Underdiagnosis of Dementia: an Observational Study of Patterns in Diagnosis and Awareness in US Older Adults

Service providers' use of harm reduction approaches in working with older adults experiencing abuse: a qualitative study

BACKGROUND

Although abuse experienced by older adults is common and expected to increase, disclosure, reporting and interventions to prevent or mitigate abuse remain sub-optimal. Incorporating principles of harm reduction into service provision has been advocated as a strategy that may improve outcomes for this population. This paper explores whether and how these principles of harm reduction were employed by professionals who provide services to older adults experiencing abuse.

METHODS

Thematic analysis of qualitative interviews with 23 professionals providing services to older adults experiencing abuse across three Western provinces of Canada was conducted. Key principles of harm reduction (humanism, incrementalism, individualism, pragmatism, autonomy, and accountability without termination) were used as a framework for organizing the themes.

RESULTS

Our analysis illustrated a clear congruence between each of the six harm reduction principles and the approaches reflected in the narratives of professionals who provided services to this population, although these were not explicitly articulated as harm reduction by participants. Each of the harm reduction principles was evident in service providers' description of their professional practice with abused older adults, although some principles were emphasized differentially at different phases of the disclosure and intervention process. Enactment of a humanistic approach formed the basis of the therapeutic client-provider relationships with abused older adults, with incremental, individual, and pragmatic principles also apparent in the discourse of participants. While respect for the older adult's autonomy figured prominently in the data, concerns about the welfare of the older adults with questionable capacity were expressed when they did not engage with services or chose to return to a high-risk environment. Accountability without termination of the client-provider relationship was reflected in continuation of support regardless of the decisions made by the older adult experiencing abuse.

CONCLUSIONS

Harm reduction approaches are evident in service providers' accounts of working with older adults experiencing abuse. While further refinement of the operational definitions of harm reduction principles specific to their application with older adults is still required, this harm reduction framework aligns well with both the ethical imperatives and the practical realities of supporting older adults experiencing abuse.

Building a National Program for Pilot Studies of Embedded Pragmatic Clinical Trials in Dementia Care

Sixteen million caregivers currently provide care to more than 5 million persons living with dementia (PLWD) in the United States. Although this population is growing and highly complex, evidence-based management remains poorly integrated within healthcare systems. Therefore, the National Institute on Aging IMPACT Collaboratory was formed to build the nation's ability to conduct embedded pragmatic clinical trials (ePCTs) for PLWD and their caregivers. The pilot core of the IMPACT Collaboratory seeks to provide funds for upward of 40 pilots for ePCTs to accelerate the testing of nonpharmacologic interventions with the goal that these pilots lead to full-scale ePCTs and eventually the embedding of evidence-based care into healthcare systems. The first two challenges for the pilot core in building the pilot study program were (1) to develop a transparent, ethical, and open nationwide process for soliciting, reviewing, and selecting pilot studies; and (2) to begin the process of describing the necessary components of a pilot study for an ePCT. During our initial funding cycle, we received 35 letters of intent, of which 17 were accepted for a full proposal and 14 were submitted. From this process we learned that investigators lack knowledge in ePCTs, many interventions lack readiness for an ePCT pilot study, and many proposed studies lack key pragmatic design elements. We therefore have set three key criteria that future pilot studies must meet at a minimum to be considered viable. We additionally discuss key design decisions investigators should consider in designing a pilot study for an ePCT. J Am Geriatr Soc 68:S14-S20, 2020.

Polypharmacy among older adults with dementia compared with those without dementia in the United States

BACKGROUND/OBJECTIVES

In older persons with dementia (PWD), extensive medication use is often unnecessary, discordant with goals of care, and possibly harmful. The objective of this study was to determine the prevalence and medication constituents of polypharmacy among older PWD attending outpatient visits in the United States.

DESIGN

Cross-sectional analysis.

SETTING AND PARTICIPANTS

PWD and persons without dementia (PWOD) aged ≥65 years attending outpatient visits recorded in the nationally representative National Ambulatory Medical Care Survey (NAMCS), 2014-2016.

MEASUREMENTS

PWD were identified as those with a diagnosis of dementia on the NAMCS encounter form and/or those receiving an anti-dementia medication. Visits with PWD and PWOD were compared in terms of sociodemographic, practice/physician factors, comorbidities, and prescribing outcomes. Regression analyses examined the effect of dementia diagnosis on contributions by clinically relevant medication categories to polypharmacy (defined as being prescribed ≥5 prescription and/or nonprescription medications).

RESULTS

The unweighted sample involved 918 visits for PWD and 26,543 visits for PWOD, representing 29.0 and 780 million outpatient visits. PWD had a median age of 81 and on average had 2.8 comorbidities other than dementia; 63% were female. The median number of medications in PWD was eight compared with three in PWOD (p < 0.001). After adjustment, PWD had significantly higher odds of being prescribed ≥5 medications (AOR 3.0; 95% CI: 2.1-4.3) or ≥10 medications (AOR 2.8; 95% CI: 2.0-4.2) compared with PWOD. The largest sources of medications among PWD were cardiovascular and central nervous system medications; usage from other categories was generally elevated in PWD compared with PWOD. PWD had higher odds of receiving at least one highly sedating or anticholinergic medication (AOR 2.5; 95% CI: 1.6-3.9).

CONCLUSION

In a representative sample of outpatient visits, polypharmacy was extremely common among PWD, driven by a wide array of medication categories. Addressing polypharmacy in PWD will require cross-cutting and multidisciplinary approaches.

Traumatic Spinal Cord Injury and Risk of Early and Late Onset Alzheimer's Disease and Related Dementia: Large Longitudinal Study

OBJECTIVE

Traumatic spinal cord injury (TSCI) is a life altering event most often causing permanent physical disability. Little is known about the risk of developing Alzheimer disease and related dementia (ADRD) among middle-aged and older adults living with TSCI. Time to diagnosis of and adjusted hazard for ADRD was assessed.

DESIGN

Cohort study.

SETTING

Using 2007-2017 claims data from the Optum Clinformatics Data Mart, we identified adults (45+) with diagnosis of TSCI (n=7019). Adults without TSCI diagnosis were included as comparators (n=916,516). Using age, sex, race/ethnicity, cardiometabolic, psychological, and musculoskeletal chronic conditions, US Census division, and socioeconomic variables, we propensity score matched persons with and without TSCI (n=6083). Incidence estimates of ADRD were compared at 4 years of enrollment. Survival models were used to quantify unadjusted, fully adjusted, and propensity-matched unadjusted and adjusted hazard ratios (HRs) for incident ADRD.

PARTICIPANTS

Adults with and without TSCI (N=6083).

INTERVENTION

Not applicable.

MAIN OUTCOMES MEASURES

Diagnosis of ADRD.

RESULTS

Both middle-aged and older adults with TSCI had higher incident ADRD compared to those without TSCI (0.5% vs 0.2% and 11.7% vs 3.3% among 45-64 and 65+ y old unmatched cohorts, respectively) (0.5% vs 0.3% and 10.6% vs 6.2% among 45-64 and 65+ y old matched cohorts, respectively). Fully adjusted survival models indicated that adults with TSCI had a greater hazard for ADRD (among 45-64y old: unmatched HR: 3.19 [95% confidence interval, 95% CI, 2.30-4.44], matched HR: 1.93 [95% CI, 1.06-3.51]; among 65+ years old: unmatched HR: 1.90 [95% CI, 1.77-2.04], matched HR: 1.77 [1.55-2.02]).

CONCLUSIONS

Adults with TSCI are at a heightened risk for ADRD. Improved clinical screening and early interventions aiming to preserve cognitive function are of paramount importance for this patient cohort.

Memory care approaches to better leverage capacity of dementia specialists: a narrative synthesis

Prior research suggests that a scarcity of dementia specialists could hamper access to disease-modifying Alzheimer's treatments. We describe alternative approaches on how to leverage specialist time for memory care in this narrative synthesis based on 17 semi-structured interviews and a targeted literature review on memory care approaches that leverage specialist time. We identified four types of approaches: community primary care practices empowered with better tools and training; primary care memory clinics; specialty memory clinics and; specialty memory centers. Several approaches to use specialist time efficiently have been implemented and some but not all evaluated. The optimal approach may depend on the local context.

Blood biomarkers for dementia in Hispanic and non-Hispanic White adults

INTRODUCTION

The study evaluated if blood markers reflecting diverse biological pathways differentiate clinical diagnostic groups among Hispanic and non-Hispanic White adults.

METHODS

Within Hispanic (n = 1193) and non-Hispanic White (n = 650) participants, serum total tau (t-tau), neurofilament light (NfL), ubiquitin carboxyl-terminal hydrolase LI, glial fibrillary acidic protein (GFAP), soluble cluster of differentiation-14, and chitinase-3-like protein 1 (YKL-40) were quantified. Mixed-effects partial proportional odds ordinal logistic regression and linear mixed-effects models were used to evaluate the association of biomarkers with diagnostic group and cognition, adjusting for age, sex, ethnicity, apolipoprotein E ε4, education, and site.

RESULTS

T-tau, NfL, GFAP, and YKL-40 discriminated between diagnostic groups (receiver operating curve: 0.647-0.873). Higher t-tau (odds ratio [OR] = 1.671, 95% confidence interval [CI] = 1.457-1.917, P < .001), NfL (OR = 2.150, 95% CI = 1.819-2.542, P < .001), GFAP (OR = 2.283, 95% CI = 1.915-2.722, P < .001), and YKL-40 (OR = 1.288, 95% CI = 1.125-1.475, P < .001) were associated with increased likelihood of dementia relative to cognitively unimpaired and mild cognitive impairment groups. Higher NfL was associated with poorer global cognition (β = -0.455, standard error [SE] = 0.083, P < .001), semantic fluency (β = -0.410, SE = 0.133, P = .002), attention/processing speed (β = 2.880, SE = 0.801, P < .001), and executive function (β = 5.965, SE = 2.037, P = .003). Higher GFAP was associated with poorer global cognition (β = -0.345, SE = 0.092, P = .001), learning (β = -1.426, SE = 0.359, P < .001), and memory (β = -0.890, SE = 0.266, P < .001). Higher YKL-40 (β = -0.537, SE = 0.186, P = .004) was associated with lower memory scores. Interactions with ethnicity were observed for learning (NfL, GFAP, YKL-40), memory (NfL, GFAP), and semantic fluency (NfL; interaction terms P < .008), which were generally no longer significant in a demographically matched subset of Hispanic and non-Hispanic White participants.

DISCUSSION

Blood biomarkers of neuronal/axonal and glial injury differentiated between clinical diagnostic groups in a bi-ethnic cohort of Hispanic and non-Hispanic Whites. Our results add to the growing literature indicating that blood biomarkers may be viable tools for detecting neurodegenerative conditions and highlight the importance of validation in diverse cohorts.

Clustering 5-Year Multidimensional Health Care Trajectory Patterns in Alzheimer's Disease and Related Syndromes

OBJECTIVE

After diagnosis of Alzheimer's disease and related syndromes (ADRS), personalized care adapted to each patient's needs is recommended to provide a care plan and start symptomatic treatments according to guidelines. Over the past decade, dedicated structures and care have been implemented in various settings. Equal access to ADRS care, health care providers and services is crucial to ensure potential health benefits for everyone. However, the extent of use of recommended services and favorable health care utilization trajectories (HUT) may vary according to individual and contextual characteristics. The aim of this article was to (1) describe HUT patterns after multidimensional clustering of similar trajectories, (2) assess the proportion of individuals presenting favorable HUTs, and (3) identify factors associated with favorable HUTs.

DESIGN

Cohort study.

SETTING AND PARTICIPANTS

A cohort of 103,317 people newly diagnosed with ADRS identified in the French health reimbursement system (SNDS) was followed for 5 years with their monthly utilization on 11 health care dimensions.

METHODS

For 3 age groups (65-74, 75-84, ≥85 years), 15 clusters of patients were identified using partitioning around medoids applied to Levenshtein distances. They were qualitatively assessed by pluridisciplinary experts. Individual and contextual determinants of clusters denoting favorable trajectories were identified using mixed random effects multivariable logistic regression models.

RESULTS

Clusters with favorable HUTs denoting slow, progressive trajectories centered on at-home care, represented approximatively 25% of the patients. Determinants of favorable HUTs were mostly individual (age, female gender, absence of certain comorbidities, circumstances of ADRS identification, lower deprivation). Contextual determinants were also identified, in particular accessibility to nurses and nursing homes. Inter-territories variance was small but significant in all age groups (from 0.9% to 1.8%).

CONCLUSION AND IMPLICATIONS

Favorable HUTs remain the minority and many efforts can still be made to improve HUTs. Qualitative studies could help understanding underlying barriers to favorable HUTs.

Cognitive measures lacking in EHR prior to dementia or Alzheimer's disease diagnosis

Introduction

The extent that cognitive measures are documented in electronic health records (EHR) is important for quality care and addressing disparities in timely diagnosis of dementia or Alzheimer's disease (AD).

Methods

Analysis of U.S. EHR data to describe the frequency and factors associated with cognitive measures prior to diagnosis of dementia (N = 111,125) or AD (N = 30,203).

Results

Only 11% of dementia patients and 24% of AD patients had a cognitive measure documented in the 5 years prior to diagnosis. Black race, older age, non‐commercial health insurance, lower mean neighborhood income, greater in‐patient stays, and fewer out‐patient visits were associated with lacking cognitive measures.

Discussion

Extensive missing cognitive data and differences in the availability of cognitive measures by race, age, and socioeconomic factors hinder patient care and limit utility of EHR for dementia research. Structured fields and prompts for cognitive data inputs at the point of care may help address these gaps.

Detecting dementia among older, ethnically diverse residents of rural subsidized housing

Rural, ethnically diverse residents face at least twice the risk of Alzheimer's disease than urban residents. Chronic diseases such as diabetes and hypertension which increase dementia risk are more prevalent in rural areas with less access to specialty providers. A home-based approach for increasing dementia detection and treatment rates was tested among rural residents of government-assisted independent living facilities (N = 139; 78% non-White, and 70% with health literacy below 5th grade). Of 28 residents identified at risk during cognitive screening, 25 agreed to further in-depth assessment by adult gerontological nurse practitioners (AGNP). Fifteen of 25 (60%) completing consequent primary provider referrals were diagnosed with dementia and receiving new care (statistically significant; [χ2(1) = 76.67, p < .001, Phi = 0.743]). Home-based dementia management through a community engagement approach can help to meet the Healthy People 2030 goals of earlier detection and treatment and reduce the length of costly institutionalizations.

Burden of illness among patients with dementia-related psychosis

BACKGROUND: More than 5.6 million Americans suffer from dementia, and that number is expected to double by 2060. This comes at a considerable burden to the health care system with costs estimated at $157-$215 billion in 2010. Depending on dementia type and disease progression, approximately 20%-70% of patients experience dementia-related psychosis (DRP), characterized by hallucinations and/or delusions resulting in worse clinical outcomes and greater caregiver burden compared with patients without DRP. OBJECTIVE: To compare real-world clinical events, health care resource utilization (HCRU), and health care costs among matched cohorts of DRP versus dementia-only patients. METHODS: This retrospective database analysis examined commercial and Medicare Advantage with Part D enrollees aged ≥ 40 years with evidence of DRP and dementia from January 1, 2010, through March 31, 2017. The first observed indicator of psychosis (≥ 2 diagnoses and/or antipsychotic pharmacy fills) co-occurring with or following evidence of dementia (≥ 2 diagnoses and/or dementia medication pharmacy fills) was the index date among patients with DRP. DRP patients were propensity score matched 1:1 to patients with dementia only based on demographics, comorbidities, dementia type, dementia severity, and pre-index all-cause HCRU. Continuous health plan enrollment ≥ 12 months before evidence of dementia through the index date and ≥ 12 months following the index date was required. Outcomes included clinical events, HCRU, and health care costs. RESULTS: A significantly higher percentage of DRP patients had ≥1 diagnosis for behavioral health conditions in the pre-index period compared with dementia-only patients (depression: 32.4% vs. 22.8%; anxiety: 19.1% vs. 11.5%; and insomnia: 9.0% vs. 6.3%; P < 0.001 for all comparisons). Diagnoses of post-index clinical events were significantly more likely among DRP patients compared with dementia-only patients including falls/fractures (28.3% vs. 14.1%), neurologic effects (17.7% vs. 12.9%), sedation (15.0% vs. 2.4%), cardiovascular effects (7.0% vs. 4.1%), and extrapyramidal reactions (3.2% vs. 1.7%; P < 0.001 for all comparisons). Higher percentages of DRP patients had an all-cause outpatient visit (80.2% vs. 68.9%), emergency visit (65.0% vs. 36.6%), or inpatient stay (47.2% vs. 20.0%) during the post-index period (P < 0.001 for all comparisons). The proportions of DRP patients with a post-index dementia-related office visit, outpatient visit, emergency visit, or inpatient stay was 48%, 147%, 339%, and 286% higher, respectively, compared with patients with dementia only. Compared with patients with dementia only, patients with DRP had significantly higher mean total post-index all-cause costs ($21,657 vs. $12,026; P < 0.001) and dementia-related costs ($11,852 vs. $3,013; P < 0.001). CONCLUSIONS: Patients with DRP were more likely to have diagnoses for behavioral health conditions, experience clinical events, and have higher mean all-cause and dementia-related HCRU and costs compared with patients with dementia only. These results reflect the unmet need of patients with DRP and an urgency for new treatment options to reduce substantial clinical and economic burden in this population. DISCLOSURES: This study was funded by Acadia Pharmaceuticals, which participated in the study design, interpretation of study results, and critical review of the manuscript. Abler, Skoog, and Rashid were employees of Acadia Pharmaceuticals at the time this study was conducted. Frazer and Halpern were employees of Optum at the time this study was conducted and were funded by Acadia Pharmaceuticals to conduct the study.

Decomposition of gender differences in cognitive functioning: National Survey of the Japanese elderly

Background

It is well known that females generally live longer than males, but women tend to suffer from more illnesses and limitations than men do, also for dementia. However, limited empirical evidence is available why this ‘male-female health-survival paradox’ is observed. This study aimed to investigate factors which account for gender differences in health, particularly cognitive functioning and decline among older adults.

Methods

Data were retrieved from the National Survey of the Japanese Elderly, which is a longitudinal survey of a nationwide representative sample of Japanese adults aged 60 or over. Gender differences in cognitive functioning and decline in three-year follow-ups were decomposed using Blinder–Oaxaca decomposition analysis, regarding demographic, socioeconomic, and health-related factors into the ‘explained’ component, by differences in individual attributes listed above, and the ‘unexplained’ component.

Results

Empirical analyses showed that women’s lower cognitive functioning was partly explained by the endowment effect. Moreover, a shorter duration of formal education and a larger proportion with their longest occupation being domestic worker accounted for steeper cognitive decline and more prevalent mild cognitive impairment in women than in men.

Conclusion

This empirical study suggested that gender differences in cognitive functioning and decline account for different individual attributes of social determinants among men and women. Particularly, men seem to be more engaged in activities which accumulate intellectual experiences through education and occupation, as suggested by the cognitive reserve hypothesis.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12877-020-01990-1.

Current State of Self-Administered Brief Computerized Cognitive Assessments for Detection of Cognitive Disorders in Older Adults: A Systematic Review

Early diagnosis of cognitive disorders in older adults is a major healthcare priority with benefits to patients, families, and health systems. Rapid advances in digital technology offer potential for developing innovative diagnostic pathways to support early diagnosis. Brief self-administered computerized cognitive tools in particular hold promise for clinical implementation by minimizing demands on staff time. In this study, we conducted a systematic review of self-administered computerized cognitive assessment measures designed for the detection of cognitive impairment in older adults. Studies were identified via a systematic search of published peer-reviewed literature across major scientific databases. All studies reporting on psychometric validation of brief (≤30 minutes) self-administered computerized measures for detection of MCI and all-cause dementia in older adults were included. Seventeen studies reporting on 10 cognitive tools met inclusion criteria and were subjected to systematic review. There was substantial variability in characteristics of validation samples and reliability and validity estimates. Only 2 measures evaluated feasibility and usability in the intended clinical settings. Similar to past reviews, we found variability across measures with regard to psychometric rigor and potential for widescale applicability in clinical settings. Despite the promise that self-administered cognitive tests hold for clinical implementation, important gaps in scientific rigor in development, validation, and feasibility studies of these measures remain. Developments in technology and biomarker studies provide potential avenues for future directions on the use of digital technology in clinical care.

Demographic, Health, and Exposure Risks Associated With Cognitive Loss, Alzheimer's Disease and Other Dementias in US Military Veterans

The US military veteran population receiving care through the Veterans Health Administration (VHA) is particularly susceptible to cognitive impairment and dementias such as Alzheimer's disease and related dementias due to demographic, clinical, and economic factors. In this report we summarize the prevalence of dementia among US veterans and risks associated with AD and related dementias. We discuss the likelihood that these risks may be increasing in those about to enter the age in which dementias are common. We propose that VHA, the largest integrated health care system in the US, has shown promise in managing health risks that impact dementia prevention and propose further system wide approaches to be assessed for effective dementia prevention and care delivery.

Cataract Surgery Complexity and Surgical Complication Rates Among Medicare Beneficiaries With and Without Dementia

PURPOSE

To evaluate cataract surgery complexity and complications among US Medicare beneficiaries with and without dementia.

DESIGN

Retrospective claims-based cohort study.

PARTICIPANTS

A 20% representative sample of Medicare beneficiaries, 2006-2015.

METHODS

Dementia was identified from diagnosis codes on or prior to each beneficiary's first-eye cataract surgery. For each surgery, we identified setting, routine vs complex coding, anesthesia provider type, duration, and any postoperative hospitalization. We evaluated 30- and 90-day complication rates-return to operating room, endophthalmitis, suprachoroidal hemorrhage, retinal detachment, retinal tear, macular edema, glaucoma, or choroidal detachment-and used adjusted regression models to evaluate likelihood of surgical characteristics and complications. Complication analyses were stratified by second-eye cataract surgery within 90 days postoperatively.

RESULTS

We identified 457,128 beneficiaries undergoing first-eye cataract surgery, 23,332 (5.1%) with dementia. None of the evaluated surgical complications were more likely in dementia-diagnosed beneficiaries. There was also no difference in likelihood of nonambulatory surgery center setting, anesthesiologist provider, or postoperative hospitalization. Dementia-diagnosed beneficiaries were more likely to have surgeries coded as complex (15.6% of cases vs 8.8%, P < .0001), and surgeries exceeding 30 minutes (OR = 1.21, 95% CI = 1.17-1.25).

CONCLUSIONS

Among US Medicare beneficiaries undergoing cataract surgery, those with dementia are more likely to have "complex" surgery" lasting more than 30 minutes. However, they do not have greater likelihood of surgical complications, higher-acuity setting, advanced anesthesia care, or postoperative hospitalization. This may be influenced by case selection and may suggest missed opportunities to improve vision. Future research is needed to identify dementia patients likely to benefit from cataract surgery.

Overcoming the COVID-19 Pandemic for Dementia Research: Engaging Rural, Older, Racially and Ethnically Diverse Church Attendees in Remote Recruitment, Intervention and Assessment

BACKGROUND

Access to cognitive screening in rural underserved communities is limited and was further diminished during the COVID-19 pandemic. We examined whether a telephone-based cognitive screening intervention would be effective in increasing ADRD knowledge, detecting the need for further cognitive evaluation, and making and tracking the results of referrals.

METHOD

Using a dependent t-test design, older, largely African American and Afro-Caribbean participants completed a brief educational intervention, pre/post AD knowledge measure, and cognitive screening.

RESULTS

Sixty of 85 eligible individuals consented. Seventy-percent of the sample self-reported as African American, Haitian Creole, or Hispanic, and 75% were female, with an average age of 70. AD knowledge pre-post scores improved significantly (t (49) = -3.4, p < .001). Of the 11 referred after positive cognitive screening, 72% completed follow-up with their provider. Five were newly diagnosed with dementia. Three reported no change in diagnosis or treatment. Ninety-percent consented to enrolling in a registry for future research.

CONCLUSION

Remote engagement is feasible for recruiting, educating, and conducting cognitive screening with rural older adults during a pandemic.

Assessing Dementia Prevalence in the Wisconsin Longitudinal Study: Cohort Profile, Protocol, and Preliminary Findings

BACKGROUND

There is growing consensus that non-genetic determinants of dementia can be linked to various risk- and resiliency-enhancing factors accumulating throughout the lifespan, including socioeconomic conditions, early life experiences, educational attainment, lifestyle behaviors, and physical/mental health. Yet, the causal impact of these diverse factors on dementia risk remain poorly understood due to few longitudinal studies prospectively characterizing these influences across the lifespan.

OBJECTIVE

The Initial Lifespan's Impact on Alzheimer's Disease and Related Dementia (ILIAD) study aims to characterize dementia prevalence in the Wisconsin Longitudinal Study (WLS), a 60-year longitudinal study documenting life course trajectories of educational, family, occupational, psychological, cognitive, and health measures.

METHODS

Participants are surveyed using the modified Telephone Interview for Cognitive Status (TICS-m) to identify dementia risk. Those scoring below cutoff undergo home-based neuropsychological, physical/neurological, and functional assessments. Dementia diagnosis is determined by consensus panel and merged with existing WLS data for combined analysis.

RESULTS

Preliminary findings demonstrate the initial success of the ILIAD protocol in detecting dementia prevalence in the WLS. Increasing age, hearing issues, lower IQ, male sex, APOE4 positivity, and a steeper annualized rate of memory decline assessed in the prior two study waves, all increased likelihood of falling below the TICS-m cutoff for dementia risk. TICS-m scores significantly correlated with standard neuropsychological performance and functional outcomes.

CONCLUSION

We provide an overview of the WLS study, describe existing key lifespan variables relevant to studies of dementia and cognitive aging, detail the current WLS-ILIAD study protocol, and provide a first glimpse of preliminary study findings.

SHARING Choices: A Pilot Study to Engage Family in Advance Care Planning of Older Adults With and Without Cognitive Impairment in the Primary Care Context

CONTEXT

Few advance care planning (ACP) interventions proactively engage family or address the needs of older adults with and without cognitive impairment in the primary care context.

OBJECTIVES

To pilot a multicomponent intervention involving: an introductory letter describing a new clinic initiative and inviting patients to complete a patient-family pre-visit agenda-setting checklist, share their electronic health information with family, and talk about their wishes for future care with a trained ACP facilitator (SHARING Choices).

METHODS

SHARING Choices was delivered to 40 patient-family dyads from 3 primary care clinics. Facilitators completed post-ACP reports. Patient and family participants completed baseline and 6-week surveys.

RESULTS

Patients were on average 75 years (range 65-90). Family were spouses (85.0%) or adult children (15.0%). At 6 weeks, nearly half of dyads participated in ACP conversations (n = 19) or used the agenda-setting checklist (n = 17), one-third (n = 13) registered family to access the patient's portal account, and most (n = 28) provided the primary care team with a new or previously completed advance directive. Of 12 patients who screened positive for cognitive impairment, 9 completed ACP conversations and 10 provided the clinic with an advance directive. ACP engagement, measured on a 4-point scale, was comparatively lower at baseline and 6 weeks among family (3.05 and 3.19) than patients (3.56 and 3.54). Patients remarked that SHARING Choices clarified communication and preferences while family reported a better understanding of their role in ACP and communication.

CONCLUSION

SHARING Choices was acceptable among older adults with and without cognitive impairment and may increase advance directive completion.

Personality and Dementia Risk in England and Australia

Evidence for the relation between personality and dementia risk comes mainly from American samples. We tested whether personality-dementia links extend to populations from England and Australia. Data from the English Longitudinal Study of Ageing (ELSA; N = 6,887; Follow-up mean: 5.64 years) and the Household, Income and Labour Dynamics in Australia (HILDA; N = 2,778; Follow-up mean: 10.96 years) were analyzed using Cox PH models. In both samples, higher neuroticism was associated with increased dementia risk. In ELSA, lower conscientiousness was related to increased risk. In HILDA, conscientiousness had a similar effect but did not reach statistical significance. The present work found a consistent association for neuroticism and suggests similar personality-dementia links across demographic groups and high-income countries.

Cognitively Impaired Older Persons' and Caregivers' Perspectives on Dementia-Specific Advance Care Planning

BACKGROUND/OBJECTIVES

Advance care planning (ACP) traditionally involves asking individuals about their treatment preferences during a brief period of incapacity near the end of life. Because dementia leads to prolonged incapacity, with many decisions arising before a terminal event, it has been suggested that dementia-specific ACP is necessary. We sought to elicit the perspectives of older adults with early cognitive impairment and their caregivers on traditional and dementia-specific ACP.

DESIGN

Qualitative study with separate focus groups for patients and caregivers.

SETTING

Memory disorder clinics.

PARTICIPANTS

Twenty eight persons aged 65+ with mild cognitive impairment or early dementia and 19 caregivers.

MEASUREMENTS

Understanding of dementia trajectory and types of planning done; how medical decisions would be made in the future; thoughts about these decisions.

RESULTS

No participants had engaged in any written form of dementia-specific planning. Barriers to dementia-specific ACP emerged, including lack of knowledge about the expected trajectory of dementia and potential medical decisions, the need to stay focused in the present because of fear of loss of self, disinterest in planning because the patient will not be aware of decisions, and the expectation that involved family members would take care of issues. Some patients had trouble engaging in the discussion. Patients had highly variable views on what the quality of their future life would be and on the leeway their surrogates should have in decision making.

CONCLUSIONS

Even among patients with early cognitive impairment seen in specialty clinics and their caregivers, most were unaware of the decisions they could face, and there were many barriers to planning for these decisions. These issues would likely be magnified in more representative populations, and highlight challenges to the use of dementia-specific advance directive documents.

Assessing the Attitudes of Greek Nurses Toward Computerized Dementia Screening

BACKGROUND

Despite the abundance of research on computerized dementia screening tests, the attitudes of hospital personnel toward this screening method have not been investigated.

OBJECTIVE

1) To conduct a confirmatory factor analysis of the first part of a two-part questionnaire about computerized dementia screening. 2) To assess the attitudes of Greek nurses toward computerized dementia screening. 3) To assess barriers to future implementation of computerized dementia screening in the Greek healthcare system, as reported by nurses.

METHODS

161 Greek nurses from two urban public general hospitals who participated in a dementia training program were recruited. They were asked to complete a two-part questionnaire about computerized dementia screening. The first part of the questionnaire assesses attitudes toward dementia screening while the second part of the questionnaire assesses barriers to its implementation.

RESULTS

Confirmatory factor analysis on the first part of the questionnaire suggested a two-factor structure (feasibility/acceptability). The total score of all items loading on each factor was calculated. For feasibility, scores ranged between 10 and 25 (M = 19.38, SD = 3.80). For acceptability, scores ranged between 6 and 20 (M = 15.27, SD = 2.76). The main barriers to implementation were cost of equipment, insufficient training, lack of a plan for the integration of computerized screening tests in the daily routine of the hospital and time needed for staff training.

CONCLUSION

The positive attitude of nurses supports the implementation of computerized dementia screening in public hospitals as long as identified barriers are addressed.

Dementia Diagnoses and Treatment in Geriatric Ward Patients: A Cross-Sectional Study in Poland

Purpose

The study aimed to determine the prevalence of dementia, its types, and treatment in geriatric ward patients.

Patients and Methods

A cross-sectional study of 406 patients (77.8% women, median age 82, IQR (77-86) years) who underwent a comprehensive geriatric assessment in one of the Polish hospitals between September 2014 and April 2015 was conducted.

Results

Dementia was diagnosed in 132 (32.5%) patients (46% mixed dementia; 32% Alzheimer's disease; 10%vascular dementia; 5% dementia in Parkinson's disease; 4% frontotemporal; 3% atypical parkinsonism). A total of 95 (72%) dementia cases were not detected before, and in the above half of these patients, it was not mentioned in the referral document. Only 33.3% of dementia patients were on cognitive enhancers (donepezil, rivastigmine, or memantine); 36.4% received antipsychotics, 45.5% received anti-depressants, 25.8% received nootropics, and 16.7% received anxiolytics/hypnotics.

Discussion

The results confirmed the high incidence of underdiagnoses and undertreatment of dementia in patients admitted to the geriatric ward. It is partly due to the lack of systematic cognitive assessment in primary care settings, although other factors can play a role.

Using Medicare claims in identifying Alzheimer's disease and related dementias

INTRODUCTION

This study develops a measure of Alzheimer's disease and related dementias (ADRD) using Medicare claims.

METHODS

Validation resembles the approach of the American Psychological Association, including (1) content validity, (2) construct validity, and (3) predictive validity.

RESULTS

We found that four items-a Medicare claim recording ADRD 1 year ago, 2 years ago, 3 years ago, and a total stay of 6 months in a nursing home-exhibit a pattern of association consistent with a single underlying ADRD construct, and presence of any two of these four items predict a direct measure of cognitive function and also future claims for ADRD.

DISCUSSION

Our four items are internally consistent with the measurement of a single quantity. The presence of any two items do a better job than a single claim when predicting both a direct measure of cognitive function and future ADRD claims.

[Diagnosis and treatment of vascular dementia]

Vascular dementias (VD, due to the various expressions of VD the plural form is used) are the second most common form of dementia after Alzheimer's dementia. These dementias play an important role especially in geriatric patients. They can occur due to acute events (e.g. stroke) and due to slowly progressive cerebrovascular damage. This article focuses on VD due to cortical and strategic infarcts, microangiopathic infarcts with lacunae as well as intracerebral bleeding. In addition to the clinical description and radiological findings, a special focus is on education, prevention and rehabilitation aspects.

Dementia and Falls Management in Underserved Populations: The Cognition and Mobility Care Management Program

BACKGROUND/OBJECTIVES

Cognitive and mobility impairments are common and underdiagnosed chronic conditions that afflict community-dwelling older adults. This study describes the organization, implementation, and evaluation of an intervention for underserved and ethnically diverse older patients with dementia and/or falls risk.

DESIGN

Observation, baseline and 1 year after intervention.

SETTING

Community-based primary care county clinics in inland southern California.

PARTICIPANTS

A total of 272 persons, aged 70 years and older, who screened positive for falls and/or dementia and enrolled in the Cognition and Mobility Care Management program during the study period.

INTERVENTION

A nurse care manager performed a patient and caregiver evaluation and created and implemented a care plan with medical, behavioral, and psychosocial interventions in partnership with patients and their primary care providers.

MEASUREMENTS

Process outcomes included rates of positive screening for dementia and fall risk, referral, enrollment, and visit completion. Patient outcomes included fall history, mobility and cognitive assessments, and depression scales. Patients and/or caregivers completed questionnaires rating perceived benefits of enrollment after 1 year in the program.

RESULTS

Medical assistants screened 573 patients aged 70 years and older during the study period; 78% screened positive for dementia and/or fall risk. Of the patients who screened positive, 94% were referred; 91% of contacted patients elected to enroll, and 272 patients completed an intake visit (mean_age = 77 years; 65% female; 75% Latino; 10% African American). The patients and caregivers who completed satisfaction questionnaires 1 year after enrollment rated the program highly, and 92% would recommend the program to others.

CONCLUSION

A primary care-based screening and comanagement program to identify and manage dementia and falls risk in primarily Latino and African American older adult patients living in an underserved area was well received, with high satisfaction and perceived benefit from patients and caregivers.

Pattern of treatment of behavioural and psychological symptoms of dementia and pain: evidence on pharmacoutilization from a large real-world sample and from a centre for cognitive disturbances and dementia

Purpose

Data concerning the number of diagnoses and of the drugs prescribed to patients affected by dementia are still scarce. Here we test whether or not (1) prescription of symptomatic drugs against Alzheimer’s disease (AD) may approximate the number of patients affected by dementia in Italy and (2) adherence to this treatment affects the pattern of prescription of drugs (i.e. antipsychotics and antidepressants) for behavioural and psychological symptoms of dementia (BPSD) and the previously reported limited prescription of analgesics.

Methods

This retrospective observational study concerns 84,235 subjects older than 60 years and registered in the provincial prescription database of the health district of Cosenza accounting for a population of 298,000 inhabitants. The prescribing pattern of antipsychotics, antidepressants, and analgesics has been investigated in patients receiving concurrent prescriptions of acetylcholinesterase inhibitors (AChEI) and/or memantine. Data from a single centre for cognitive disturbances and dementia (CDCD) in the same health district were used to explore at which stage dementia was diagnosed. The study was approved by Calabria Region Ethical Committee no. 31/2017 and registered on October 31, 2017.

Results

The data show that 859 patients are treated with AChEI and/or memantine; 420 patients (48.89%) receive at least 80% of the recommended medications. CDCD data indicate a delay in dementia diagnosis, which often was made when the patients were moderately to severely demented (Mini Mental State Examination, MMSE ≤ 20). Adherence did not influence prescription of most of the drugs explored, but use of non-steroidal anti-inflammatory drugs was higher in non-adherent patients. Antipsychotics and antidepressants are frequently used (20.61–20.71% and 42.37–51.43%, respectively), and this, at least in part, might stem from the observed under-treatment of chronic pain (opioids are prescribed in the 4.76% and 12.46% of adherent and non-adherent patients and gabapentin and pregabalin are used in the 4.29% and 4.07% of adherent and non-adherent patients respectively), resulting in more frequent BPSD. 16.43% of patients receive antipsychotics for longer than 6–12 weeks.

Conclusion

This 2-year period study, including a wide cohort of community demented patients, shows that dementia is diagnosed late and that prevalence of BPSD prescriptions is high and not impacted by adherence to anti-dementia drugs. The rate of prescription of potentially harmful antipsychotics and antidepressants appears to be high though whether the concomitantly observed limited prescription of analgesics might be a contributing factor needs to be further investigated. Our data support the development of strategies to improve the management of BPSD.

Association of Sleep Electroencephalography-Based Brain Age Index With Dementia

IMPORTANCE

Dementia is an increasing cause of disability and loss of independence in the elderly population yet remains largely underdiagnosed. A biomarker for dementia that can identify individuals with or at risk for developing dementia may help close this diagnostic gap.

OBJECTIVE

To investigate the association between a sleep electroencephalography-based brain age index (BAI), the difference between chronological age and brain age estimated using the sleep electroencephalogram, and dementia.

DESIGN, SETTING, AND PARTICIPANTS

In this retrospective cross-sectional study of 9834 polysomnograms, BAI was computed among individuals with previously determined dementia, mild cognitive impairment (MCI), or cognitive symptoms but no diagnosis of MCI or dementia, and among healthy individuals without dementia from August 22, 2008, to June 4, 2018. Data were analyzed from November 15, 2018, to June 24, 2020.

EXPOSURE

Dementia, MCI, and dementia-related symptoms, such as cognitive change and memory impairment.

MAIN OUTCOMES AND MEASURES

The outcome measures were the trend in BAI when moving from groups ranging from healthy, to symptomatic, to MCI, to dementia and pairwise comparisons of BAI among these groups.

FINDINGS

A total of 5144 sleep studies were included in BAI examinations. Patients in these studies had a median (interquartile range) age of 54 (43-65) years, and 3026 (59%) were men. The patients included 88 with dementia, 44 with MCI, 1075 who were symptomatic, and 2336 without dementia. There was a monotonic increase in mean (SE) BAI from the nondementia group to the dementia group (nondementia: 0.20 [0.42]; symptomatic: 0.58 [0.41]; MCI: 1.65 [1.20]; dementia: 4.18 [1.02]; P < .001).

CONCLUSIONS AND RELEVANCE

These findings suggest that a sleep-state electroencephalography-based BAI shows promise as a biomarker associated with progressive brain processes that ultimately result in dementia.

Using Dual Neural Network Architecture to Detect the Risk of Dementia With Community Health Data: Algorithm Development and Validation Study

Background

Recent studies have revealed lifestyle behavioral risk factors that can be modified to reduce the risk of dementia. As modification of lifestyle takes time, early identification of people with high dementia risk is important for timely intervention and support. As cognitive impairment is a diagnostic criterion of dementia, cognitive assessment tools are used in primary care to screen for clinically unevaluated cases. Among them, Mini-Mental State Examination (MMSE) is a very common instrument. However, MMSE is a questionnaire that is administered when symptoms of memory decline have occurred. Early administration at the asymptomatic stage and repeated measurements would lead to a practice effect that degrades the effectiveness of MMSE when it is used at later stages.

Objective

The aim of this study was to exploit machine learning techniques to assist health care professionals in detecting high-risk individuals by predicting the results of MMSE using elderly health data collected from community-based primary care services.

Methods

A health data set of 2299 samples was adopted in the study. The input data were divided into two groups of different characteristics (ie, client profile data and health assessment data). The predictive output was the result of two-class classification of the normal and high-risk cases that were defined based on MMSE. A dual neural network (DNN) model was proposed to obtain the latent representations of the two groups of input data separately, which were then concatenated for the two-class classification. Mean and k-nearest neighbor were used separately to tackle missing data, whereas a cost-sensitive learning (CSL) algorithm was proposed to deal with class imbalance. The performance of the DNN was evaluated by comparing it with that of conventional machine learning methods.

Results

A total of 16 predictive models were built using the elderly health data set. Among them, the proposed DNN with CSL outperformed in the detection of high-risk cases. The area under the receiver operating characteristic curve, average precision, sensitivity, and specificity reached 0.84, 0.88, 0.73, and 0.80, respectively.

Conclusions

The proposed method has the potential to serve as a tool to screen for elderly people with cognitive impairment and predict high-risk cases of dementia at the asymptomatic stage, providing health care professionals with early signals that can prompt suggestions for a follow-up or a detailed diagnosis.

Education and adolescent cognitive ability as predictors of dementia in a cohort of Danish men

BACKGROUND

An association between education and dementia is well-established but it is unclear whether education is associated with dementia after accounting for early life cognitive ability and whether there is a joint effect, such that the risk associated with one of the exposures depends on the value of the other. We examined separate and joint associations of adolescent cognitive ability and educational attainment with risk of dementia among Danish men born between 1939 and 1959.

METHODS

Men (N = 477,421) from the Danish Conscription Database were followed for dementia from the age 60 for up to 17 years via patient and prescription registry linkages. Exposure measures included cognitive ability assessed at the conscript board examination around age 18 and highest educational level (low: 0-10 year, medium: 10-13 years, high: ≥13 years) at age 30 from registry records. Associations with dementia diagnosis were estimated in Cox proportional hazards models adjusted for birth year and age at conscript board examination. Interaction was assessed on the multiplicative scale by including a product term between the two exposure measures and on the additive scale by calculating relative excess risk due to interaction (RERI) between different levels of the exposure measures.

RESULTS

Compared to men in the high education group hazard ratio [HR] for men in the medium and low group were 1.21 (95% confidence interval [CI]: 1.13, 1.30) and 1.34 (95% CI: 1.24, 1.45), respectively when not adjusting for cognitive ability. Additional adjustment for cognitive ability attenuated the magnitude of the associations, but they remained significant (education medium: HR = 1.10, 95% CI: 1.02, 1.19 and education low: HR = 1.12, 95% CI: 1.02, 1.22). A 10% higher cognitive ability score was associated with a 3.8% lower hazard of dementia (HR = 0.962; 95% CI: 0.957, 0.967), and the magnitude of the association only changed marginally after adjustment for education. Men in the low education group with relatively low cognitive ability were identified as a high-risk subgroup for dementia. The increased risk associated with exposure to both risk factors did, however, not significantly depart from the sum of risk experienced by men only exposed to one of the risk factors (estimates of RERI were not significantly different from 0) and no significant evidence of either additive or multiplicative interactions was found.

CONCLUSIONS

In conclusion, the results suggest that education and cognitive ability protect against the risk of dementia independently of one another and that increases in educational attainment may at least partially offset dementia risk due to low cognitive ability.

Evaluation of Racial Disparities in Hospice Use and End-of-Life Treatment Intensity in the REGARDS Cohort

IMPORTANCE

Although hospice use is increasing and patients in the US are increasingly dying at home, racial disparities in treatment intensity at the end of life, including hospice use, remain.

OBJECTIVE

To examine differences between Black and White patients in end-of-life care in a population sample with well-characterized causes of death.

DESIGN, SETTING, AND PARTICIPANTS

This study used data from the Reasons for Geographic and Racial Differences in Stroke (REGARDS) study, an ongoing population-based cohort study with enrollment between January 25, 2003, and October 3, 2007, with linkage to Medicare claims data. Multivariable logistic regression models were used to examine racial and regional differences in end-of-life outcomes and in stroke mortality among 1212 participants with fee-for-service Medicare who died between January 1, 2013, and December 31, 2015, owing to natural causes and excluding sudden death, with oversampling of Black individuals and residents of Southeastern states in the United States. Initial analyses were conducted in March 2019, and final primary analyses were conducted in February 2020.

MAIN OUTCOMES AND MEASURES

The primary outcomes of interest were hospice use of 3 or more days in the last 6 months of life derived from Medicare claims files. Other outcomes included multiple hospitalizations, emergency department visits, and use of intensive procedures in the last 6 months of life. Cause of death was adjudicated by an expert panel of clinicians using death certificates, proxy interviews, autopsy reports, and medical records.

RESULTS

The sample consisted of 1212 participants (630 men [52.0%]; 378 Black individuals [31.2%]; mean [SD] age at death, 81.0 [8.6] years) of 2542 total deaths. Black decedents were less likely than White decedents to use hospice for 3 or more days (132 of 378 [34.9%] vs 385 of 834 [46.2%]; P < .001). After stratification by cause of death, substantial racial differences in treatment intensity and service use were found among persons who died of cardiovascular disease but not among patients who died of cancer. In analyses adjusted for cause of death (dementia, cancer, cardiovascular disease, and other) and clinical and demographic variables, Black decedents were significantly less likely to use 3 or more days of hospice (odds ratio [OR], 0.72; 95% CI, 0.54-0.96) and were more likely to have multiple emergency department visits (OR, 1.35; 95% CI, 1.01-1.80) and hospitalizations (OR, 1.39; 95% CI, 1.02-1.89) and undergo intensive treatment (OR, 1.94; 95% CI, 1.40-2.70) in the last 6 months of life compared with White decedents.

CONCLUSIONS AND RELEVANCE

Despite the increase in the use of hospice care in recent decades, racial disparities in the use of hospice remain, especially for noncancer deaths. More research is required to better understand racial disparities in access to and quality of end-of-life care.

Combining diagnostic memory clinic with rehabilitation follow-up after hip fracture

PURPOSE

Cognitive impairment and dementia are common in older hip fracture patients. We describe new diagnoses of cognitive disorders (NDCDs) and associated factors in a two-year post-hip fracture follow-up including the use of the diagnostic facilities of a memory clinic.

METHODS

Data were collected on admission and at outpatient assessment 4-6 months post-hip fracture. Diagnoses of cognitive disorders followed the evidence-based Finnish national care guideline including internationally accepted criteria. NDCDs up to 2 years post-hip fracture were extracted manually from the patient files. Logistic regression models were computed to examine the associations between the pre-fracture factors and the domains of the outpatient geriatric assessment and NDCDs.

RESULTS

Of the 1165 hip fracture patients aged ≥ 65 years, 831 had no previous diagnosis of cognitive disorder. Of these, NDCD was documented in 23.3%. Alzheimer's disease (AD) with or without vascular cognitive impairment (VCI) was the most common diagnosis. Cognitive disorder was usually at a moderate stage. Age, higher ASA score and poor nutritional status on admission were associated with new cognitive disorders. At the outpatient follow-up, poorer activities of daily living and mobility disability were associated with NDCD. Patients with a NDCD were more likely to suffer greater mobility impairment, poorer nutritional status and to have more supported living arrangements at follow-up than in the pre-fracture situation.

CONCLUSION

NDCDs are common after hip fracture and associated with impaired rehabilitation outcomes and poor nutritional status. A post-hip fracture assessment co-organized in the form of a memory clinic seems to be feasible to detect previously undiagnosed cognitive disorders. Earlier diagnosis of cognitive disorders is warranted.

Receipt of Eye Care Services among Medicare Beneficiaries with and without Dementia

PURPOSE

To examine the relationship between dementia status and receipt of eye care among US Medicare beneficiaries.

DESIGN

Retrospective, claims-based analysis.

PARTICIPANTS

A 20% representative sample of Medicare beneficiaries who received care between January 1, 2006, and December 31, 2015.

METHODS

Dementia was identified from diagnosis codes documented in a beneficiary's first 3 years of observed Medicare enrollment. Eye care visits were identified from provider specialty codes on each encounter claim. We used multivariable Cox proportional hazards regression models with time-varying covariates to compare the likelihood of receiving eye care between beneficiaries with and without dementia. All models were adjusted for potential confounders, including demographics, urban/rural residence, systemic health (Charlson Index), and ocular comorbidities.

MAIN OUTCOME MEASURES

Hazard ratio (HR) and 95% confidence interval (CI) for (1) being seen by any eye care provider (ophthalmologist or optometrist); (2) being seen by an ophthalmologist specifically; and (3) receiving cataract surgery (among beneficiaries with ophthalmologist encounters).

RESULTS

A total of 4 451 200 beneficiaries met inclusion criteria; 3 805 718 (85.5%) received eye care during the study period, and 391 556 (8.8%) had diagnosed dementia. Some 73.4% of beneficiaries diagnosed with dementia saw an eye care provider during the study period and 55.4% saw an ophthalmologist versus 86.7% and 74.0% of beneficiaries, respectively, without dementia diagnoses. Compared with those without dementia diagnoses, beneficiaries with diagnosed dementia had lower likelihood of seeing any eye care provider (adjusted HR, 0.69; 95% CI, 0.69-0.70) and were less likely to see an ophthalmologist (adjusted HR, 0.55; 95% CI, 0.55-0.55). Among the subset of beneficiaries who did see ophthalmologists, those with diagnosed dementia were also less likely to receive cataract surgery than beneficiaries without diagnosed dementia (HR, 0.62; 95% CI, 0.62-0.63) and less likely to receive a cataract diagnosis (18% vs. 82%).

CONCLUSIONS

US Medicare beneficiaries diagnosed with dementia are less likely to receive eye care than those without diagnosed dementia. Depending on visual acuity and functional status, this may have implications for injury prevention, physical and cognitive function, and quality of life. Further work is needed to identify barriers to receiving eye care, determine eye care services and settings that provide greatest value to patients with dementia, and implement measures to improve access to appropriate eye care.

Amyloid Beta Immunoreactivity in the Retinal Ganglion Cell Layer of the Alzheimer's Eye

Alzheimer’s disease (AD) is the most prevalent form of dementia, accounting for 60–70% of all dementias. AD is often under-diagnosed and recognized only at a later, more advanced stage, and this delay in diagnosis has been suggested as a contributing factor in the numerous unsuccessful AD treatment trials. Although there is no known cure for AD, early diagnosis is important for disease management and care. A hallmark of AD is the deposition of amyloid-β (Aβ)-containing senile neuritic plaques and neurofibrillary tangles composed of hyperphosporylated tau in the brain. However, current in vivo methods to quantify Aβ in the brain are invasive, requiring radioactive tracers and positron emission tomography. Toward development of alternative methods to assess AD progression, we focus on the retinal manifestation of AD pathology. The retina is an extension of the central nervous system uniquely accessible to light-based, non-invasive ophthalmic imaging. However, earlier studies in human retina indicate that the literature is divided on the presence of Aβ in the AD retina. To help resolve this disparity, this study assessed retinal tissues from neuropathologically confirmed AD cases to determine the regional distribution of Aβ in retinal wholemounts and to inform on future retinal image studies targeting Aβ. Concurrent post-mortem brain tissues were also collected. Neuropathological cortical assessments including neuritic plaque (NP) scores and cerebral amyloid angiopathy (CAA) were correlated with retinal Aβ using immunohistochemistry, confocal microscopy, and quantitative image analysis. Aβ load was compared between AD and control (non-AD) eyes. Our results indicate that levels of intracellular and extracellular Aβ retinal deposits were significantly higher in AD than controls. Mid-peripheral Aβ levels were greater than central retina in both AD and control eyes. In AD retina, higher intracellular Aβ was associated with lower NP score, while higher extracellular Aβ was associated with higher CAA score. Our data support the feasibility of using the retinal tissue to assess ocular Aβ as a surrogate measure of Aβ in the brain of individuals with AD. Specifically, mid-peripheral retina possesses more Aβ deposition than central retina, and thus may be the optimal location for future in vivo ocular imaging.

Prognostic value of complementary biomarkers of neurodegeneration in a mixed memory clinic cohort

Background

Biomarkers of neurodegeneration, e.g. MRI brain atrophy and [¹⁸F]FDG-PET hypometabolism, are often evaluated in patients suspected of neurodegenerative disease.

Objective

Our primary objective was to investigate prognostic properties of atrophy and hypometabolism.

Methods

From March 2015-June 2016, 149 patients referred to a university hospital memory clinic were included. The primary outcome was progression/stable disease course as assessed by a clinician at 12 months follow-up. Intracohort defined z-scores of baseline MRI automatic quantified volume and [¹⁸F]FDG-PET standardized uptake value ratios were calculated for all unilaterally defined brain lobes and dichotomized as pronounced atrophy (+A)/ pronounced hypometabolism (+H) at z-score <0. A logistic regression model with progression status as the outcome was carried out with number of lobes with the patterns +A/-H, -A/+H, +A/+H respectively as predictors. The model was mutually adjusted along with adjustment for age and sex. A sensitivity analysis with a z-score dichotomization at −0.1 and −0.5 and dichotomization regarding number of lobes affected at one and three lobes was done.

Results

Median follow-up time was 420 days [IQR: 387-461 days] and 50 patients progressed. Patients with two or more lobes affected by the pattern +A/+H compared to patients with 0–1 lobes affected had a statistically significant increased risk of progression (odds ratio, 95 % confidence interval: 4.33, 1.90–9.86) in a multivariable model. The model was partially robust to the applied sensitivity analysis.

Conclusion

Combined atrophy and hypometabolism as assessed by MRI and [¹⁸F]FDG-PET in patients under suspicion of neurodegenerative disease predicts progression over 1 year.

Transforming Dementia Care Through Pragmatic Clinical Trials Embedded in Learning Healthcare Systems

The current evidence base for testing nonpharmacological interventions for people living with dementia (PLWD) and their caregivers is limited, especially within care settings such as ambulatory care, assisted living communities, nursing homes, hospitals, and hospices. There has been even less attention to translation of effective interventions for PLWD into delivery of care. Thus, there is an urgent need for researchers to partner with these care settings, especially those that follow a learning healthcare systems (LHSs) model, and vice versa to conduct embedded pragmatic clinical trials (ePCTs). These trials are conducted within sites that offer routine care and are designed to answer important, relevant clinical questions and leverage existing electronic health and administrative data. ePCTs set in LHSs create a unique opportunity for researchers, healthcare providers, and PLWD and their families to work and learn together as potentially effective interventions are studied and stress tested in real-world situations. Healthcare settings that embrace research or quality improvement as part of a culture of continuous learning are ideal settings for ePCTs. In this article, we summarize what we have learned from the National Institutes of Health's Health Care Systems Research Collaboratory-funded ePCTs, discuss challenges of ePCTs within settings that serve PLWD, and describe the work of the Health Care Systems Core within the National Institute on Aging's IMbedded Alzheimer's Disease and Related Dementias Clinical Trials Collaboratory that will occur over the next 5 years. J Am Geriatr Soc 68:S43-S48, 2020.

A Matter of Intent: A Social Obligation to Improve Criminal Procedures for Individuals with Dementia

The relationship between dementia and criminal behavior perplexes legal and health care systems. Dementia is a progressive clinical syndrome defined by impairment in at least two cognitive domains that interferes with one's activities of daily. Dementia symptoms have been associated with behaviors that violate social norms and constitute criminal actions. A failure to address a gap in policies that support appropriate management of individuals with dementia reflects a failure in our social obligation to care for those who are most vulnerable amongst us. Categorical protections, informed by precedent models applied to juveniles and individuals with psychiatric illness, could help meet a social obligation to provide protections to individuals with dementia. We propose an approach that integrates affirmative defenses to mitigate criminal liability and sentencing restrictions to prevent cruel and unusual punishment.

A training program for primary health care nurses on timely diagnosis and management of dementia in general practice: An evaluation study

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.

Racial and Ethnic Differences in Knowledge About One's Dementia Status

OBJECTIVES

To examine racial and ethnic differences in knowledge about one's dementia status.

DESIGN

Prospective cohort study.

SETTING

The 2000 to 2014 Health and Retirement Study.

PARTICIPANTS

Our sample included 8,686 person-wave observations representing 4,065 unique survey participants, aged 70 years or older, with dementia, as identified by a well-validated statistical prediction model based on individual demographic and clinical characteristics.

MEASUREMENTS

Primary outcome measure was knowledge of one's dementia status, as reported in the survey. Patient characteristics included race/ethnicity, age, sex, survey year, cognition, function, comorbidity, and whether living in a nursing home.

RESULTS

Among subjects identified as having dementia by the prediction model, 43.5% to 50.2%, depending on the survey year, reported that they were informed of the dementia status by their physician. This proportion was lower among Hispanics (25.9%-42.2%) and non-Hispanic blacks (31.4%-50.5%) than among non-Hispanic whites (47.7%-52.9%). Our fully adjusted regression model indicated lower dementia awareness among non-Hispanic blacks (odds ratio [OR] = 0.74; 95% confidence interval [CI] = 0.58-0.94) and Hispanics (OR = 0.60; 95% CI = 0.43-0.85), compared to non-Hispanic whites. Having more instrumental activity of daily living limitations (OR = 1.65; 95% CI = 1.56-1.75) and living in a nursing home (OR = 2.78; 95% CI = 2.32-3.32) were associated with increased odds of subjects reporting being told about dementia by a physician.

CONCLUSION

Less than half of individuals with dementia reported being told by a physician about the condition. A higher proportion of non-Hispanic blacks and Hispanics with dementia may be unaware of their condition, despite higher dementia prevalence in these groups, compared to non-Hispanic whites. Dementia outreach programs should target diverse communities with disproportionately high disease prevalence and low awareness. J Am Geriatr Soc 68:1763-1770, 2020.

Changes in Predictive Performance of a Frailty Index with Availability of Clinical Domains

OBJECTIVES

Determine the effects of missing data in frailty identification and risk prediction.

DESIGN

Analysis of the National Health in Aging Trends Study.

SETTING

Community.

PARTICIPANTS

About 6206 older adults.

MEASUREMENTS

A 41-variable frailty index (FI) was constructed with the following domains: comorbidities, activities of daily living (ADLs), instrumental activities of daily living, self-reported physical limitations, physical performance, and neuropsychiatric tests. We evaluated discrimination after removing single and multiple domains, comparing C-statistics for predicting 5-year risk of mortality and 1-year risks of disability and falls.

RESULTS

The full FI yielded a mean of .18 and C-statistics of .72 (95% confidence interval, .70-.74) for mortality, .80 (.77-.82) for disability, and .66 (.64-.68) for falls. Removal of any single domain shifted the FI distribution, resulting in a mean FI ranging from .13 (removing comorbidities) to .20 (removing ADLs) and frailty prevalence (FI ≥ .25) from 16.0% to 28.7%. Among robust participants models missing ADLs misclassified most often, (19% as pre-frail). Among pre-frail and frail participants missing comorbidities misclassified most often(69.2% from pre-frail to robust, 24% from frail to pre-frail, and 4.9% from frail to robust). Removal of any single domain minimally changed C-statistics: mortality, .71-.73; disability, .79-.80; and falls, .64-.66. Removing neuropsychiatric testing and physical performance yielded comparable C-statistics of .70, .78, and .66 for mortality, ADLs, and falls, respectively. However, removal of three or four domains based on likely availability decreased C-statistics for mortality (.69, .66),disability (.75, .70), and falls (.64, .63), respectively.

CONCLUSION

While FI discrimination is robust to missing information in any single domain, risk prediction is affected by absence of multiple domains. This work informs the application of FI as a clinical and research tool. J Am Geriatr Soc 68:1771-1777, 2020.

Undiagnosed dementia in primary care: a record linkage study

Background

The number of people living with dementia is greater than the number with a diagnosis of dementia recorded in primary care. This suggests that a significant number are living with dementia that is undiagnosed. Little is known about this group and there is little quantitative evidence regarding the consequences of diagnosis for people with dementia.

Objectives

The aims of this study were to (1) describe the population meeting the criteria for dementia but without diagnosis, (2) identify predictors of being diagnosed and (3) estimate the effect of diagnosis on mortality, move to residential care, social participation and well-being.

Design

A record linkage study of a subsample of participants (n = 598) from the Cognitive Function and Ageing Study II (CFAS II) (n = 7796), an existing cohort study of the population of England aged ≥ 65 years, with standardised validated assessment of dementia and consent to access medical records.

Data sources

Data on dementia diagnoses from each participant’s primary care record and covariate and outcome data from CFAS II.

Setting

A population-representative cohort of people aged ≥ 65 years from three regions of England between 2008 and 2011.

Participants

A total of 598 CFAS II participants, which included all those with dementia who consented to medical record linkage (n = 449) and a stratified sample without dementia (n = 149).

Main outcome measures

The main outcome was presence of a diagnosis of dementia in each participant’s primary care record at the time of their CFAS II assessment(s). Other outcomes were date of death, cognitive performance scores, move to residential care, hospital stays and social participation.

Results

Among people with dementia, the proportion with a diagnosis in primary care was 34% in 2008–11 and 44% in 2011–13. In both periods, a further 21% had a record of a concern or a referral but no diagnosis. The likelihood of having a recorded diagnosis increased with severity of impairment in memory and orientation, but not with other cognitive impairment. In multivariable analysis, those aged ≥ 90 years and those aged < 70 years were less likely to be diagnosed than other age groups; those living with a spouse (odds ratio 2.38, 95% confidence interval 1.04 to 5.41) were more likely to be diagnosed than people living alone. The median time to diagnosis from first meeting the criteria for dementia was 3 years. Diagnosis did not affect survival or the probability of a move to residential care.

Limitations

People with moderate to severe dementia at baseline could not consent to record linkage. The small numbers in some groups limited power to detect effects.

Conclusions

The lack of relationship between severity of non-memory impairment and diagnosis may reflect low awareness of other symptoms of dementia. There remains little objective evidence for benefits of diagnosis for people with dementia.

Future work

Potential benefits of diagnosis can be realised only if effective interventions are accessible to patients and carers. Future work should focus on improving support for people living with cognitive impairment.

Study registration

National Institute for Health Research Clinical Research Network Central Portfolio Management System (CPMS 30655).

Funding

This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research; Vol. 8, No. 20. See the NIHR Journals Library website for further project information.

Dementia awareness, beliefs and barriers among family caregivers in Pakistan

OBJECTIVES

Dementia research and services in Pakistan are limited. The following was explored in experiences of family caregivers of people with dementia in Pakistan: (a) to determine whether culture and religion play a role in caregiving; (b) to draw insights on how family caregivers cope, what barriers they face and what help they would be willing to accept and (c) to determine how these findings could be used to raise awareness and influence public policies in improving the lives of families living with dementia.

METHODS

The experiences of family caregivers of people with dementia in Pakistan were explored via semi-structured interviews (10 in Lahore; 10 in Karachi). This was part of a larger qualitative study conducted about dementia in Pakistan. Caregivers interviewed were aged 35-80 (14 female). Most caregivers in the study were educated and affluent. Interviews were conducted in Urdu, translated into English and thematically analysed.

RESULTS

Five themes emerged: knowledge and awareness; stigma; importance of religion and duty to care; use of day care centres and home-help; and barriers. A lack of dementia awareness exists in Pakistan. The religious duty to care for family influenced caregiving decisions. Day care centres and home-help were accessed and viewed positively. The caregivers also wanted extracurricular activities for people with dementia, support groups for caregivers and better training for healthcare staff. Novel findings included that caregivers felt that dementia should not be stigmatised, and awareness should be raised in Pakistan via TV, radio and social media, but not inside mosques.

DISCUSSION

Additional research is necessary to determine if positive views of day care centres and home-help exist more widely. Attitudes and experiences regarding stigma may be different for caregivers of people with more advanced dementia. We recommend raising dementia awareness, allocating more funds to dementia services and an emphasis on home-based care.

Stratifying risk for dementia onset using large-scale electronic health record data: A retrospective cohort study

INTRODUCTION

Preventing dementia, or modifying disease course, requires identification of presymptomatic or minimally symptomatic high-risk individuals.

METHODS

We used longitudinal electronic health records from two large academic medical centers and applied a validated natural language processing tool to estimate cognitive symptomatology. We used survival analysis to examine the association of cognitive symptoms with incident dementia diagnosis during up to 8 years of follow-up.

RESULTS

Among 267,855 hospitalized patients with 1,251,858 patient years of follow-up data, 6516 (2.4%) received a new diagnosis of dementia. In competing risk regression, an increasing cognitive symptom score was associated with earlier dementia diagnosis (HR 1.63; 1.54-1.72). Similar results were observed in the second hospital system and in subgroup analysis of younger and older patients.

DISCUSSION

A cognitive symptom measure identified in discharge notes facilitated stratification of risk for dementia up to 8 years before diagnosis.

Racial disparities and temporal trends in dementia misdiagnosis risk in the United States

Introduction

Systematic disparities in misdiagnosis of dementia across racial/ethnic groups have implications for health disparities. We compared the risk of dementia under- and overdiagnosis in clinical settings across racial/ethnic groups from 2000 to 2010.

Methods

We linked fee-for-service Medicare claims to participants aged ≥70 from the nationally representative Health and Retirement Study. We classified dementia status using an algorithm with similar sensitivity and specificity across racial/ethnic groups and assigned clinical dementia diagnosis status using ICD-9-CM codes from Medicare claims. Multinomial logit models were used to estimate relative risks of clinical under- and overdiagnosis between groups and over time.

Results

Non-Hispanic blacks had roughly double the risk of underdiagnosis as non-Hispanic whites. While primary analyses suggested a shrinking disparity over time, this was not robust to sensitivity analyses or adjustment for covariates. Risk of overdiagnosis increased over time in both groups.

Discussion

Our results suggest that efforts to reduce racial disparities in underdiagnosis are warranted.

Dementia assessment and management in primary care settings: a survey of current provider practices in the United States

BACKGROUND

Primary care providers (PCPs) are typically the first to screen and evaluate patients for neurocognitive disorders (NCDs), including mild cognitive impairment and dementia. However, data on PCP attitudes and evaluation and management practices are sparse. Our objective was to quantify perspectives and behaviors of PCPs and neurologists with respect to NCD evaluation and management.

METHODS

A cross-sectional survey with 150 PCPs and 50 neurologists in the United States who evaluated more than 10 patients over age 55 per month. The 51-item survey assessed clinical practice characteristics, and confidence, perceived barriers, and typical practices when diagnosing and managing patients with NCDs.

RESULTS

PCPs and neurologists reported similar confidence and approaches to general medical care and laboratory testing. Though over half of PCPs performed cognitive screening or referred patients for cognitive testing in over 50% of their patients, only 20% reported high confidence in interpreting results of cognitive tests. PCPs were more likely to order CT scans than MRIs, and only 14% of PCPs reported high confidence interpreting brain imaging findings, compared to 70% of specialists. Only 21% of PCPs were highly confident that they correctly recognized when a patient had an NCD, and only 13% were highly confident in making a specific NCD diagnosis (compared to 72 and 44% for neurologists, both p < 0.001). A quarter of all providers identified lack of familiarity with diagnostic criteria for NCD syndromes as a barrier to clinical practice.

CONCLUSIONS

This study demonstrates how PCPs approach diagnosis and management of patients with NCDs, and identified areas for improvement in regards to cognitive testing and neuroimaging. This study also identified all providers' lack of familiarity with published diagnostic criteria for NCD syndromes. These findings may inform the development of new policies and interventions to help providers improve the efficacy of their decision processes and deliver better quality care to patients with NCDs.

Discussion of memory during primary care visits of older adults with cognitive impairment and accompanying family

OBJECTIVES

Cognitive impairment is underdiagnosed in primary care. Understanding factors that precipitate memory-related discussion could inform strategies to improve diagnosis and counseling. We assessed whether: 1) having a cognitive impairment or dementia diagnosis, 2) ratings of cognition by clinicians, or 3) ratings of cognition by family companions were associated with memory-related discussion during primary care visits.

METHODS

We examined audio-recorded primary care visits of cognitively impaired patients aged 65 years and older, family companions (n = 93 dyads), and clinicians (n = 14). Cognitive impairment and dementia diagnoses were extracted from the electronic health record. Clinicians and family rated patient cognition on a 10-point scale in postvisit surveys. We measured memory-related discussion using a ratio of memory-related discussion episodes to total visit statements.

RESULTS

We observed more memory-related discussion during primary care visits of patients with a diagnosis of mild cognitive impairment (+7.8% episodes; P < .001) or dementia (+26.3% episodes; P < .001) than no diagnosis. Clinician and family ratings of cognition varied by diagnosis: among patients with no diagnosis, family rated worse impairment than clinicians (average: 2.4 versus 1.3; P = .004) while for patients with a dementia diagnosis, clinicians rated worse impairment than family (average: 7.1 versus 5.5; P = .006). Each unit increase in clinician-rated severity of cognitive impairment was associated with more memory-related discussion (+2.6% episodes; P < .001); this association was attenuated for family (+0.7% episodes; P = .095).

CONCLUSIONS

Discussion of cognitive impairment appears largely driven by clinician ratings of cognition and presence of an established diagnosis. Findings suggest potential benefit of engaging family to improve cognitive impairment detection in primary care.

The Newly Normed SKT Reveals Differences in Neuropsychological Profiles of Patients with MCI, Mild Dementia and Depression

The SKT (Syndrom-Kurztest) is a short cognitive performance test assessing deficits of memory and attention in the sense of speed of information processing. The new standardization of the SKT (2015) aimed at improving its sensitivity for early cognitive decline due to dementia in subjects aged 60 or older. The goal of this article is to demonstrate how the neuropsychological test profile of the SKT can be used to provide valuable information for a differential diagnosis between MCI (mild cognitive impairment), dementia and depression. n = 549 patients attending a memory clinic (Nuremberg, Germany) were diagnosed according to ICD-10 and tested with the SKT. The SKT consists of nine subtests, three for the assessment of memory and six for measuring attention in the sense of speed of information processing. The result of the SKT test procedure is a total score, which indicates the severity of overall cognitive impairment. Besides the summary score, two subscores for memory and attention can be interpreted. Using the level of depression as a covariate, statistical comparisons of SKT test profiles between the three patient groups revealed that depressed patients showed more pronounced deficits than MCI patients in all six attention subtests. On the other hand, MCI patients displayed significantly greater mnestic impairment than the depressed group, which was indicated by significant differences in the memory subscore. MCI and dementia patients showed similar deficit patterns dominated by impairment of memory (delayed recall) with MCI patients demonstrating less overall impairment. In sum, the SKT neuropsychological test profiles provided indicators for a differential diagnosis between MCI and beginning dementia vs. depression.