Tube Feeding in US Nursing Home Residents With Advanced Dementia, 2000-2014

Systems Forces Leading to Feeding Tube Placement in Patients with Advanced Dementia: A Qualitative Exploration of Clinical Momentum

Background: Older adults with serious illness near the end-of-life often receive invasive treatments. We developed a conceptual model called clinical momentum that describes system-level forces producing a trajectory of care that is difficult to modify and contributes to overtreatment. We sought to evaluate the empirical fit of our model by examining an event with clear guidelines against intervention: permanent feeding tube placement in patients with advanced dementia. Methods: We screened three hospitals and identified patients 65 years and older with advanced dementia who received a permanent feeding tube. We interviewed 34 family members and clinicians. We coded transcripts and characterized factors that arose during the course of care and their relationships to feeding tube placement. We used abductive analysis to compare the data with theory and identify areas of discordance and alignment. Results: We found that the course of care started with a temporary tube to correct an acute problem. As problems were identified, multiple clinicians were consulted to address a specific problem without collective discussion of the patient's health trajectory. Eventually, clinicians had to address the temporary tube, which was framed to families as a decision to place a permanent feeding tube or withdraw treatment. Conclusion: Elements of the model-including recognition-primed decision-making, "fix-it," and sunk costs-contributed to placement of a feeding tube, which set in motion a path toward intervention long before a goals-of-care conversation occurs. Clinical momentum expands our understanding of overtreatment at the end-of-life and may reveal opportunities to reduce other nonbeneficial interventions.

Mechanical Ventilation in Older Adults With Dementia: Opportunities to Promote Goal-Concordant Care

CONTEXT

Recent studies show increasing use of mechanical ventilation among people living with dementia. There are concerns that this trend may not be driven by patient preferences.

OBJECTIVES

To better understand decision-making regarding mechanical ventilation in people living with dementia.

METHODS

This was an electronic health record-based retrospective cohort study of older adults with dementia (n = 295) hospitalized at one of two teaching hospitals between 2015 and 2019 who were supported with mechanical ventilation (n = 191) or died without mechanical ventilation (n = 104). Multivariable logistic regression was used to examine associations between patient characteristics and mechanical ventilation use.

RESULTS

The median age was 78 years (IQR 71-86), 41% were female, 28% resided in a nursing home, and 58% had clinical markers of advanced dementia (dehydration, weight loss, mobility limitations, or pressure ulcers). Among patients supported with mechanical ventilation, 70% were intubated within 24 hours of presentation, including 31% intubated before hospital arrival. Younger age, higher illness acuity, and absence of a treatment-limiting Physician Orders for Life-Sustaining Treatment document were associated with mechanical ventilation use; nursing home residence and clinical markers of advanced dementia were not. Most patients (89%) had a documented goals of care discussion (GOCD) during hospitalization.

CONCLUSION

Future efforts to promote goal-concordant care surrounding mechanical ventilation use for people living with dementia should involve identifying barriers to goal-concordant care in pre-hospital settings, assessing the timeliness of in-hospital GOCD, and developing strategies for in-the-moment crisis communication across settings.

Factors Associated with Differences in Physicians' Attitudes toward Percutaneous Endoscopic Gastrostomy Feeding in Older Adults Receiving End-of-Life Care in Japan: A Cross-Sectional Study

Background

Although percutaneous endoscopic gastrostomy (PEG) placement is still widely practiced in Japan, studies from Western countries report that it is less beneficial for patients in end-of-life care with cognitive decline. Decisions regarding PEG placement are largely influenced by physician judgment.

Objectives

The aim of this study was to investigate the background and perceptions of Japanese physicians regarding PEG for older adults in end-of-life care and to identify the factors associated with differences in physician judgment regarding PEG.

Design

The study employed a cross-sectional design.

Setting/Subjects

A questionnaire on PEG for older adults in end-of-life care was sent to Japanese physicians. Logistic regression analysis was used to calculate the odds ratios (ORs) and confidence intervals (CIs) of the association between PEG recommendations and each factor.

Results

PEG placement was advised for bedridden patients and older adults with cognitive decline by 26% of the physicians who responded to the survey. Differences in physician perceptions of PEG feeding were associated with the recommendation for PEG, benefits of preventing aspiration pneumonia (OR: 4.9; 95% CI: 3.1-8.2), impact on post-discharge accommodation decisions (OR: 6.1; 95% CI: 1.9-30.9), and hesitancy to recommend a PEG placement (OR: 1.9; 95% CI: 1.3-4.5). Working in a facility with PEG placement (OR: 2.0; 95% CI: 1.2-3.5) was an associated background factor.

Conclusions

Differences in Japanese physicians' attitudes toward using PEG feeding for older adults in end-of-life care were significantly associated with differences in their perceptions of the impact of PEG feeding and working in a facility with PEG placement.

Factors Associated with Costly Hospital Care among Patients with Dementia and Acute Respiratory Failure

Rationale: Understanding contributors to costly and potentially burdensome care for patients with dementia is of interest to healthcare systems and may facilitate efforts to promote goal-concordant care. Objective: To identify risk factors, in particular whether an early goals-of-care discussion (GOCD) took place, for high-cost hospitalization among patients with dementia and acute respiratory failure. Methods: We conducted an electronic health record-based retrospective cohort study of 298 adults with dementia hospitalized with respiratory failure (receiving ⩾48 h of mechanical ventilation) within an academic healthcare system. We collected demographic and clinical characteristics, including clinical markers of advanced dementia (weight loss, pressure ulcers, hypernatremia, mobility limitations) and intensive care unit (ICU) service (medical, surgical, neurologic). We ascertained whether a GOCD was documented within 48 hours of ICU admission. We used logistic regression to identify patient characteristics associated with high-cost hospitalization measured using the hospital system accounting database and defined as total cost in the top third of the sample (⩾$145,000). We examined a path model that included hospital length of stay as a final mediator between exposure variables and high-cost hospitalization. Results: Patients in the sample had a median age of 71 (IQR, 62-79) years. Approximately half (49%) were admitted to a medical ICU, 29% to a surgical ICU, and 22% to a neurologic ICU. More than half (59%) had a clinical indicator of advanced dementia. A minority (31%) had a GOCD documented within 48 hours of ICU admission; those who did had a 50% lower risk of a high-cost hospitalization (risk ratio, 0.50; 95% confidence interval, 0.2-0.8). Older age, limited English proficiency, and nursing home residence were associated with a lower likelihood of high-cost hospitalization, whereas greater comorbidity burden and admission to a surgical or neurologic ICU compared with a medical ICU were associated with a higher likelihood of high-cost hospitalization. Conclusions: Early GOCDs for patients with dementia and respiratory failure may promote high-value care by ensuring aggressive and costly life support interventions are aligned with patients' goals. Future work should focus on increasing early palliative care delivery for patients with dementia and respiratory failure, in particular in surgical and neurologic ICU settings.

Inpatient Palliative Care and Healthcare Utilization Among Older Patients With Alzheimer's Disease and Related Dementia (ADRD) and High Risk of Mortality in U.S. Hospitals

Background. Despite the potential of palliative care (PC) to enhance the quality of life for patients with advanced dementia, there is limited knowledge of its inpatient utilization patterns. This study investigated inpatient PC consultation utilization patterns and evaluated its impact on hospital length of stay (LOS) and medical costs among older patients diagnosed with Alzheimer's Disease and Related Dementia who were at a high risk of mortality (ADRD-HRM). Methods. Using the 2016-2019 National Inpatient Sample database, we conducted multivariable logistic regression analyses to identify individual and hospital characteristics influencing PC consultation utilization. We subsequently performed generalized linear models to estimate LOS (using Poisson distribution) and hospital charges (via log-transformation). Results. Our sample encompassed 965,644 hospital discharges (weighted n = 4,828,219) of patients aged 65 years and above with ADRD-HRM. Among them, 14.6% received inpatient PC. There was a notable uptrend in PC consultation utilization from 13.3% in 2016 to 16.3% in 2019 (p trend<.001). Factors positively influencing and associated with PC utilization included patients that are older, non-Hispanic White, with higher income, receiving care from teaching hospitals, and facilitated with greater bed capacity (all P < .05). Although patients who received PC were more likely to have 3.0% longer LOS (P < .001), they had 19.2% lower hospital charges (P < .001). Conclusions. PC substantially reduced hospital expenditures for older patients with ADRD-HRM, but the prevalence remained low at 14.6% in the study period. Future studies should explore the unmet needs of patients with lower sociodemographic status and those in rural hospitals to further increase their PC consultation utilization.

2024 Alzheimer's disease facts and figures

This article describes the public health impact of Alzheimer's disease (AD), including prevalence and incidence, mortality and morbidity, use and costs of care and the ramifications of AD for family caregivers, the dementia workforce and society. The Special Report discusses the larger health care system for older adults with cognitive issues, focusing on the role of caregivers and non-physician health care professionals. An estimated 6.9 million Americans age 65 and older are living with Alzheimer's dementia today. This number could grow to 13.8 million by 2060, barring the development of medical breakthroughs to prevent or cure AD. Official AD death certificates recorded 119,399 deaths from AD in 2021. In 2020 and 2021, when COVID-19 entered the ranks of the top ten causes of death, Alzheimer's was the seventh-leading cause of death in the United States. Official counts for more recent years are still being compiled. Alzheimer's remains the fifth-leading cause of death among Americans age 65 and older. Between 2000 and 2021, deaths from stroke, heart disease and HIV decreased, whereas reported deaths from AD increased more than 140%. More than 11 million family members and other unpaid caregivers provided an estimated 18.4 billion hours of care to people with Alzheimer's or other dementias in 2023. These figures reflect a decline in the number of caregivers compared with a decade earlier, as well as an increase in the amount of care provided by each remaining caregiver. Unpaid dementia caregiving was valued at $346.6 billion in 2023. Its costs, however, extend to unpaid caregivers' increased risk for emotional distress and negative mental and physical health outcomes. Members of the paid health care and broader community-based workforce are involved in diagnosing, treating and caring for people with dementia. However, the United States faces growing shortages across different segments of the dementia care workforce due to a combination of factors, including the absolute increase in the number of people living with dementia. Therefore, targeted programs and care delivery models will be needed to attract, better train and effectively deploy health care and community-based workers to provide dementia care. Average per-person Medicare payments for services to beneficiaries age 65 and older with AD or other dementias are almost three times as great as payments for beneficiaries without these conditions, and Medicaid payments are more than 22 times as great. Total payments in 2024 for health care, long-term care and hospice services for people age 65 and older with dementia are estimated to be $360 billion. The Special Report investigates how caregivers of older adults with cognitive issues interact with the health care system and examines the role non-physician health care professionals play in facilitating clinical care and access to community-based services and supports. It includes surveys of caregivers and health care workers, focusing on their experiences, challenges, awareness and perceptions of dementia care navigation.

Racial Disparities in Low-Value Care in the Last Year of Life for Medicare Beneficiaries With Neurodegenerative Disease

Background and Objectives

There are racial disparities in health care services received by patients with neurodegenerative diseases, but little is known about disparities in the last year of life, specifically in high-value and low-value care utilization. This study evaluated racial disparities in the utilization of high-value and low-value care in the last year of life among Medicare beneficiaries with dementia or Parkinson disease.

Methods

This was a retrospective, population-based cohort analysis using data from North and South Carolina fee-for-service Medicare claims between 2013 and 2017. We created a decedent cohort of beneficiaries aged 50 years or older at diagnosis with dementia or Parkinson disease. Specific low-value utilization outcomes were selected from the Choosing Wisely initiative, including cancer screening, peripheral artery stenting, and feeding tube placement in the last year of life. Low-value outcomes included hospitalization, emergency department visits, neuroimaging services, and number of days receiving skilled nursing. High-value outcomes included receipt of occupational and physical therapy, hospice care, and medications indicated for dementia and/or Parkinson disease.

Results

Among 70,650 decedents, 13,753 were Black, 55,765 were White, 93.1% had dementia, and 7.7% had Parkinson disease. Adjusting for age, sex, Medicaid dual enrollment status, rural vs urban location, state (NC and SC), and comorbidities, Black decedents were more likely to receive low-value care including colorectal cancer screening (adjusted hazard ratio [aHR] 1.46 [1.32-1.61]), peripheral artery stenting (aHR 1.72 [1.43-2.08]), and feeding tube placement (aHR 2.96 [2.70-3.24]) and less likely to receive physical therapy (aHR 0.73 [0.64-0.85)], dementia medications (aHR 0.90 [0.86-0.95]), or Parkinson disease medications (aHR 0.88 [0.75-1.02]) within the last year of life. Black decedents were more likely to be hospitalized (aHR 1.28 [1.25-1.32]), more likely to be admitted to skilled nursing (aHR 1.09 [1.05-1.13]), and less likely to be admitted to hospice (aHR 0.82 [0.79-0.85]) than White decedents.

Discussion

We found racial disparities in care utilization among patients with neurodegenerative disease in the last year of life, such that Black decedents were more likely to receive specific low-value care services and less likely to receive high-value supportive care than White decedents, even after adjusting for health status and socioeconomic factors.

Mapping racial and ethnic healthcare disparities for persons living with dementia: A scoping review

INTRODUCTION

We set out to map evidence of disparities in Alzheimer's disease and Alzheimer's disease related dementias healthcare, including issues of access, quality, and outcomes for racial/ethnic minoritized persons living with dementia (PLWD) and family caregivers.

METHODS

We conducted a scoping review of the literature published from 2000 to 2022 in PubMed, PsycINFO, and CINAHL. The inclusion criteria were: (1) focused on PLWD and/or family caregivers, (2) examined disparities or differences in healthcare, (3) were conducted in the United States, (4) compared two or more racial/ethnic groups, and (5) reported quantitative or qualitative findings.

RESULTS

Key findings include accumulating evidence that minoritized populations are less likely to receive an accurate and timely diagnosis, be prescribed anti-dementia medications, and use hospice care, and more likely to have a higher risk of hospitalization and receive more aggressive life-sustaining treatment at the end-of-life.

DISCUSSION

Future studies need to examine underlying processes and develop interventions to reduce disparities while also being more broadly inclusive of diverse populations.

Pre-hospitalization dysphagia and feeding tube placement in nursing home residents with advanced dementia

BACKGROUND

Despite research demonstrating the risks of using feeding tubes in persons with advanced dementia, they continue to be placed. The natural history of dysphagia among patients with advanced dementia has not been examined. We conducted a secondary analysis of a national cohort of persons with advanced dementia staying at a nursing home stay before hospitalization to examine (1) pre-hospitalization dysphagia prevalence and (2) risk of feeding tube placement during hospitalization based on preexisting dysphagia.

METHODS

A retrospective cohort study consisting of all nursing home (NH) residents (≥66 years) with advanced dementia (Cognitive Function Scale score ≥2), a hospitalization between 2013-2017, and a Minimum Data Set (MDS) 3.0 assessment within 120 days before hospitalization. Pre-hospitalization dysphagia status and surgically placed feeding tube insertion during hospitalization were determined by MDS 3.0 swallowing items and ICD-9 codes, respectively. A multivariate logistic model clustering on hospital was used to examine the association of dysphagia with percutaneous endoscopic gastrostomy (PEG) feeding tube placement after adjustment for confounders.

RESULTS

Between 2013 and 2017, 889,983 persons with NH stay with advanced dementia (mean age: 84.5, SD: 7.5, and 63.5% female) were hospitalized. Pre-hospitalization dysphagia was documented in 5.4% (n = 47,574) and characterized by oral dysphagia (n = 21,438, 2.4%), pharyngeal dysphagia (n = 24,257, 2.7%), and general swallowing complaints/pain (n = 14,928, 1.7%). Overall, PEG feeding tubes were placed in 3529 patients (11.2%) with pre-hospitalization dysphagia, whereas 27,893 (88.8%) did not have pre-hospitalization dysphagia according to MDS 3.0 items. Feeding tube placement risk increased with the number of dysphagia items noted on the pre-hospitalization MDS (6 vs. 0 dysphagia variables: OR = 5.43, 95% CI: 3.19-9.27).

CONCLUSIONS

Based on MDS 3.0 assessment, only 11% of PEG feeding tubes were inserted in persons with prior dysphagia. Future research is needed on whether this represents inadequate assessment or the impact of potentially reversible intercurrent illness resulting in feeding tube placement.

Can an effective end-of-life intervention for advanced dementia be viewed as moral?

Many people dread prolonged dying with suffering in the terminal illness, advanced dementia. To successfully facilitate a timely dying, advance directives must be effective and acceptable. This article considers whether authorities, including treating physicians, can accept as moral, the effective intervention that ceases caregivers' assistance with oral feeding and hydrating. The article presents eight criticisms and "alternate views" regarding ceasing assisted feeding/hydrating. It draws on perspectives from clinical medicine, law, ethics, and religion. The conflict is between (A) people's core beliefs that reflect cultural norms and religious teachings regarding what is moral versus (B) patients' autonomous right of self-determination and claim right to avoid suffering. The article presents each side as strongly as possible. Accepting the intervention as moral could allow patients a peaceful and timely dying from patients' underlying disease. Confidence in future success can deter patients and their surrogates from considering a hastened dying in earlier stages of dementia.

Advanced-Comfort: Usability Testing of a Care Planning Intervention for Nursing Home Residents With Advanced Dementia

Many nursing home (NH) residents with advanced dementia receive burdensome interventions rather than interventions that promote comfort or quality of life. The purpose of the current study was to test the usability of a novel intervention, ADVANCED-Comfort, which aims to enhance the provision of personalized care for residents with advanced dementia. The intervention comprises structured care plan meetings between the NH team and proxies of residents with dementia (e.g., family members). Using the ADVANCED-Comfort workbook, proxies create individualized care plans addressing six domains adapted from the Age-Friendly Health System Framework. The purpose of this article is to describe the intervention and its theoretical underpinnings and report the usability of the intervention evaluated with surveys, observation, and exit interviews. The study demonstrated that proxies and NH staff found the intervention usable (acceptable, appropriate, and feasible). Based on these preliminary findings, additional testing of the ADVANCED-Comfort intervention is warranted. [Journal of Gerontological Nursing, 49(11), 15-23.].

Interventions that may increase control at the end of life in persons with dementia: the cross-cultural CONT-END acceptability study protocol and pilot-testing

BACKGROUND

Interventions such as advance care planning (ACP), technology, or access to euthanasia may increase the sense of control over the end of life. In people with advanced dementia, the loss of cognitive and physical function limits the ability to control care. To date, little is known about the acceptability of these interventions from the perspective of persons with dementia and others involved. This study will examine the cross-cultural acceptability, and factors associated with acceptability, of four end-of-life interventions in dementia which contain an element of striving for control. Also, we report on the development and pilot testing of animation video vignettes that explain the interventions in a standardized manner.

METHODS

Cross-sectional mixed-methods vignette study. We assess acceptability of two ACP approaches, technology use at the end of life and euthanasia in persons with dementia, their family caregivers and physicians in six countries (Netherlands, Japan, Israel, USA, Germany, Switzerland). We aim to include 80 participants per country, 50 physicians, 15 persons with dementia, and 15 family caregivers. After viewing each animation video, participants are interviewed about acceptability of the intervention. We will examine differences in acceptability between group and country and explore other potentially associated factors including variables indicating life view, personality, view on dementia and demographics. In the pilot study, participants commented on the understandability and clarity of the vignettes and instruments. Based on their feedback, the scripts of the animation videos were clarified, simplified and adapted to being less slanted in a specific direction.

DISCUSSION

In the pilot study, the persons with dementia, their family caregivers and other older adults found the adapted animation videos and instruments understandable, acceptable, feasible, and not burdensome. The CONT-END acceptability study will provide insight into cross-cultural acceptability of interventions in dementia care from the perspective of important stakeholders. This can help to better align interventions with preferences. The study will also result in a more fundamental understanding as to how and when having control at the end of life in dementia is perceived as beneficial or perhaps harmful.

TRIAL REGISTRATION

The CONT-END acceptability study was originally registered at the Netherlands Trial Register (NL7985) at 31 August, 2019, and can be found on the International Clinical Trials Registry Platform.

Advanced practice clinician care and end-of-life outcomes for community- and nursing home-dwelling Medicare beneficiaries with dementia

INTRODUCTION

Older adults with Alzheimer's disease and related dementias (ADRD) often face burdensome end-of-life care transfers. Advanced practice clinicians (APCs)-which include nurse practitioners and physician assistants-increasingly provide primary care to this population. To fill current gaps in the literature, we measured the association between APC involvement in end-of-life care versus hospice utilization and hospitalization for older adults with ADRD.

METHODS

Using Medicare data, we identified nursing home- (N=517,490) and community-dwelling (N=322,461) beneficiaries with ADRD who died between 2016 and 2018. We employed propensity score-weighted regression methods to examine the association between different levels of APC care during their final 9 months of life versus hospice utilization and hospitalization during their final month.

RESULTS

For both nursing home- and community-dwelling beneficiaries, higher APC care involvement associated with lower hospitalization rates and higher hospice rates.

DISCUSSION

APCs are an important group of providers delivering end-of-life primary care to individuals with ADRD.

HIGHLIGHTS

For both nursing home- and community-dwelling Medicare beneficiaries with ADRD, adjusted hospitalization rates were lower and hospice rates were higher for individuals with higher proportions of APC care involvement during their final 9 months of life. Associations between APC care involvement and both adjusted hospitalization rates and adjusted hospice rates persisted when accounting for primary care visit volume.

Palliative care to support the needs of adults with neurological disease

Neurological diseases cause physical, psychosocial, and spiritual or existential suffering from the time of their diagnosis. Palliative care focuses on improving quality of life for people with serious illness and their families by addressing this multidimensional suffering. Evidence from clinical trials supports the ability of palliative care to improve patient and caregiver outcomes by the use of outpatient or home-based palliative care interventions for people with motor neuron disease, multiple sclerosis, or Parkinson's disease; inpatient palliative care consultations for people with advanced dementia; telephone-based case management for people with dementia in the community; and nurse-led discussions with decision aids for people with advanced dementia in long-term care. Unfortunately, most people with neurological diseases do not get the support that they need for their palliative care under current standards of healthcare. Improving this situation requires the deployment of routine screening to identify individual palliative care needs, the integration of palliative care approaches into routine neurological care, and collaboration between neurologists and palliative care specialists. Research, education, and advocacy are also needed to raise standards of care.

Black and white proxy experiences and perceptions that influence advanced dementia care in nursing homes: The ADVANCE study

BACKGROUND

Regional, facility, and racial variability in intensity of care provided to nursing home (NH) residents with advanced dementia is poorly understood.

MATERIALS AND METHODS

Assessment of Disparities and Variation for Alzheimer's disease NH Care at End of life (ADVANCE) is a multisite qualitative study of 14 NHs from four hospital referral regions providing varied intensity of advanced dementia care based on tube-feeding and hospital transfer rates. This report explored the perceptions and experiences of Black and White proxies (N = 44) of residents with advanced dementia to elucidate factors driving these variations. Framework analyses revealed themes and subthemes within the following a priori domains: understanding of advanced dementia and care decisions, preferences related to end-of-life care, advance care planning, decision-making about managing feeding problems and acute illness, communication and trust in NH providers, support, and spirituality in decision-making. Matrix analyses explored similarities/differences by proxy race. Data were collected from June 1, 2018 to July 31, 2021.

RESULTS

Among 44 proxies interviewed, 19 (43.1%) were Black, 36 (81.8%) were female, and 26 (59.0%) were adult children of residents. In facilities with the lowest intensity of care, Black and White proxies consistently reported having had previous conversations with residents about wishes for end-of-life care and generally better communication with providers. Black proxies held numerous misconceptions about the clinical course of advanced dementia and effectiveness of treatment options, notably tube-feeding and cardiopulmonary resuscitation. Black and White proxies described mistrust of NH staff but did so towards different staffing roles. Religious and spiritual beliefs commonly thought to underlie preferences for more intense care among Black residents, were rarely, but equally mentioned by race.

CONCLUSIONS

This report refuted commonly held assumptions about religiosity and spirituality as drivers of racial variations in advanced dementia care and revealed several actionable facility-level factors, which may help reduce these variations.

2023 Alzheimer's disease facts and figures

This article describes the public health impact of Alzheimer's disease, including prevalence and incidence, mortality and morbidity, use and costs of care, and the overall impact on family caregivers, the dementia workforce and society. The Special Report examines the patient journey from awareness of cognitive changes to potential treatment with drugs that change the underlying biology of Alzheimer's. An estimated 6.7 million Americans age 65 and older are living with Alzheimer's dementia today. This number could grow to 13.8 million by 2060 barring the development of medical breakthroughs to prevent, slow or cure AD. Official death certificates recorded 121,499 deaths from AD in 2019, and Alzheimer's disease was officially listed as the sixth-leading cause of death in the United States. In 2020 and 2021, when COVID-19 entered the ranks of the top ten causes of death, Alzheimer's was the seventh-leading cause of death. Alzheimer's remains the fifth-leading cause of death among Americans age 65 and older. Between 2000 and 2019, deaths from stroke, heart disease and HIV decreased, whereas reported deaths from AD increased more than 145%. This trajectory of deaths from AD was likely exacerbated by the COVID-19 pandemic in 2020 and 2021. More than 11 million family members and other unpaid caregivers provided an estimated 18 billion hours of care to people with Alzheimer's or other dementias in 2022. These figures reflect a decline in the number of caregivers compared with a decade earlier, as well as an increase in the amount of care provided by each remaining caregiver. Unpaid dementia caregiving was valued at $339.5 billion in 2022. Its costs, however, extend to family caregivers' increased risk for emotional distress and negative mental and physical health outcomes - costs that have been aggravated by COVID-19. Members of the paid health care workforce are involved in diagnosing, treating and caring for people with dementia. In recent years, however, a shortage of such workers has developed in the United States. This shortage - brought about, in part, by COVID-19 - has occurred at a time when more members of the dementia care workforce are needed. Therefore, programs will be needed to attract workers and better train health care teams. Average per-person Medicare payments for services to beneficiaries age 65 and older with AD or other dementias are almost three times as great as payments for beneficiaries without these conditions, and Medicaid payments are more than 22 times as great. Total payments in 2023 for health care, long-term care and hospice services for people age 65 and older with dementia are estimated to be $345 billion. The Special Report examines whether there will be sufficient numbers of physician specialists to provide Alzheimer's care and treatment now that two drugs are available that change the underlying biology of Alzheimer's disease.

Medical choices regarding feeding tubes in patients with end-stage dementia in Israel: nasogastric vs. percutaneous endoscopic gastrostomy

A previous study conducted more than 15 years ago in Israel found a high overall use of tube-feeding for institutionalized end-stage dementia patients (52%) and a proportionally higher use (2:1) of naso-gastric tube (NG) over Percutaneous Endoscopic Gastrostomy (PEG) tubes for enteral feeding. This rate was markedly higher than that observed in other western countries (4.9-34%), and did not conform with clinical guidelines preferring spoon-feeding over tube-feeding for these patients, and PEG over NG for those in whom tube-feeding was initiated in long-term care. Over the past decade, the Israeli Ministry of Health conducted a policy reform to neutralize the administrative incentives presumed to be responsible for this situation. Further administrative and legislative developments followed suit. Despite these, we found no significant reduction in the prevalence of tube-feeding over spoon-feeding. However, we did observe a reduction in the proportional use of NG over PEG.

Ethical analysis of vulnerabilities in cluster randomized trials involving people living with dementia in long-term care homes

Cluster randomized trials (CRT) of non-pharmacological interventions are an important means of improving the quality of care and quality of life of people living with dementia (PLWD) in long-term care (LTC) homes. PLWD in LTC homes are, however, vulnerable in manifold ways. Therefore, researchers require guidance to ensure that the rights and welfare of PLWD are protected in the course of this valuable research. In this article, we introduce a framework for identifying vulnerabilities in randomized trials and apply it to three CRTs involving PLWD in LTC homes. CRTs may render PLWD in LTC homes vulnerable to three autonomy wrongs: inadequately informed consent, inadequately voluntary consent, and invasions of privacy; two welfare wrongs: risks of therapeutic procedure exceed potential benefits, and excessive risk of non-therapeutic procedures; and one justice wrong: unjust impact of research activities on care. We then discuss appropriate, feasible additional protections that can be implemented to mitigate vulnerability while preserving the scientific validity of the CRT. Corresponding additional protections that can be feasibly implemented include capacity assessments, substitute decision-makers, assent, insulation from LTC home employees during the consent process, patient advocates, utilizing LTC home employees for data collection, stakeholder engagement, additional supervision during study procedures, using caregivers to complete questionnaires by proxy, and gatekeeper permission. Reassuringly, many of these additional protections promote, rather than imperil, the scientific validity of these trials.

Survival and characteristics of older adults receiving home-based medical care: A nationwide analysis in Taiwan

BACKGROUND

In Taiwan, the National Health Insurance Administration initiated the integrated home-based medical care (iHBMC) program in 2016 to improve accessibility to health care for homebound patients. This study aimed to describe the characteristics of older people receiving iHBMC services in Taiwan as well as the relationship between patient characteristics and survival.

METHODS

All older adults registered in the iHBMC application dataset were enrolled between March 1, 2016, and December 31, 2018. Data on social determinants of health (income level, residential area), functional status, consciousness status, nasogastric tube or urinary catheter placement, and major diseases were retrieved from the database. Data on the frequency of multidisciplinary team members' visits were collected. The survival rate was investigated using the Kaplan-Meier method. A Cox proportional hazards univariate regression was conducted to analyze factors influencing survival rates.

RESULTS

A total of 41,079 patients aged ≥65 years were enrolled in iHBMC services. The results showed that the one-year survival rates were 72.1%, 67.4%, and 14.7% in the home-based primary care (HBPC), home-based primary care plus (HBPC-Plus), and home-based palliative care (HBPalC), respectively. Nearly two-thirds of the HBPC-Plus patients underwent nasogastric tube placement. The Cox proportional hazards univariate regression analysis showed that a low urbanization level, a low income level, a low functional status, and an impaired consciousness status were significant predictors of poor survival after adjustment for confounding variables.

CONCLUSIONS

Older adults receiving iHBMC services had a high mortality rate. The high rate of feeding tube use indicated that education and support for both clinical practitioners and family caregivers regarding careful hand feeding are warranted. There was a relationship between low income levels and poor survival in rural areas. Further research on whether social care could impact prognosis should be considered.

Hospital Careful Hand Feeding Program Reduced Feeding Tube Use in Patients with Advanced Dementia

OBJECTIVES

Tube feeding is prevalent among patients with advanced dementia despite empirical data that suggest its lack of benefit. To provide an alternative to tube feeding for end-of-life patients, a careful hand feeding program was launched in a Hong Kong geriatric convalescent hospital in February 2017. We aim to compare the rates of feeding tube insertion before and after program implementation and determine risk factors for feeding tube insertion. For patients on careful hand feeding, we evaluated their sustainability on oral feeding and the rates of hospital readmissions compared with tube feeding patients over the next 12 months.

DESIGN

Retrospective cohort study.

SETTING AND PARTICIPANTS

Advanced dementia patients ≥60 years with indication for tube feeding due to feeding problems admitted from January 2015-June 2019.

METHODS

Data was collected on demographic and clinical variables, initial feeding mode (careful hand feeding vs. tube feeding), subsequent feeding mode changes, and hospital admissions over the next 12 months. Rates of feeding tube insertion, sustainability on oral feeding, and hospital readmissions were compared using Chi-square test. Risk factors for feeding tube insertion were assessed using logistic regression models.

RESULTS

Among 616 advanced dementia patients admitted with feeding problems, feeding tube insertion rate declined significantly after careful hand feeding program implementation (72% vs 51% p<.001). Independent risk factors for feeding tube insertion were admission prior to program implementation, presence of dysphagia alone, dysphagia combined with poor intake, and lack of advance care planning. Among patients on careful hand feeding, 91% were sustained on oral feeding over the next twelve months and did not differ significantly before or after careful hand feeding program implementation (p=.67). There was no significant difference in hospital readmission rates between careful hand feeding patients and tube feeding patients before (83% vs 86%, p=.55) and after careful hand feeding program implementation (87% vs 85%, p=.63).

CONCLUSIONS AND IMPLICATIONS

A hospital careful hand feeding program significantly reduced the feeding tube insertion rate among advanced dementia patients with feeding problems. The vast majority of patients on careful hand feeding were sustained on oral feeding over the next 12 months but their rate of hospital readmissions remained similarly high after program implementation.

Palliative care for people with dementia

Dementia is the most common neurologic disease, affecting approximately 55 million people worldwide. Dementia is a terminal illness, although not always recognized as such. This chapter discusses the key issues in providing palliative care for people with living with dementia and their families. Common palliative care needs and symptoms are presented, including psychosocial, physical, emotional, and spiritual, and the need to actively anticipate and seek symptoms according to the dementia type and stage is emphasized. Families are hugely impacted by a dementia diagnosis, and throughout this chapter, they are considered in the unit of care, and also as a member of the care team. Multiple challenges particular to dementia palliative care are highlighted throughout, such as the lack of timely dementia diagnoses, difficulty with symptom prognostication, the person's inability to verbally express their symptoms and care preferences, and a low threshold for medication side effects. Finally, service models for dementia palliative care in community, residential, and acute hospital settings are discussed, along with the evidence for each. Overall, this chapter reinforces that the individual needs of the person living with dementia and their family must be considered to provide person-centered and comprehensive palliative care, enabling them to live well until death.

Prevalence and management of dysphagia in nursing home residents in Europe and Israel: the SHELTER Project

Background

Dysphagia is a frequent condition in older nursing home residents (NHRs) which may cause malnutrition and death. Nevertheless, its prevalence is still underestimated and there is still debate about the appropriateness and efficacy of artificial nutrition (AN) in subjects with severe dysphagia. The aim is to assess the prevalence of dysphagia in European and Israeli NHRs, its association with mortality, and the relationship of different nutritional interventions, i.e. texture modified diets and AN—with weight loss and mortality.

Methods

A prospective observational study of 3451 European and Israeli NHRs older than 65 years, participating in the SHELTER study from 2009 to 2011, at baseline and after 12 months. All residents underwent a standardized comprehensive evaluation using the interRAI Long Term Care Facility (LTCF). Cognitive status was assessed using the Cognitive Performance Scale (CPS), functional status using Activities of Daily Living (ADL) Hierarchy scale. Trained staff assessed dysphagia at baseline by clinical observation. Data on weight loss were collected for all participants at baseline and after 12 months. Deaths were registered by NH staff.

Results

The prevalence of dysphagia was 30.3%. During the one-year follow-up, the mortality rate in subjects with dysphagia was significantly higher compared with that of non-dysphagic subjects (31.3% vs 17.0%,p = 0,001). The multivariate analysis showed that NHRs with dysphagia had 58.0% higher risk of death within 1 year compared with non-dysphagic subjects (OR 1.58, 95% CI, 1.31–1.91). The majority of NHRs with dysphagia were prescribed texture modified diets (90.6%), while AN was used in less than 10% of subjects. No statistically significant difference was found concerning weight loss and mortality after 12 months following the two different nutritional treatments.

Conclusions

Dysphagia is prevalent among NHRs and it is associated with increased mortality, independent of the nutritional intervention used. Noticeably, after 12 months of nutritional intervention, NHRs treated with AN had similar mortality and weight loss compared to those who were treated with texture modified diets, despite the clinical conditions of patients on AN were more compromised.

Facility Characteristics Associated With Intensity of Care of Nursing Homes and Hospital Referral Regions

OBJECTIVES

Intensity of care, such as hospital transfers and tube feeding of residents with advanced dementia varies by nursing home (NH) within and across regions. Little work has been done to understand how these 2 levels of influence relate. This study's objectives are to identify facility factors associated with NHs providing high-intensity care to residents with advanced dementia and determine whether these factors differ within and across hospital referral regions (HRRs).

DESIGN

Cross-sectional analysis.

SETTING AND PARTICIPANTS

1449 NHs.

METHODS

Nationwide 2016-2017 Minimum Data Set was used to categorize NHs and HRRs into 4 levels of care intensity based on rates of hospital transfers and tube feeding among residents with advanced dementia: low-intensity NH in a low-intensity HRR, high-intensity NH in a low-intensity HRR, low-intensity NH in a high-intensity HRR, and a high-intensity NH in a high-intensity HRR.

RESULTS

In high-intensity HRRs, high-vs low-intensity NHs were more likely to be urban, lack a dementia unit, have a nurse practitioner or physician (NP or PA) on staff, and have a higher proportion of residents who were male, aged <65 years, Black, had pressure ulcers, and shorter hospice stays. In low-intensity HRRs, higher proportion of Black residents was the only characteristic associated with being a high-intensity NH.

CONCLUSIONS AND IMPLICATIONS

These findings suggest that within high-intensity HRRs, there are potentially modifiable factors that could be targeted to reduce burdensome care in advanced dementia, including having a dementia unit, palliative care training for NPs and PAs, and increased use of hospice care.

National trends in gastrostomy in older adults between 2014 and 2019 in Japan

AIM

Previous studies have shown temporal trends in the number of gastrostomies until 2016, but the recent trend is yet to be analyzed. This study aimed to evaluate temporal trends in gastrostomy (mostly percutaneous endoscopic gastrostomy) in older adults in Japan in more recent years.

METHODS

We extracted data on the numbers of gastrostomies and swallowing function assessment prior to gastrostomy, using the national aggregated open data (NDB Open Data) from 2014 to 2019.

RESULTS

Adults in their 80s accounted for the largest portion of gastrostomy during the study period. A decreasing trend in the total number of gastrostomy was observed in older adults from 2014 to 2016, but became almost stable thereafter (57 103 in 2014, 47 228 in 2016, and 47 944 in 2019). The age group-stratified numbers of gastrostomy per 100 000 individuals decreased by -33.9% (≥90 years group) to -6.1% (65-69 years group) from 2014 to 2019. The implementation rate of the swallowing function assessment remained relatively low, despite a slight increase (21.4% in 2015 to 23.7% in 2019).

CONCLUSION

We showed that the total number of gastrostomies remained almost stable after 2016 despite population aging. We considered that the avoidance of gastrostomy in frail or disabled older adults might explain the decrease, particularly for those aged over 80 years. Our findings would regain attention to appropriate decision-making for gastrostomy. Geriatr Gerontol Int ••; ••: ••-•• Geriatr Gerontol Int 2022; ••: ••-••.

Reduced Pneumonia Risk in Advanced Dementia Patients on Careful Hand Feeding Compared With Nasogastric Tube Feeding

OBJECTIVES

To compare survival and pneumonia risk among hospitalized patients with advanced dementia on nasogastric tube feeding (NGF) vs careful hand feeding (CHF) and to examine outcomes by feeding problem type.

DESIGN

Retrospective cohort study.

SETTING AND PARTICIPANTS

Advanced dementia patients aged ≥60 years with indication for tube feeding admitted to 2 geriatric convalescent hospitals between January 1, 2015, and June 30, 2019.

METHODS

Comparison on the effect of NGF and CHF on survival and pneumonia risk using Kaplan Meier survival analysis and Cox proportional hazards models.

RESULTS

Of the 764 patients (mean age 89 years, 61% female, 74% residential care home residents), 464 (61%) were initiated on NGF and 300 (39%) on CHF. The primary feeding problem types were dysphagia (50%), behavioral feeding problem (33%), or both (17%). There was no difference in 1-year survival rate between NGF and CHF groups (36% vs 37%, P = .71) and survival did not differ by feeding problem type. Nasogastric tube feeding was not a significant predictor for survival (adjusted hazard ratio 1.15, 95% CI 0.94-1.39). Among 577 (76%) patients who survived to discharge, pneumonia rates were lower in the CHF group (48% vs 60%, P = .004). After adjusting for cofounders, NGF was a significant risk factor for pneumonia (adjusted hazard ratio 1.41, 95% CI 1.08-1.85). In subgroup analyses, NGF was associated with increased pneumonia risk for patients with both dysphagia and behavioral feeding problem (P = .01) but not in patients with behavioral feeding problem alone (P = .24) or dysphagia alone (P = .30).

CONCLUSIONS AND IMPLICATIONS

For advanced dementia patients with feeding problems, there is no difference in survival between NGF and CHF. However, NGF is associated with a higher pneumonia risk, particularly for patients with both dysphagia and behavioral feeding problem. Further research on how the feeding problem type impacts pneumonia risk for patients on NGF is needed.

Trends in US Medicare Decedents’ Diagnosis of Dementia From 2004 to 2017

Question

To what degree did the diagnosis of Alzheimer disease and related dementias (ADRD) change at the end of life between 2004 and 2017?

Findings

Among 3 515 329 Medicare fee-for-service decedents, the percentage who received an ADRD diagnosis within 2 years of death increased from 34.7% in 2004 to 47.2% in 2017. The likelihood of receiving an ADRD diagnosis particularly increased in the inpatient, hospice, and home health settings; individual characteristics and service use were stable over time, while the intensity of end-of-life care declined on most measures.

Meaning

Dying with an ADRD diagnosis has become more common among older US decedents, potentially owing to increased awareness and temporal changes in billing.

Importance

Alzheimer disease and related dementias (ADRD) have received considerable attention among clinicians, researchers, and policy makers in recent years. Despite increased awareness, few studies have documented temporal changes in the documentation of ADRD diagnoses despite its new importance for risk adjustment for health plans in Medicare.

Objective

To assess trends in frequency of ADRD diagnosis in the last 2 years of life from 2004 to 2017, as well as any associated changes in billing practices, characteristics of the population with diagnosed ADRD, and intensity of end-of-life care.

Design, Setting, and Participants

This is a serial cross-sectional study of older adult decedents (67 years or older) from 2004 to 2017 using a 20% sample of fee-for-service Medicare decedents. An ADRD diagnosis within the last 2 years of life was identified using diagnosis codes from inpatient, professional service, home health, or hospice claims, requiring the standard claims algorithm that required at least 1 claim and a more stringent algorithm that required at least 2 claims. Trends in ADRD diagnosis among decedents were used to lessen influence of new diagnostic technologies for early stage disease. Demographic characteristics, selected comorbidities, place of death, and health service use at the end-of-life were also examined. Data were analyzed from July 9, 2020, to May 3, 2021.

Exposures

Calendar year 2004 to 2017.

Main Outcome and Measure

An ADRD diagnosis within 2 years of death.

Results

Among the included 3 515 329 Medicare fee-for-service decedents, when adjusted for age and sex, the percentage of older decedents with an ADRD diagnosis increased from 34.7% in 2004 to 47.2% in 2017. The trend was attenuated (25.2% to 39.2%) using a stringent ADRD definition. There was an inflection in the curve from 2011 to 2013, the time at which additional diagnoses were added to Medicare claims and the National Alzheimer Care Act was enacted. The ADRD diagnosis frequency increased considerably in inpatient (49.0% to 67.3%), hospice (12.2% to 42.0%), and home health (10.1% to 28.7%) claims. However, individual characteristics, number of visits, and hospitalizations were similar across the study period, and the intensity of end-of-life care declined on most measures.

Conclusions and Relevance

In this cross-sectional study, nearly half of older Medicare decedents had a diagnosis of ADRD at the time of death. From 2004 to 2017, the percentage of older adult decedents who received an ADRD diagnosis increased substantially prior to announcement of the addition of ADRD to Medicare risk adjustment strategies.

2022 Alzheimer's disease facts and figures

This article describes the public health impact of Alzheimer's disease (AD), including incidence and prevalence, mortality and morbidity, use and costs of care, and the overall impact on family caregivers, the dementia workforce and society. The Special Report discusses consumers' and primary care physicians' perspectives on awareness, diagnosis and treatment of mild cognitive impairment (MCI), including MCI due to Alzheimer's disease. An estimated 6.5 million Americans age 65 and older are living with Alzheimer's dementia today. This number could grow to 13.8 million by 2060 barring the development of medical breakthroughs to prevent, slow or cure AD. Official death certificates recorded 121,499 deaths from AD in 2019, the latest year for which data are available. Alzheimer's disease was officially listed as the sixth-leading cause of death in the United States in 2019 and the seventh-leading cause of death in 2020 and 2021, when COVID-19 entered the ranks of the top ten causes of death. Alzheimer's remains the fifth-leading cause of death among Americans age 65 and older. Between 2000 and 2019, deaths from stroke, heart disease and HIV decreased, whereas reported deaths from AD increased more than 145%. More than 11 million family members and other unpaid caregivers provided an estimated 16 billion hours of care to people with Alzheimer's or other dementias in 2021. These figures reflect a decline in the number of caregivers compared with a decade earlier, as well as an increase in the amount of care provided by each remaining caregiver. Unpaid dementia caregiving was valued at $271.6 billion in 2021. Its costs, however, extend to family caregivers' increased risk for emotional distress and negative mental and physical health outcomes - costs that have been aggravated by COVID-19. Members of the dementia care workforce have also been affected by COVID-19. As essential care workers, some have opted to change jobs to protect their own health and the health of their families. However, this occurs at a time when more members of the dementia care workforce are needed. Average per-person Medicare payments for services to beneficiaries age 65 and older with AD or other dementias are almost three times as great as payments for beneficiaries without these conditions, and Medicaid payments are more than 22 times as great. Total payments in 2022 for health care, long-term care and hospice services for people age 65 and older with dementia are estimated to be $321 billion. A recent survey commissioned by the Alzheimer's Association revealed several barriers to consumers' understanding of MCI. The survey showed low awareness of MCI among Americans, a reluctance among Americans to see their doctor after noticing MCI symptoms, and persistent challenges for primary care physicians in diagnosing MCI. Survey results indicate the need to improve MCI awareness and diagnosis, especially in underserved communities, and to encourage greater participation in MCI-related clinical trials.

Days out of Institution after Tracheostomy and Gastrostomy Placement in Critically Ill Older Adults

Rationale: Tracheostomy and gastrostomy tubes are frequently placed during critical illness for long-term life support, with most placed in older adults. Large knowledge gaps exist regarding outcomes expressed as most important to patients. Objectives: To determine the number of days alive and out of institution (DAOIs) and mortality after tracheostomy and gastrostomy placement during critical illness and to evaluate associations between health states before critical illness and outcomes. Methods: In this retrospective cohort study of Medicare beneficiaries admitted to an intensive care unit (ICU) who received a tracheostomy, gastrostomy, or both, we determined the number of DAOIs after procedure date; 90-day, 6-month, and 1-year mortality; hospital discharge destination; and hospital length of stay. We used claims from the year before admission to define eight mutually exclusive pre-ICU health states (permutations of one or more of cancer, chronic organ failure, frail, and robust) and assessed their association with DAOIs in 90 days and 1-year mortality. Results: Among 3,365 patients who received a tracheostomy, 6,709 patients who received a gastrostomy tube, and 3,540 patients who received both procedures, the median number of DAOIs in the first 90 days after placement was 3 (interquartile range, 0-46), 12 (0-61), and 0 (0-37), respectively. Over half died within 180 days. One-year mortality was 62%, 60%, and 64%, respectively. When compared with the robust state, all other pre-ICU health states were associated with loss of DAOIs and increased 1-year mortality; however, between the seven non-robust pre-ICU health states, there were no differences in outcomes. Conclusions: Medicare beneficiaries with prior comorbidity who received tracheostomy, gastrostomy tube, or both during critical illness spent few DAOIs and had high short- and long-term mortality.

Association of Nursing Home Organizational Culture and Staff Perspectives With Variability in Advanced Dementia Care: The ADVANCE Study

IMPORTANCE

Regional, facility, and racial and ethnic variability in intensity of care provided to nursing home residents with advanced dementia is well documented but poorly understood.

OBJECTIVE

To assess the factors associated with facility and regional variation in the intensity of care for nursing home residents with advanced dementia.

DESIGN, SETTING, AND PARTICIPANTS

In the ADVANCE (Assessment of Disparities and Variation for Alzheimer Disease Nursing Home Care at End of Life) qualitative study, conducted from June 1, 2018, to July 31, 2021, nationwide 2016-2017 Medicare Minimum Data Set information identified 4 hospital referral regions (HRRs) with high (n = 2) and low (n = 2) intensity of care for patients with advanced dementia based on hospital transfer and tube-feeding rates. Within those HRRs, 14 facilities providing relatively high-intensity and low-intensity care were recruited. A total of 169 nursing home staff members were interviewed, including administrators, directors of nursing, nurses, certified nursing assistants, social workers, occupational therapists, speech-language pathologists, dieticians, medical clinicians, and chaplains.

MAIN OUTCOMES AND MEASURES

Data included 275 hours of observation, 169 staff interviews, and abstraction of public nursing home material (eg, websites). Framework analyses explored organizational factors and staff perceptions across HRRs and nursing homes in the following 4 domains: physical environment, care processes, decision-making processes, and implicit and explicit values.

RESULTS

Among 169 staff members interviewed, 153 (90.5%) were women, the mean (SD) age was 47.6 (4.7) years, and 54 (32.0%) were Black. Tube-feeding rates ranged from 0% in 5 low-intensity facilities to 44.3% in 1 high-intensity facility, and hospital transfer rates ranged from 0 transfers per resident-year in 2 low-intensity facilities to 1.6 transfers per resident-year in 1 high-intensity facility. The proportion of Black residents in facilities ranged from 2.9% in 1 low-intensity facility to 71.6% in 1 high-intensity facility, and the proportion of Medicaid recipients ranged from 45.3% in 1 low-intensity facility to 81.3% in 1 high-intensity facility. Factors distinguishing facilities providing the lowest-intensity care from those providing the highest-intensity care facilities included more pleasant physical environment (eg, good repair and nonmalodorous), standardized advance care planning, greater staff engagement in shared decision-making, and staff implicit values unfavorable to tube feeding. Many staff perceptions were ubiquitous (eg, adequate staffing needs), with no distinct pattern across nursing homes or HRRs. Staff in all nursing homes expressed assumptions that proxies for Black residents were reluctant to engage in advance care planning and favored more aggressive care. Except in nursing homes providing the lowest-intensity care, many staff believed that feeding tubes prolonged life and had other clinical benefits.

CONCLUSIONS AND RELEVANCE

This study found that variability in the care of patients with advanced dementia may be reduced by addressing modifiable nursing home factors, including enhancing support for low-resource facilities, standardizing advance care planning, and educating staff about evidence-based care and shared decision-making. Given pervasive staff biases toward proxies of Black residents, achieving health equity for nursing home residents with advanced dementia must be the goal behind all efforts aimed at reducing disparities in their care.

Race and prevalence of percutaneous endoscopic gastrostomy tubes in patients with advanced dementia

OBJECTIVE

Millions of Americans may face hard decisions when it comes to providing nutrition for their loved ones with advanced dementia. This study aimed to ascertain whether there is a difference in feeding tube placement between White and Black patients with advanced dementia and whether this potential difference varied by patient's other demographic and clinical characteristics.

METHOD

This is a retrospective, observational study conducted at Novant Health, a 15-hospital system in the southeastern United States. Data were obtained from Epic systems and included all hospital admissions with a diagnosis of advanced dementia, a total of 21,939, between July 1, 2015, and December 31, 2018. Descriptive statistics and logistics analyses were conducted to assess the relationship between receiving percutaneous endoscopic gastrostomy (PEG) and race, controlling for demographic and clinical characteristics.

RESULTS

Among patients admitted with advanced dementia, the multivariable logistic regression, controlled for age, gender, LOS, palliative care, and vascular etiology showed that Blacks had higher odds of having PEG tubes inserted than White patients (OR 1.97; CI 1.51-2.55; P < 0.001). Patients with longer stays had higher odds of PEG tube insertion. Females had lower odds of PEG tube insertion than males. There was no statistical significance in PEG insertion based on age, etiology, and palliative care consult.

SIGNIFICANCE OF RESULTS

The reasons for the observed higher odds of receiving PEG tubes among Black patients than White patients are likely multifactorial and embedded in a different approach to end-of-life care conversations by providers and caregivers of Black and White patients. Providers may need to be more aware of potential unconscious biases when talking to caregivers, especially in race-discordant relationships, have courageous conversations with caregivers, and be more aware of the importance of keeping in mind families' and caregivers' culture, including spirituality, when making end-of-life decisions.

Association between teeth loss and nasogastric tube feeding dependency in older adults from Taiwan: a retrospective cohort study

Background

To examine the association between teeth loss and nasogastric tube feeding dependency in older people.

Methods

The National Health Interview Survey (NHIS) 2005, 2009, and 2013 in Taiwan. Participants were selected by a multistage stratified sampling method and baseline characteristics, including socioeconomic status and health habits, were obtained by well-trained interviewers. The NHIS was linked with the National Health Insurance research database 2000–2016 and the National Deaths Dataset, which contains all the medical information of ambulatory and inpatient care. Cox regression was used to examine the association between the number of teeth lost and nasogastric tube feeding dependency.

Results

There were 6165 adults older than 65 years old enrolled in the analysis, with 2959 male (48%) and the mean (SD) age was 73.95(6.46) years old. The mean follow-up duration was 6.5(3.3) years. Regarding the teeth loss categories, 1660 (26.93%), 2123 (34.44%), and 2382 (38.64%) of participants were categorized as having no teeth loss, loss of 1–9 teeth, and loss of 10–28 teeth, respectively. During 39,962 person-years of follow-up, new-onset nasogastric feeding dependency was recognized in 220(13.25%), 256(12.06%), and 461(19.35%) participants who were categorized as having no teeth loss, loss of 1–9 teeth, and loss of 10–28 teeth, respectively. Kaplan-Meier curves demonstrated significant findings (Log-rank P < 0.01). After potential confounders were adjusted, compared with those without teeth loss, older adults who had lost 10–28 teeth had significantly increased risks of occurrence nasogastric feeding dependency (AHR, 1.31; 95% CI, 1.05–1.62; p-value = 0.02). Furthermore, a significant dose-response relation between the number of teeth lost and increased risk of nasogastric feeding was found (p for trend< 0.01).

Conclusions

Older adults who had lost 10–28 teeth had a significantly increased risk of nasogastric tube feeding dependency. Early identification of the oral disease is crucial for the prevention of the occurrence of teeth loss and the following nutrition problems, which would reduce risk of nasogastric tube feeding dependency.

The Trial to Reduce Antimicrobial Use in Nursing Home Residents With Alzheimer Disease and Other Dementias (TRAIN-AD): A Cluster Randomized Clinical Trial

IMPORTANCE

Antimicrobials are extensively prescribed to nursing home residents with advanced dementia, often without evidence of infection or consideration of the goals of care.

OBJECTIVE

To test the effectiveness of a multicomponent intervention to improve the management of suspected urinary tract infections (UTIs) and lower respiratory infections (LRIs) for nursing home residents with advanced dementia.

DESIGN, SETTING, AND PARTICIPANTS

A cluster randomized clinical trial of 28 Boston-area nursing homes (14 per arm) and 426 residents with advanced dementia (intervention arm, 199 residents; control arm, 227 residents) was conducted from August 1, 2017, to April 30, 2020.

INTERVENTIONS

The intervention content integrated best practices from infectious diseases and palliative care for management of suspected UTIs and LRIs in residents with advanced dementia. Components targeting nursing home practitioners (physicians, physician assistants, nurse practitioners, and nurses) included an in-person seminar, an online course, management algorithms (posters, pocket cards), communication tips (pocket cards), and feedback reports on prescribing of antimicrobials. The residents' health care proxies received a booklet about infections in advanced dementia. Nursing homes in the control arm continued routine care.

MAIN OUTCOMES AND MEASURES

The primary outcome was antimicrobial treatment courses for suspected UTIs or LRIs per person-year. Outcomes were measured for as many as 12 months. Secondary outcomes were antimicrobial courses for suspected UTIs and LRIs when minimal criteria for treatment were absent per person-year and burdensome procedures used to manage these episodes (bladder catherization, chest radiography, venous blood sampling, or hospital transfer) per person-year.

RESULTS

The intervention arm had 199 residents (mean [SD] age, 87.7 [8.0] years; 163 [81.9%] women; 36 [18.1%] men), of which 163 (81.9%) were White and 27 (13.6%) were Black. The control arm had 227 residents (mean [SD] age, 85.3 [8.6] years; 190 [83.7%] women; 37 [16.3%] men), of which 200 (88.1%) were White and 22 (9.7%) were Black. There was a 33% (nonsignificant) reduction in antimicrobial treatment courses for suspected UTIs or LRIs per person-year in the intervention vs control arm (adjusted marginal rate difference, -0.27 [95% CI, -0.71 to 0.17]). This reduction was primarily attributable to reduced antimicrobial use for LRIs. The following secondary outcomes did not differ significantly between arms: antimicrobials initiated when minimal criteria were absent, bladder catheterizations, venous blood sampling, and hospital transfers. Chest radiography use was significantly lower in the intervention arm (adjusted marginal rate difference, -0.56 [95% CI, -1.10 to -0.03]). In-person or online training was completed by 88% of the targeted nursing home practitioners.

CONCLUSIONS AND RELEVANCE

This cluster randomized clinical trial found that despite high adherence to the training, a multicomponent intervention promoting goal-directed care for suspected UTIs and LRIs did not significantly reduce antimicrobial use among nursing home residents with advanced dementia.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT03244917.

Enteral tube feeding for people with severe dementia

BACKGROUND

The balance of benefits and harms associated with enteral tube feeding for people with severe dementia is not clear. An increasing number of guidelines highlight the lack of evidenced benefit and potential risks of enteral tube feeding. In some areas of the world, the use of enteral tube feeding is decreasing, and in other areas it is increasing.

OBJECTIVES

To assess the effectiveness and safety of enteral tube feeding for people with severe dementia who develop problems with eating and swallowing or who have reduced food and fluid intake.

SEARCH METHODS

We searched ALOIS, the Cochrane Dementia and Cognitive Improvement Group's register, MEDLINE, Embase, four other databases and two trials registers on 14 April 2021.

SELECTION CRITERIA

We included randomised controlled trials (RCTs), or controlled non-randomised studies. Our population of interest was adults of any age with a diagnosis of primary degenerative dementia of any cause, with severe cognitive and functional impairment, and poor nutritional intake. Eligible studies evaluated the effectiveness and complications of enteral tube feeding via a nasogastric or gastrostomy tube, or via jejunal post-pyloric feeding, in comparison with standard care or enhanced standard care, such as an intervention to promote oral intake. Our primary outcomes were survival time, quality of life, and pressure ulcers.

DATA COLLECTION AND ANALYSIS

Three review authors screened citations and two review authors assessed full texts of potentially eligible studies against inclusion criteria. One review author extracted data, which were then checked independently by a second review author. We used the 'Risk Of Bias In Non-randomised Studies of Interventions' (ROBINS-I) tool to assess the risk of bias in the included studies. Risk of confounding was assessed against a pre-agreed list of key potential confounding variables. Our primary outcomes were survival time, quality of life, and pressure ulcers. Results were not suitable for meta-analysis, so we presented them narratively. We presented results separately for studies of percutaneous endoscopic gastrostomy (PEG) feeding, nasogastric tube feeding and studies using mixed or unspecified enteral tube feeding methods. We used GRADE methods to assess the overall certainty of the evidence related to each outcome for each study.

MAIN RESULTS

We found no eligible RCTs. We included fourteen controlled, non-randomised studies. All the included studies compared outcomes between groups of people who had been assigned to enteral tube feeding or oral feeding by prior decision of a healthcare professional. Some studies controlled for a range of confounding factors, but there were high or very high risks of bias due to confounding in all studies, and high or critical risks of selection bias in some studies. Four studies with 36,816 participants assessed the effect of PEG feeding on survival time. None found any evidence of effects on survival time (low-certainty evidence). Three of four studies using mixed or unspecified enteral tube feeding methods in 310 participants (227 enteral tube feeding, 83 no enteral tube feeding) found them to be associated with longer survival time. The fourth study (1386 participants: 135 enteral tube feeding, 1251 no enteral tube feeding) found no evidence of an effect. The certainty of this body of evidence is very low. One study of PEG feeding (4421 participants: 1585 PEG, 2836 no enteral tube feeding) found PEG feeding increased the risk of pressure ulcers (moderate-certainty evidence). Two of three studies reported an increase in the number of pressure ulcers in those receiving mixed or unspecified enteral tube feeding (234 participants: 88 enteral tube feeding, 146 no enteral tube feeding). The third study found no effect (very-low certainty evidence).  Two studies of nasogastric tube feeding did not report data on survival time or pressure ulcers. None of the included studies assessed quality of life. Only one study, using mixed methods of enteral tube feeding, reported on pain and comfort, finding no difference between groups. In the same study, a higher proportion of carers reported very heavy burden in the enteral tube feeding group compared to no enteral tube feeding. Two studies assessed the effect of nasogastric tube feeding on mortality (236 participants: 144 nasogastric group, 92 no enteral tube feeding). One study of 67 participants (14 nasogastric, 53 no enteral tube feeding) found nasogastric feeding was associated with increased mortality risk. The second study found no difference in mortality between groups. The certainty of this evidence is very low. Results on mortality for those using PEG or mixed methods of enteral tube feeding were mixed and the certainty of evidence was very low. There was some evidence from two studies for enteral tube feeding improving nutritional parameters, but this was very low-certainty evidence. Five studies reported a variety of harm-related outcomes with inconsistent results. The balance of evidence suggested increased risk of pneumonia with enteral tube feeding. None of the included studies assessed behavioural and psychological symptoms of dementia.

AUTHORS' CONCLUSIONS

We found no evidence that tube feeding improves survival; improves quality of life; reduces pain; reduces mortality; decreases behavioural and psychological symptoms of dementia; leads to better nourishment; improves family or carer outcomes such as depression, anxiety, carer burden, or satisfaction with care; and no indication of harm. We found some evidence that there is a clinically significant risk of pressure ulcers from enteral tube feeding. Future research should focus on better reporting and matching of control and intervention groups, and clearly defined interventions, measuring all the outcomes referred to here.

ADVANCE: Methodology of a qualitative study

BACKGROUND/OBJECTIVES

Quantitative studies have documented persistent regional, facility, and racial differences in the intensity of care provided to nursing home (NH) residents with advanced dementia including, greater intensity in the Southeastern United States, among black residents, and wide variation among NHs in the same hospital referral region (HRR). The reasons for these differences are poorly understood, and the appropriate way to study them is poorly described.

DESIGN

Assessment of Disparities and Variation for Alzheimer's disease Nursing home Care at End of life (ADVANCE) is a large qualitative study to elucidate factors related to NH organizational culture and proxy perspectives contributing to differences in the intensity of advanced dementia care. Using nationwide 2016-2017 Minimum DataSet information, four HRRs were identified in which the relative intensity of advanced dementia care was high (N = 2 HRRs) and low (N = 2 HRRs) based on hospital transfer and tube-feeding rates among residents with this condition. Within those HRRs, we identified facilities providing high (N = 2 NHs) and low (N = 2 NHs) intensity care relative to all NHs in that HRR (N = 16 total facilities; 4 facilities/HRR).

RESULTS/CONCLUSIONS

To date, the research team conducted 275 h of observation in 13 NHs and interviewed 158 NH providers from varied disciplines to assess physical environment, care processes, decision-making processes, and values. We interviewed 44 proxies (black, N = 19; white, N = 25) about their perceptions of advance care planning, decision-making, values, communication, support, trust, literacy, beliefs about death, and spirituality. This report describes ADVANCE study design and the facilitators and challenges of its implementation, providing a template for the successful application of large qualitative studies focused on quality care in NHs.

Characteristics Associated with Feeding Tube Placement: Retrospective Cohort Study of Texas Nursing Home Residents with Advanced Dementia

OBJECTIVES

To investigate resident-level, provider-type, nursing home (NH), and regional factors associated with feeding tube (FT) placement in advanced dementia.

DESIGN

Retrospective cohort study.

SETTING AND PARTICIPANTS

NH residents in Texas with dementia diagnosis and severe cognitive impairment (N = 20,582).

METHODS

This study used 2011-2016 Texas Medicare data to identify NH residents with a stay of at least 120 days who had a diagnosis of dementia on Long Term Care Minimum Data Set (MDS) evaluation and severe cognitive impairment on clinical score. Multivariable repeated measures analyses were conducted to identify associations between FT placement and resident-level, provider-type, NH, and regional factors.

RESULTS

The prevalence of FT placement in advanced dementia in Texas between 2011 and 2016 ranged from 12.5% to 16.1% with a nonlinear trend. At the resident level, the prevalence of FT decreased with age [age > 85 years, prevalence ratio (PR) 0.60, 95% confidence interval (CI) 0.52-0.69] and increased among residents who are black (2.74, 95% CI 2.48-3.03) or Hispanic (PR 1.91, 95% CI 1.71-2.13). Residents cared for by a nurse practitioner or physician assistant were less likely to have an FT (PR 0.90, 95% CI 0.85-0.96). No facility characteristics were associated with prevalence of FT placement in advanced dementia. There were regional differences in FT placement with the highest use areas on the Texas-Mexico border and in South and East Texas (Harlingen border area, PR 4.26, 95% CI 3.69-4.86; San Antonio border area, PR 3.93, 95% CI 3.04-4.93; Houston, PR 2.17, 95% CI 1.87-2.50), and in metro areas (PR 1.36, 95% CI 1.22-1.50).

CONCLUSIONS AND IMPLICATIONS

Regional, race, and ethnic variations in prevalence of FT use among NH residents suggest opportunities for clinicians and policy makers to improve the quality of end-of-life care by especially considering other palliative care measures for minorities living in border towns.

Embedded Pragmatic Trials in Dementia Care: Realizing the Vision of the NIA IMPACT Collaboratory

Close to 6 million Americans have Alzheimer's disease (AD) or Alzheimer's disease and related dementia (AD/ADRD). These high-need, high-cost patients are vulnerable to receiving poor quality uncoordinated care, ultimately leading to adverse health outcomes, poor quality of life, and misuse of resources. Improving the care of persons living with dementia (PLWD) and their caregivers is an urgent public health challenge that must be informed by high-quality evidence. Although prior research has elucidated opportunities to improve AD/ADRD care, the adoption of promising interventions has been stymied by the lack of research evaluating their effectiveness when implemented under real-world conditions. Embedded pragmatic clinical trials (ePCTs) in healthcare systems have the potential to accelerate the translation of evidence-based interventions into clinical practice. Building from the foundation of the National Institutes of Healthcare Systems Collaboratory, in September 2019 the National Institute on Aging Imbedded Pragmatic AD/ADRD Clinical Trials (IMPACT) Collaboratory was launched. Its mission is to build the nation's capacity to conduct ePCTs within healthcare systems for PLWD and their caregivers by (1) developing and disseminating best practice research methods, (2) supporting the design and conduct of ePCTs including pilot studies, (3) building investigator capacity through training and knowledge generation, (4) catalyzing collaboration among stakeholders, and (5) ensuring the research includes culturally tailored interventions for people from diverse backgrounds. This report presents the rationale, structure, key activities, and markers of success for the overall NIA IMPACT Collaboratory. The articles that follow in this special Issue describe the specific work of its 10 core working groups and teams. J Am Geriatr Soc 68:S1-S7, 2020.

Cross-cultural adaptation and content validity of the the patient decision aid "Making Choices: Feeding Options for Patients with Dementia" to Brazilian Portuguese language

PURPOSE

Cross-cultural adaptation to Brazilian Portuguese and evaluation of content validity of a patient decision aid to help in choosing the feeding route for patients with severe dementia entitled "Making Choices: Feeding Options for Patients with Dementia".

METHODS

The cross-cultural adaptation involved two independent translations, synthesis of translations, two independent back-translations, their synthesis, and pretest with 30 caregivers. Content validation was based on analyzes of 35 Brazilian specialists (physicians, speech-language therapists and nurses experienced in caring for patients with severe dementia) through measures of content validity index and concordance between multiple judges by Fleiss' kappa.

RESULTS

The level of comprehension of the instrument by caregivers in the pretest was almost perfect. The specialists committee considered the contents of the instrument valid, in a statistically significant way.

CONCLUSION

The patient decision aid in Brazilian Portuguese entitled "Fazendo escolhas: opções de alimentação para pacientes com demência" obtained evidence of cross-cultural equivalence and content validity for use in the Brazilian population. Further studies are needed to assess its effects on the decision-making process in our population.

Dying with dementia in Medicare Advantage, Accountable Care Organizations, or traditional Medicare

BACKGROUND/OBJECTIVE

Medicare Advantage (MA) and Accountable Care Organizations (ACOs) operate under incentives to reduce burdensome and costly care at the end of life. We compared end-of-life care for persons with dementia who are in MA, ACOs, or traditional Medicare (TM).

DESIGN, SETTING, AND PARTICIPANTS

Retrospective study of decedents with dementia enrolled in MA, attributed to an ACO, or in TM. Decedents had a nursing home stay between 91 and 180 days prior to death, two or more functional impairments, and mild to severe cognitive impairment.

MEASUREMENTS

Hospitalization, invasive mechanical ventilation (IMV) use, and in-hospital death in the last 30 days of life reported in Medicare billing.

RESULTS

Among 370,094 persons with dementia, 93,801 (25.4%) were in MA (mean age [SD], 86.9 [7.7], 67.6% female), 39,586 (10.7%) were ACO attributed (mean age [SD], 87.2 [7.6], 67.3% female), and 236,707 (63.9%) were in TM (mean age [SD], 87.0 [7.8], 67.6% female). The proportion hospitalized in the last 30 days of life was higher among TM enrollees (27.9%) and those ACO attributed (28.1%) than among MA enrollees (20.5%, p ≤ 0.001). After adjustment for socio-demographics, cognitive and functional impairments, comorbidities, and Hospital Referral Region, adjusted odds of hospitalization in the 30 days prior to death was 0.72 (95% confidence interval [CI] 0.70-0.74) among MA enrollees and 1.05 (95% CI 1.02-1.09) among those attributed to ACOs relative to TM enrollees. Relative to TM, the adjusted odds of death in the hospital were 0.78 (95% CI 0.75-0.81) among MA enrollees and 1.02 (95% CI 0.96-1.08) for ACO participants. Dementia decedents in MA had a lower likelihood of IMV use (adjusted odds ratio 0.80, 95% CI 0.75-0.85) compared to TM.

CONCLUSIONS

Among decedents with dementia, MA enrollees but not decedents in ACOs experienced less costly and potentially burdensome care compared with those with TM. Policy changes are needed for ACOs.

Enteral Nutrition by Nasogastric Tube in Adult Patients under Palliative Care: A Systematic Review

Nutritional management of patients under palliative care can lead to ethical issues, especially when Enteral Nutrition (EN) is prescribed by nasogastric tube (NGT). The aim of this review is to know the current status in the management of EN by NG tube in patients under palliative care, and its effect in their wellbeing and quality of life. The following databases were used: PubMed, Web of Science (WOS), Scopus, Scielo, Embase and Medline. After inclusion and exclusion criteria were applied, as well as different qualities screening, a total of three entries were used, published between 2015 and 2020. In total, 403 articles were identified initially, from which three were selected for this review. The use of NGT caused fewer diarrhea episodes and more restrictions than the group that did not use NG tubes. Furthermore, the use of tubes increased attendances to the emergency department, although there was no contrast between NGT and PEG devices. No statistical difference was found between use of tubes (NGT and PEG) or no use, with respect to the treatment of symptoms, level of comfort, and satisfaction at the end of life. Nevertheless, it improved hospital survival compared with other procedures, and differences were found in hospital stays in relation to the use of other probes or devices. Finally, there are not enough quality studies to provide evidence on improving the health status and quality of life of the use of EN through NGT in patients receiving palliative care. For this reason, decision making in this field must be carried out individually, weighing the benefits and damages that they can cause in the quality of life of the patients.

Palliative Care in Advanced Dementia: Comparison of Strategies in Three Countries

Palliative care including hospice care is appropriate for advanced dementia, but policy initiatives and implementation have lagged, while treatment may vary. We compare care for people with advanced dementia in the United States (US), The Netherlands, and Israel. We conducted a narrative literature review and expert physician consultation around a case scenario focusing on three domains in the care of people with advanced dementia: (1) place of residence, (2) access to palliative care, and (3) treatment. We found that most people with advanced dementia live in nursing homes in the US and The Netherlands, and in the community in Israel. Access to specialist palliative and hospice care is improving in the US but is limited in The Netherlands and Israel. The two data sources consistently showed that treatment varies considerably between countries with, for example, artificial nutrition and hydration differing by state in the US, strongly discouraged in The Netherlands, and widely used in Israel. We conclude that care in each country has positive elements: hospice availability in the US, the general palliative approach in The Netherlands, and home care in Israel. National Dementia Plans should include policy regarding palliative care, and public and professional awareness must be increased.

Decomposing Racial and Ethnic Disparities in Nursing Home Influenza Vaccination

OBJECTIVES

Quantify how observable characteristics contribute to influenza vaccination disparities among White, Black, and Hispanic nursing home (NH) residents.

DESIGN

Retrospective cohort.

SETTING AND PARTICIPANTS

Short- and long-stay U.S. NH residents aged ≥65 years.

METHODS

We linked Minimum Data Set (MDS) and Medicare data to LTCFocUS and other facility data. We included residents with 6-month continuous enrollment in Medicare and an MDS assessment between October 1, 2013, and March 31, 2014. Residents were classified as short-stay (<100 days in NH) or long-stay (≥100 days in NH). We fit multivariable logistic regression models to assess the relationships between 27 resident and NH-level characteristics and receipt of influenza vaccination. Using nonlinear Oaxaca-Blinder decomposition, we decomposed the disparity in influenza vaccination between White versus Black and White versus Hispanic NH residents. Analyses were repeated separately for short- and long-stay residents.

RESULTS

Our study included 630,373 short-stay and 1,029,593 long-stay residents. Proportions vaccinated against influenza included 67.2% of White, 55.1% of Black, and 54.5% of Hispanic individuals among short-stay residents and 84.2%, 76.7%, and 80.8%, respectively among long-stay residents. Across 4 comparisons, the crude disparity in influenza vaccination ranged from 3.4 to 12.7 percentage points. By equalizing 27 prespecified characteristics, these disparities could be reduced 37.7% to 59.2%. Living in a predominantly White facility and proxies for NH quality were important contributors across all analyses. Characteristics unmeasured in our data (eg, NH staff attitudes and beliefs) may have also contributed significantly to the disparity.

CONCLUSIONS AND IMPLICATIONS

The racial/ethnic disparity in influenza vaccination was most dramatic among short-stay residents. Intervening on factors associated with NH quality would likely reduce these disparities; however, future qualitative research is essential to explore potential contributors that were unmeasured in our data and to understand the degree to which these factors contribute to the overall disparity in influenza vaccination.

2021 Alzheimer's disease facts and figures

This article describes the public health impact of Alzheimer's disease (AD), including incidence and prevalence, mortality and morbidity, use and costs of care, and the overall impact on caregivers and society. The Special Report discusses the challenges of providing equitable health care for people with dementia in the United States. An estimated 6.2 million Americans age 65 and older are living with Alzheimer's dementia today. This number could grow to 13.8 million by 2060 barring the development of medical breakthroughs to prevent, slow or cure AD. Official death certificates recorded 121,499 deaths from AD in 2019, the latest year for which data are available, making Alzheimer's the sixth-leading cause of death in the United States and the fifth-leading cause of death among Americans age 65 and older. Between 2000 and 2019, deaths from stroke, heart disease and HIV decreased, whereas reported deaths from AD increased more than 145%. This trajectory of deaths from AD was likely exacerbated in 2020 by the COVID-19 pandemic. More than 11 million family members and other unpaid caregivers provided an estimated 15.3 billion hours of care to people with Alzheimer's or other dementias in 2020. These figures reflect a decline in the number of caregivers compared with a decade earlier, as well as an increase in the amount of care provided by each remaining caregiver. Unpaid dementia caregiving was valued at $256.7 billion in 2020. Its costs, however, extend to family caregivers' increased risk for emotional distress and negative mental and physical health outcomes - costs that have been aggravated by COVID-19. Average per-person Medicare payments for services to beneficiaries age 65 and older with AD or other dementias are more than three times as great as payments for beneficiaries without these conditions, and Medicaid payments are more than 23 times as great. Total payments in 2021 for health care, long-term care and hospice services for people age 65 and older with dementia are estimated to be $355 billion. Despite years of efforts to make health care more equitable in the United States, racial and ethnic disparities remain - both in terms of health disparities, which involve differences in the burden of illness, and health care disparities, which involve differences in the ability to use health care services. Blacks, Hispanics, Asian Americans and Native Americans continue to have a higher burden of illness and lower access to health care compared with Whites. Such disparities, which have become more apparent during COVID-19, extend to dementia care. Surveys commissioned by the Alzheimer's Association recently shed new light on the role of discrimination in dementia care, the varying levels of trust between racial and ethnic groups in medical research, and the differences between groups in their levels of concern about and awareness of Alzheimer's disease. These findings emphasize the need to increase racial and ethnic diversity in both the dementia care workforce and in Alzheimer's clinical trials.

Improving Patient Preparedness and Confidence in Discussing Advance Directives for End-of-Life Care with Health Care Providers in the United States and Japan

BACKGROUND

The low completion rate of advance directives (ADs) has received attention in Japan and the United States, as policy makers and health care professionals face aging populations with multiple comorbidities. Among the barriers to AD planning, cultural values and attitudes appear to be particularly influential. A comparison of culturally distinct societies provides a deeper understanding of these barriers. Through such an approach, this study identifies strategies for increasing AD planning among late-middle-age Japanese and US individuals.

METHODS

After giving informed consent for the Institutional Review Board-approved study, Japanese and US respondents (45-65 y; 50% female) without ADs completed a language-appropriate online survey. Participants were asked to review a decision aid as part of a scenario-based physician consultation regarding artificial nutrition and hydration (ANH). Hypotheses were analyzed using multigroup structural equation modeling.

RESULTS

Important similarities were identified across the 2 groups. After reviewing the decision aid, both samples strongly preferred "no ANH." Respondents who strongly valued either self-reliance or interpersonal relationships experienced greater preparedness for AD planning. In both countries, greater decision preparedness and positive death attitude predicted greater confidence to discuss care options with a provider. Finally, cultural values predicted preference for family participation: respondents with a strong interdependent self-concept desired more family involvement, whereas high independents preferred less.

CONCLUSIONS

Findings indicate the importance of documenting care preferences and accounting for individual differences. To increase AD adoption, providers should identify patient segments likely to benefit most from the interventions. Targeting individuals in both countries who value self-reliance and interpersonal relationships appears to be a good place to begin. Such individuals can be identified clinically through administration of validated measures used in this study.

Top Ten Tips Palliative Care Clinicians Should Know About Cognitive Impairment and Institutional Care

Most long-term care (LTC) residents are of age >65 years and have multiple chronic health conditions affecting their cognitive and physical functioning. Although some individuals in nursing homes return home after receiving therapy services, most will remain in a LTC facility until their deaths. This article seeks to provide guidance on how to assess and effectively select treatment for delirium, behavioral and psychological symptoms for patients with dementia, and address other common challenges such as advanced care planning, decision-making capacity, and artificial hydration at the end of life. To do so, we draw upon a team of physicians with training in various backgrounds such as geriatrics, palliative medicine, neurology, and psychiatry to shed light on those important topics in the following "Top 10" tips.

The Black and White of Invasive Mechanical Ventilation in Advanced Dementia

BACKGROUND/OBJECTIVES

Over the past decade, feeding tube use in nursing home residents with advanced dementia has declined by 50% among white and black patients. Little is known about whether a similar reduction has occurred in other invasive interventions, such as mechanical ventilation.

DESIGN

Retrospective cohort study.

SETTING

Acute-care hospitals in the United States.

PARTICIPANTS

Medicare beneficiaries with advanced dementia who previously resided in a nursing home and were hospitalized between 2001 and 2014 with pneumonia and/or septicemia and of either black or white race.

MEASUREMENT

Invasive mechanical ventilation (IMV), as identified by International Classification of Diseases (ICD) procedure codes. Two multivariable logistic regression models examined the association between race and the likelihood of receiving IMV, adjusting for patients' demographics, physical function, and comorbidities. A hospital fixed-effects model examined the association of race within a hospital, whereas a random-effects logistic model was used to estimate the between-hospital variation in the probability of receiving IMV and examine the overall association of race and use of IMV.

RESULTS

Between 2001 and 2014, 289,017 patients with advanced dementia were hospitalized for pneumonia or septicemia. Use of IMV increased from 3.7% to 12.1% in white patients and from 8.6% to 21.8% in blacks. Among those ventilated, 1-year mortality rates remained high, at 82.7% for whites and 84.2% for blacks dying in 2013. Compared with whites, blacks had a higher odds of receiving IMV in the fixed-effects (within-hospital) model (adjusted odds ratio (AOR) = 1.34; 95% confidence interval (CI) = 1.29-1.39) and in the random-effects (between-hospital) model (AOR = 1.46; 95% CI = 1.40-1.51).

CONCLUSION

IMV use in patients with advanced dementia has increased substantially, with black patients having a larger increase than whites, based, in part, on the hospitals where black patients receive care.

Hospice Staff Perspectives on Caring for People with Dementia: A Multisite, Multistakeholder Study

Background: In the United States, 45% of people enrolled in hospice have dementia. We know little about how hospice professionals facilitate preference-aligned end-of-life care for people with dementia (PWD) and their families. Objective: To examine hospice stakeholders' perspectives on caring for PWD and their families. Design: Multisite qualitative study using semi-structured interviews with interdisciplinary hospice clinicians, leaders, and administrators. The interdisciplinary team used the constant comparative method to identify, code, and characterize relevant themes. Setting/participants: Four geographically distinct nonprofit U.S. hospice organizations. Fifty-one hospice employees: 61% clinical staff, 25% executive leaders, and 14% administrators. Measurements: Interview domains included participants' practices of engaging patients/families in discussions of preferences for end-of-life care and professional opinions of changes over time. Cross-topic probes focused on delivering hospice care to PWD and their proxies/families. Results: Four themes regarding caring for PWD in hospice. (1) Dementia prevalence in hospice is increasing and some hospices are developing programs to accommodate specific needs. (2) Setting impacts discussions of preferences and care decisions. (3) Caring for PWD on hospice poses unique challenges caused by (i) perceptions that dementia is not terminal, (ii) a lack of advance care planning discussions before hospice admission, and (iii) proxy decision-makers who were inadequately prepared for their role. (4) Hospice regulatory and policy changes disproportionately impact PWD. Conclusions: Hospice professionals perceive increasing demand for, and multilevel challenges to, caring for PWD. Clinicians "upstream" from hospice may help by engaging patients and proxies in discussions of preferences for end-of-life care and providing anticipatory guidance.

Diagnosed prevalence of Alzheimer's disease and related dementias in Medicare Advantage plans

INTRODUCTION

One-third of Medicare beneficiaries are enrolled in Medicare Advantage (MA). Yet, little is known about MA beneficiaries diagnosed with Alzheimer's disease (AD) and AD-related dementias (AD/ADRD).

METHODS

We calculated the prevalence of AD/ADRD diagnoses in 2014 and 2016 in three MA plans. We determined the demographic characteristics of beneficiaries diagnosed with AD/ADRD, and whether they disenrolled from the MA plan for any reason within 364 days from the index date.

RESULTS

In 2014 and 2016, the overall prevalence of AD/ADRD diagnoses was 5.6% and 6.5%, respectively. In 2016, AD/ADRD beneficiaries were on average 82.4 (SD = 7.4) years of age, 61.8% female, and had multiple comorbidities. By 364 days post-index date, 32% of beneficiaries with AD/ADRD had disenrolled from their plan. The demographic characteristics of 2014 beneficiaries with diagnosed AD/ADRD were similar to their 2016 counterparts.

DISCUSSION

The prevalence of AD/ADRD diagnosis in MA is lower than rates reported in Medicare fee-for-service.

Percutaneous endoscopic gastrostomy – Too often? Too late? Who are the right patients for gastrostomy?

Percutaneous endoscopic gastrostomy is an established method to provide nutrition to patients with restricted oral uptake of fluids and calories. Here, we review the methods, indications and complications of this procedure. While gastrostomy can be safely and easily performed during gastroscopy, the right patients and timing for this intervention are not always chosen. Especially in patients with dementia, the indication for and timing of gastrostomies are often improper. In this patient group, clear data for enteral nutrition are lacking; however, some evidence suggests that patients with advanced dementia do not benefit, whereas patients with mild to moderate dementia might benefit from early enteral nutrition. Additionally, other patient groups with temporary or permanent restriction of oral uptake might be a useful target population for early enteral nutrition to maintain mobilization and muscle strength. We plead for a coordinated study program for these patient groups to identify suitable patients and the best timing for tube implantation.