been used to assess cognition and to categorize patients in the groups no/moderate cognitive impairments (probably no dementia) and severe cognitive impairments (probable dementia). Moreover, lengths of hospital stay and complication rates have been assessed, using a binary questionnaire (if occurred during hospital stay or not; behavioral symptoms were adapted from the Cohen-Mansfield Agitation Inventory). Data have been acquired by the nursing staff who received a special multi-day training. RESULTS Patients with severe cognitive impairments showed higher complication rates (including incontinence, disorientation, irritability/aggression, restlessness/anxiety, necessity of Tranquilizers and psychiatric consults, application of measures limiting freedom, and falls) and longer hospital stays (+1.4 days) than patients with no/moderate cognitive impairments. Both groups showed comparably high ACSC-caused admission rates of around 23%. CONCLUSIONS The study indicates that about one-fourth of hospital admissions of cognitively normal and impaired older adults are caused by ACSCs, which are mostly treatable on an ambulatory basis. This implies that an improved ambulatory care might reduce the frequency of hospitalizations, which is of particular importance in cognitively impaired elderly due to increased complication rates.
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195
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Bouza C, Martínez-Alés G, López-Cuadrado T. The impact of dementia on hospital outcomes for elderly patients with sepsis: A population-based study. PLoS One 2019; 14:e0212196. [PMID: 30779777 PMCID: PMC6380589 DOI: 10.1371/journal.pone.0212196] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2018] [Accepted: 01/29/2019] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Prior studies have suggested that dementia adversely influences clinical outcomes and increases resource utilization in patients hospitalized for acute diseases. However, there is limited population-data information on the impact of dementia among elderly hospitalized patients with sepsis. METHODS From the 2009-2011 National Hospital Discharge Database we identified hospitalizations in adults aged ≥65 years. Using ICD9-CM codes, we selected sepsis cases, divided them into two cohorts (with and without dementia) and compared both groups with respect to organ dysfunction, in-hospital mortality and the use of hospital resources. We estimated the impact of dementia on these primary endpoints through multivariate regression models. RESULTS Of the 148 293 episodes of sepsis identified, 16 829 (11.3%) had diagnoses of dementia. Compared to their dementia-free counterparts, they were more predominantly female and older, had a lower burden of comorbidities and were more frequently admitted due to a principal diagnosis of sepsis. The dementia cohort showed a lower risk of organ dysfunction (adjusted OR: 0.84, 95% Confidence Interval [CI]: 0.81, 0.87) but higher in-hospital mortality (adjusted OR: 1.32, 95% [CI]: 1.27, 1.37). The impact of dementia on mortality was higher in the cases of younger age, without comorbidities and without organ dysfunction. The cases with dementia also had a lower length of stay (-3.87 days, 95% [CI]: -4.21, -3.54) and lower mean hospital costs (-3040€, 95% [CI]: -3279, -2800). CONCLUSIONS This nationwide population-based study shows that dementia is present in a substantial proportion of adults ≥65s hospitalized with sepsis, and while the condition does seem to come with a lower risk of organ dysfunction, it exerts a negative influence on in-hospital mortality and acts as an independent mortality predictor. Furthermore, it is significantly associated with shorter length of stay and lower hospital costs.
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Affiliation(s)
- Carmen Bouza
- Health Technology Assessment Agency, Carlos III Health Institute, Madrid, Spain
- * E-mail:
| | - Gonzalo Martínez-Alés
- Department of Psychiatry, La Paz University Hospital, Madrid, Spain
- School of Medicine, Autonomous University of Madrid, Madrid, Spain
| | - Teresa López-Cuadrado
- School of Medicine, Autonomous University of Madrid, Madrid, Spain
- National Epidemiology Centre, Carlos III Health Institute, Madrid, Spain
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196
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Hospitalization, surgery, and incident dementia. Alzheimers Dement 2019; 15:534-542. [PMID: 30777379 DOI: 10.1016/j.jalz.2018.12.005] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2018] [Revised: 10/15/2018] [Accepted: 12/03/2018] [Indexed: 11/20/2022]
Abstract
INTRODUCTION We evaluated whether hospitalization with or without surgery increases risk for dementia or Alzheimer's disease. METHODS A clinical sample (843 clinically diagnosed dementia cases; 1686 matched nondemented individuals) was identified from Swedish Twin Registry studies. A register-based sample (4293 cases; 21,465 matched controls) was identified by linkage of Swedish Twin Registry to Swedish Patient Registry records. Apolipoprotein E (APOE) status and within-pair comparisons of dementia discordant twins indicated genetic susceptibility. RESULTS Nonsurgical hospitalization is associated with greater dementia risk than hospitalization with surgical intervention. In the register sample, thoracic, abdominal, and major orthopedic procedures entailed dementia risk; in the clinical sample, orthopedic alone. Within-pair analyses indicate that associations in part reflect genetic susceptibility in common to hospitalization and dementia. Potential gene-environment interactions were indicated by greater risk due to hospitalization among APOE ε4 noncarriers. DISCUSSION We confirm hospitalization as a risk factor for dementia, with repeated hospitalizations a more important risk factor than surgery.
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197
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Möllers T, Perna L, Ihle P, Schubert I, Bauer J, Brenner H. Factors Associated with Length of Stay in Hospital Patients with and Without Dementia. J Alzheimers Dis 2019; 67:1055-1065. [DOI: 10.3233/jad-180593] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Affiliation(s)
- Tobias Möllers
- Network Aging Research, University of Heidelberg, Heidelberg, Baden-Wuerttemberg, Germany
- Division of Clinical Epidemiology and Aging Research, German Cancer Research Center, Heidelberg, Baden-Wuerttemberg, Germany
- Medical Faculty, University of Heidelberg, Baden-Wuerttemberg, Germany
| | - Laura Perna
- Division of Clinical Epidemiology and Aging Research, German Cancer Research Center, Heidelberg, Baden-Wuerttemberg, Germany
| | - Peter Ihle
- PMV Research Group, Department of Child and Adolescent Psychiatry, University of Cologne, Cologne, North Rhine-Westphalia, Germany
| | - Ingrid Schubert
- PMV Research Group, Department of Child and Adolescent Psychiatry, University of Cologne, Cologne, North Rhine-Westphalia, Germany
| | - Jürgen Bauer
- Network Aging Research, University of Heidelberg, Heidelberg, Baden-Wuerttemberg, Germany
- Center for Geriatric Medicine, University of Heidelberg, Agaplesion Bethanien Krankenhaus Heidelberg, Baden-Wuerttemberg, Germany
| | - Hermann Brenner
- Network Aging Research, University of Heidelberg, Heidelberg, Baden-Wuerttemberg, Germany
- Division of Clinical Epidemiology and Aging Research, German Cancer Research Center, Heidelberg, Baden-Wuerttemberg, Germany
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Bott NT, Sheckter CC, Yang D, Peters S, Brady B, Plowman S, Borson S, Leff B, Kaplan RM, Platchek T, Milstein A. Systems Delivery Innovation for Alzheimer Disease. Am J Geriatr Psychiatry 2019; 27:149-161. [PMID: 30477913 PMCID: PMC6331256 DOI: 10.1016/j.jagp.2018.09.015] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2018] [Revised: 09/22/2018] [Accepted: 09/24/2018] [Indexed: 12/20/2022]
Abstract
OBJECTIVE The authors describe a comprehensive care model for Alzheimer disease (AD) that improves value within 1-3 years after implementation by leveraging targeted outpatient chronic care management, cognitively protective acute care, and timely caregiver support. METHODS Using current best evidence, expert opinion, and macroeconomic modeling, the authors designed a comprehensive care model for AD that improves the quality of care while reducing total per capita healthcare spending by more than 15%. Cost savings were measured as reduced spending by payers. Cost estimates were derived from medical literature and national databases, including both public and private U.S. payers. All estimates reflect the value in 2015 dollars using a consumer price index inflation calculator. Outcome estimates were determined at year 2, accounting for implementation and steady-state intervention costs. RESULTS After accounting for implementation and recurring operating costs of approximately $9.5 billion, estimated net cost savings of between $13 and $41 billion can be accomplished concurrently with improvements in quality and experience of coordinated chronic care ($0.01-$6.8 billion), cognitively protective acute care ($8.7-$26.6 billion), timely caregiver support ($4.3-$7.5 billion), and caregiver efficiency ($4.1-$7.2 billion). CONCLUSION A high-value care model for AD may improve the experience of patients with AD while significantly lowering costs.
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Affiliation(s)
- Nicholas T Bott
- Clinical Excellence Research Center (NTB, CCS, DY, SP, BB, SP, RMK, TP, AM), Stanford University School of Medicine, Stanford University, Stanford, CA.
| | - Clifford C Sheckter
- Clinical Excellence Research Center (NTB, CCS, DY, SP, BB, SP, RMK, TP, AM), Stanford University School of Medicine, Stanford University, Stanford, CA
| | - Daniel Yang
- Clinical Excellence Research Center (NTB, CCS, DY, SP, BB, SP, RMK, TP, AM), Stanford University School of Medicine, Stanford University, Stanford, CA
| | - Stephanie Peters
- Clinical Excellence Research Center (NTB, CCS, DY, SP, BB, SP, RMK, TP, AM), Stanford University School of Medicine, Stanford University, Stanford, CA
| | - Brian Brady
- Clinical Excellence Research Center (NTB, CCS, DY, SP, BB, SP, RMK, TP, AM), Stanford University School of Medicine, Stanford University, Stanford, CA
| | - Scooter Plowman
- Clinical Excellence Research Center (NTB, CCS, DY, SP, BB, SP, RMK, TP, AM), Stanford University School of Medicine, Stanford University, Stanford, CA
| | - Soo Borson
- the Department of Psychiatry and Behavioral Sciences (SB), University of Washington, Seattle; the Department of Neurology (SB), University of Minnesota, Minneapolis
| | - Bruce Leff
- Center for Transformative Geriatric Research (BL), Division of Geriatric Medicine and Gerontology, Johns Hopkins University School of Medicine, Baltimore
| | - Robert M Kaplan
- Clinical Excellence Research Center (NTB, CCS, DY, SP, BB, SP, RMK, TP, AM), Stanford University School of Medicine, Stanford University, Stanford, CA
| | - Terry Platchek
- Clinical Excellence Research Center (NTB, CCS, DY, SP, BB, SP, RMK, TP, AM), Stanford University School of Medicine, Stanford University, Stanford, CA
| | - Arnold Milstein
- Clinical Excellence Research Center (NTB, CCS, DY, SP, BB, SP, RMK, TP, AM), Stanford University School of Medicine, Stanford University, Stanford, CA
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Jennings LA, Laffan AM, Schlissel AC, Colligan E, Tan Z, Wenger NS, Reuben DB. Health Care Utilization and Cost Outcomes of a Comprehensive Dementia Care Program for Medicare Beneficiaries. JAMA Intern Med 2019; 179:161-166. [PMID: 30575846 PMCID: PMC6439653 DOI: 10.1001/jamainternmed.2018.5579] [Citation(s) in RCA: 68] [Impact Index Per Article: 13.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
IMPORTANCE An estimated 4 to 5 million Americans have Alzheimer disease or another dementia. OBJECTIVE To determine the health care utilization and cost outcomes of a comprehensive dementia care program for Medicare fee-for-service beneficiaries. DESIGN, SETTING, AND PARTICIPANTS In this case-control study, we used a quasiexperimental design to compare health care utilization and costs for 1083 Medicare fee-for-service beneficiaries enrolled in the University of California Los Angeles Health System Alzheimer and Dementia Care program between July 1, 2012, and December 31, 2015, with those of 2166 similar patients with dementia not participating in the program. Patients in the comparison cohort were selected using the zip code of residence as a sampling frame and matched with propensity scores, which included demographic characteristics, comorbidities, and prior-year health care utilization. We used Medicare claims data to compare utilization and cost outcomes for the 2 groups. INTERVENTIONS Patients in the dementia care program were comanaged by nurse practitioners and physicians, and the program consisted of structured needs assessments of patients and their caregivers, creation and implementation of individualized dementia care plans with input from primary care physicians, monitoring and revising care plans, referral to community organizations for dementia-related services and support, and access to a clinician for assistance and advice 24 hours per day, 7 days per week. MAIN OUTCOMES AND MEASURES Admissions to long-term care facilities; average difference-in-differences per quarter over the 3-year intervention period for all-cause hospitalization, emergency department visits, 30-day hospital readmissions, and total Medicare Parts A and B costs of care. Program costs were included in the cost estimates. RESULTS Program participants (n = 382 men, n = 701 women; mean [SD] age, 82.10 [7.90] years; age range 54-101 years) were less likely to be admitted to a long-term care facility (hazard ratio, 0.60; 95% CI, 0.59-0.61) than those not participating in the dementia care program (n = 759 men, n = 1407 women; mean [SD] age, 82.42 [8.50] years; age range, 34-103 years). There were no differences between groups in terms of hospitalizations, emergency department visits, or 30-day readmissions. The total cost of care to Medicare, excluding program costs, was $601 less per patient per quarter (95% CI, -$1198 to -$5). After accounting for the estimated program costs of $317 per patient per quarter, the program was cost neutral for Medicare, with an estimated net cost of -$284 (95% CI, -$881 to $312) per program participant per quarter. CONCLUSIONS AND RELEVANCE Comprehensive dementia care may reduce the number of admissions to long-term care facilities, and depending on program costs, may be cost neutral or cost saving. Wider implementation of such programs may help people with dementia stay in their communities.
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Affiliation(s)
- Lee A Jennings
- Reynolds Department of Geriatric Medicine at the University of Oklahoma Health Sciences Center, Oklahoma City
| | | | | | - Erin Colligan
- Centers for Medicare & Medicaid Services, Center for Medicare and Medicaid Innovation, Baltimore, Maryland
| | - Zaldy Tan
- Multicampus Program in Geriatric Medicine and Gerontology, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles
| | - Neil S Wenger
- Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles
| | - David B Reuben
- Multicampus Program in Geriatric Medicine and Gerontology, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles
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Yaffe K, Lwi SJ, Hoang TD, Xia F, Barnes DE, Maguen S, Peltz CB. Military-related risk factors in female veterans and risk of dementia. Neurology 2019; 92:e205-e211. [PMID: 30541865 PMCID: PMC6340384 DOI: 10.1212/wnl.0000000000006778] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2018] [Accepted: 08/31/2018] [Indexed: 12/19/2022] Open
Abstract
OBJECTIVE To determine whether diagnoses of traumatic brain injury (TBI), posttraumatic stress disorder (PTSD), and depression, alone or in combination, increase dementia risk among older female veterans. METHODS This cohort study included data from 109,140 female veterans ≥55 years of age receiving care from Veterans Health Administration medical centers in the United States between October 2004 and September 2015 with at least 1 follow-up visit. TBI, PTSD, depression, and medical conditions at study baseline and incident dementia were determined according to ICD-9-CM codes. Fine-Gray proportional hazards models were used to determine the association between military-related risk factors and dementia diagnosis, accounting for the competing risk of death. RESULTS During follow-up (mean 4.0 years, SD 2.3), 4% of female veterans (n = 4,125) developed dementia. After adjustment for demographics and medical conditions, women with TBI, PTSD, and depression had a significant increase in risk of developing dementia compared to women without these diagnoses (TBI-adjusted subdistribution hazard ratio [adjusted sHR] 1.49, 95% confidence interval [CI] 1.01-2.20; PTSD adjusted sHR 1.78, 95% CI 1.34-2.36; and depression-adjusted sHR 1.67, 95% CI 1.55-1.80), while women with >1 diagnosis had the highest risk for dementia (adjusted sHR 2.15, 95% CI 1.84-2.51). CONCLUSIONS We found that women with military-related risk factors had an ≈50% to 80% increase in developing dementia relative to women without these diagnoses, while female veterans with multiple risk factors had a >2-fold risk of developing dementia. These findings highlight the need for increased screening of TBI, PTSD, and depression in older women, especially female veterans.
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Affiliation(s)
- Kristine Yaffe
- From the San Francisco Veterans Affairs Health Care System (K.Y., S.J.L., T.D.H., F.X., D.E.B., S.M., C.B.P.); and Departments of Psychiatry (K.Y., D.E.B., S.M.), Neurology (K.Y.), and Epidemiology & Biostatistics (K.Y.), University of California, San Francisco.
| | - Sandy J Lwi
- From the San Francisco Veterans Affairs Health Care System (K.Y., S.J.L., T.D.H., F.X., D.E.B., S.M., C.B.P.); and Departments of Psychiatry (K.Y., D.E.B., S.M.), Neurology (K.Y.), and Epidemiology & Biostatistics (K.Y.), University of California, San Francisco
| | - Tina D Hoang
- From the San Francisco Veterans Affairs Health Care System (K.Y., S.J.L., T.D.H., F.X., D.E.B., S.M., C.B.P.); and Departments of Psychiatry (K.Y., D.E.B., S.M.), Neurology (K.Y.), and Epidemiology & Biostatistics (K.Y.), University of California, San Francisco
| | - Feng Xia
- From the San Francisco Veterans Affairs Health Care System (K.Y., S.J.L., T.D.H., F.X., D.E.B., S.M., C.B.P.); and Departments of Psychiatry (K.Y., D.E.B., S.M.), Neurology (K.Y.), and Epidemiology & Biostatistics (K.Y.), University of California, San Francisco
| | - Deborah E Barnes
- From the San Francisco Veterans Affairs Health Care System (K.Y., S.J.L., T.D.H., F.X., D.E.B., S.M., C.B.P.); and Departments of Psychiatry (K.Y., D.E.B., S.M.), Neurology (K.Y.), and Epidemiology & Biostatistics (K.Y.), University of California, San Francisco
| | - Shira Maguen
- From the San Francisco Veterans Affairs Health Care System (K.Y., S.J.L., T.D.H., F.X., D.E.B., S.M., C.B.P.); and Departments of Psychiatry (K.Y., D.E.B., S.M.), Neurology (K.Y.), and Epidemiology & Biostatistics (K.Y.), University of California, San Francisco
| | - Carrie B Peltz
- From the San Francisco Veterans Affairs Health Care System (K.Y., S.J.L., T.D.H., F.X., D.E.B., S.M., C.B.P.); and Departments of Psychiatry (K.Y., D.E.B., S.M.), Neurology (K.Y.), and Epidemiology & Biostatistics (K.Y.), University of California, San Francisco
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