[People with dementia in primary care : Prevalence, incidence, risk factors and interventions]

Sociodemographic and Clinical Characteristics of People Living with Dementia and Their Associations with Unmet Healthcare Needs: Insights from the Baseline Assessment of the InDePendent Study

Background

The healthcare needs of People living with Dementia (PlwD) (such as Alzheimer's disease) are often unmet. Information about the needs of community-dwelling PlwD and their association with sociodemographic and clinical characteristics is needed to fill the knowledge gap regarding factors influencing unmet needs among PlwD and to conduct a comprehensive needs assessment to develop tailored interventions.

Objective

To describe sociodemographic and clinical characteristics of the InDePendent study population with particular reference to determinants of unmet needs.

Methods

We analyzed baseline data of the multi-centre cluster-randomized controlled trial (InDePendent) using descriptive statistics to describe patients' sociodemographic and clinical characteristics and Poisson regression models to predict unmet needs, separated by sex. Data were collected personally via face-to-face interviews.

Results

Most of the n = 417 participating PlwD were mild to moderately cognitively impaired, were not depressed, had an average of 10.8 diagnoses, took 6.7 medications, and had, on average, 2.4 unmet needs (62% of PlwD had at least one unmet need) measured by the Camberwell Assessment of Need for the Elderly (CANE). Low social support, a high body-mass-index, a lower education, functional impairment, and worse health status were associated with more unmet needs, regardless of sex. In women, higher unmet needs were associated with more depressive symptoms, a poor financial situation, living alone and not being recently treated by a general practitioner. In males, unmet needs increased with the number of medications taken.

Conclusions

PlwD had a broad array of unmet healthcare needs, indicating primary healthcare provision improvement potentials. The results underscore the significance of early assessment of patient's clinical characteristics and unmet needs as a basis for individualized gender-sensible intervention strategies.∥ClinicalTrials.gov Identifier: NCT04741932, Registered on February 5, 2021.

Describing people with cognitive impairment and their complex treatment needs during routine care in the hospital - cross-sectional results of the intersec-CM study

BACKGROUND

Cognitive impairment is an important determinant in health care. In the acute hospital setting cognition has a strong impact on treatment and care. Cognitive impairment can negatively affect diagnostics and treatment success. However, little is known about the individual situation and specific risks of people with cognitive impairments during hospital stays. The aim of the present research is to describe and analyze the treatment needs of people with cognitive impairments in acute hospital care.

METHODS

The analyses use baseline data of the ongoing multisite, longitudinal, randomized controlled intervention trial intersec-CM (Supporting elderly people with cognitive impairment during and after hospital stays with Intersectoral Care Management), which recruited 402 participants at baseline. We assessed sociodemographic aspects, cognitive status, functional status, frailty, comorbidities, level of impairment, formal diagnosis of dementia, geriatric diagnoses, delirium, depression, pharmacological treatment, utilization of health care services and health care related needs.

RESULTS

The sample under examination had been on average mildly cognitively impaired (MMSE M = 22.3) and had a mild to moderate functional impairment (Barthel Index M = 50.4; HABAM M = 19.1). The Edmonton Frail Scale showed a mean of 7.4 and half of the patients (52.3%) had been assigned a care level. About 46.9% had a geriatric diagnosis, 3.0% had a diagnosis of dementia. According to DSM-V 19.2% of the patients had at least one main symptom of depression. The mean number of regularly taken drugs per patient was 8.2. Utilization of health care services prior to the hospital stay was rather low. On average, the sample showed 4.38 care related needs in general, of which 0.60 needs were unaddressed at the time of assessment.

CONCLUSIONS

Descriptive analyses highlight an in-depth insight into impairments and different care needs of people with cognitive impairments. The results emphasize the need for gender-specific analyses as well as an increased attention to the heterogeneity of needs of people with cognitive impairments related to specific wards, settings and regions where they are admitted. Our results indicate also that people with cognitive impairments represent a high proportion of older patients in acute hospital care.

TRIAL REGISTRATION

The intersec-CM trial is registered at ClinicalTrials.gov ( NCT03359408 ).

Recruiting general practitioners and patients with dementia into a cluster randomised controlled trial: strategies, barriers and facilitators

Background

Recruitment of general practitioners (GPs) and their patients is reported as one of the most challenging steps when undertaking primary care research. The present paper describes the recruitment process of a cluster randomised controlled trial (cRCT) aiming to improve dementia care in the primary care setting.

Methods

Recruitment data was analysed descriptively using frequency tables to investigate comparisons of recruitment rates and results of different recruitment strategies as well as reasons for participation and non-participation of GPs, patients with dementia (PwD) and their caregivers.

Results

Over a period of 23 months, N = 28 GPs were successfully included in the cRCT. This represents an overall recruitment rate of 4.6%. The most efficient strategy in terms of high response and low labour-intensity involved the dissemination of calls for participation in a GP research network. Most frequently reported reasons for GP’s participation were Improvement of patient’s well-being (n = 22, 79%) followed by Interest in dementia research (n = 18, 64%). The most common reasons for non-participation were Lack of time (n = 71, 34%) followed by Not interested in participation (n = 63, 30%). On a patient level, N = 102 PwD were successfully recruited. On average, each GP referred about n = 7 PwD (range: 1–17; mdn = 6; IQR = 3.5) and successfully recruited about n = 4 PwD (range: 1–11; mdn = 3; IQR = 3.5).

Conclusion

First, our findings propose GP research networks as a promising strategy to promote recruitment and participation of GPs and their patients in research. Second, present findings highlight the importance of including GPs and their interests in specific research topics in early stages of research in order to ensure a successful recruitment. Finally, results do not support cold calls as a successful strategy in the recruitment of GPs.

Trial registration

The trial was prospectively registered with the ISRCTN registry (Trial registration number: ISRCTN15854413). Registered 01 April 2019.

Protocol for a randomized clinical trial: telephone-based psychoeducation and support for female informal caregivers of patients with dementia

OBJECTIVE: The burden felt by informal caregivers of patients with dementia is a source of physical, emotional, and financial problems. Face-to-face interventions for caregivers have accessibility limitations that may prevent them from receiving adequate care. Telehealth tools can be a solution to this problem. We will compare a telephone psychoeducational and support intervention protocol to usual care for informal female caregivers of patients with dementia treated at specialized outpatient clinics. METHODS: In this single-blind randomized clinical trial, the intervention group will receive one weekly call for 8 weeks that addresses issues such as disease education, communication with the patient, and problematic behaviors. The control group will receive printed material on problematic behaviors in dementia. The primary outcome will be the difference in caregiver burden between baseline and 8 weeks, which will be assessed by blinded investigators through the Zarit Burden Interview scale. Caregiver burden at 16 weeks after baseline, depression, anxiety, and quality of life at 8 and 16 weeks are secondary outcomes. CONCLUSIONS: We expect the intervention to reduce caregiver burden. These results could lead to public health programs for improving dementia care in lower-middle-income countries. Ethics and dissemination: This trial was approved by an independent ethics committee. The results will be published in an international peer-reviewed medical journal. Trial registration number: NCT03260608.

[Healthcare of the future-Insights and strategy for (dementia) health services research]

BACKGROUND

Due to the demographic change healthcare for older people is becoming more important. A key strategic document for the near future is the national dementia strategy (NDS), which defines four fields of action including promoting excellent research on dementia. The NDS will guide and influence the further development of dementia healthcare research in the coming years.

OBJECTIVE

The current research on specific NDS topics is presented and an outlook on expected developments is given.

MATERIAL AND METHODS

This article provides a narrative review in which concepts and examples for selected sections of the NDS are presented: funding and promotion of healthcare research, development of evidence-based prevention and healthcare concepts and transfer into routine care, support for people with dementia (PwD) and their caregiver, cross-sectoral networking, participation in dementia research and networks in healthcare research. These were analyzed with respect to future developments and concretized based on current healthcare and promotion models.

RESULTS

Insights are given into the healthcare concept of dementia care management, rethinking regional healthcare models such as medicine and e‑health. The innovation fund and research practice networks are described as examples of current structural methods of evidence-based design of future healthcare.

CONCLUSION

The NDS represents an ambitious agenda with very comprehensive goals and topics for the improvement of healthcare for PwD and will probably significantly influence healthcare research and thus healthcare in the future. Overarching, mutually influencing and strengthening components on the way to improvement of the situation for PwD and the healthcare system are translation, participation and networking in research.

Knowledge, attitudes and skills of dementia care in general practice: a cross-sectional study in primary health settings in Beijing, China

Background

General practitioners (GPs) play a significant role in dementia care. However, the knowledge and attitudes of them towards dementia care are poorly characterized. The present study aimed to investigate GPs’ knowledge, attitudes and skills of dementia care in primary health settings in Beijing.

Methods

A cross-sectional survey was conducted in 27 community health service centers (CHSCs) in Beijing. The GPs’ knowledge, attitudes and skills were assessed utilizing the Alzheimer’s Disease Knowledge Scale (ADKS), Dementia Care Attitude Scale (DCAS) and self-designed questionnaire, respectively.

Results

A total of 341 participants returned the questionnaire. The overall mean score of GPs’ dementia knowledge measured by the ADKS was 21.42 (SD = 2.73) out of 30 (71.4%), GPs’ attitudes to dementia care was 36.25 (SD = 5.12) out of 50 (72.5%), and GPs’ self-confidence on dementia care skills was 53.93 (SD = 9.57) out of 75 (71.9%). GPs’ overall knowledge towards dementia care was limited and the attitudes were generally positive. They had low level recognition of their roles towards dementia care. The majority of GPs believed that dementia care was within a specialist’s domain not that of general practice.

Conclusion

GPs demonstrate low levels of dementia knowledge and skills, but express generally positive attitudes towards dementia in this study. It is much needed to translate detailed dementia care handbook, and adequate dementia knowledge training for GPs into practice to improve care outcomes for people with dementia in China. In addition, dementia management should be covered in the national basic package of public health services in primary care.

How Does Utilization of Health Care Services Change in People with Dementia Served by Dementia Care Networks? Results of the Longitudinal, Observational DemNet-D-Study

BACKGROUND

There is no common definition for the Dementia Care Network (DCN). They are heterogeneous and there is no general, longitudinal evidence for the effects of DCN.

OBJECTIVE

We describe changes in utilization of health services by people served by dementia care networks in Germany and factors associated with those changes over time.

METHODS

Primary data was assessed in 560 people with dementia (PwD) and their caregivers supported by DCN in Germany; sociodemographic and clinical variables, utilization of services; DCN were characterized according to governance. The design: observational study with face-to-face interviews at two time points over a period of one year. Data was assessed via semi-structured interviews at the participants' homes.

RESULTS

Utilization of health services in this study is consistently higher than reported for the general population and does not significantly change over time. The strongest predictor of utilization of any service after one year was the use of this service at baseline (OR from 3.23 to 44.16). Higher activities of daily functioning increased the chances to utilize specialist physicians (OR = 1.32; 95% -CI: 1.08-1.63) or occupational therapy (OR = 1.24; 95% -CI: 1.02-1.50) significantly. Being a female decreased chances to utilize specialist physicians (OR = 0.57; 95% -CI: 0.37-0.87) and increased the chances to utilize no services (OR = 2.08; 95% -CI: 1.29-3.33).

CONCLUSION

While health care acknowledges the importance and benefits of dementia care networks (i.e., in Germany, the results were considered in new German legislation (SGB XI)), further research is needed to define this kind of service delivery to facilitate comparison as well as promote evidence-based implementation.

Supporting elderly people with cognitive impairment during and after hospital stays with intersectoral care management: study protocol for a randomized controlled trial

BACKGROUND

The sectorization of health-care systems leads to inefficient treatment, especially for elderly people with cognitive impairment. The transition from hospital care to primary care is insufficiently coordinated, and communication between health-care providers is often lacking. Consequences include a further deterioration of health, higher rates of hospital readmissions, and institutionalization. Models of collaborative care have shown their efficacy in primary care by improving patient-related outcomes. The main goal of this trial is to compare the effectiveness of a collaborative care model with usual care for people with cognitive impairment who have been admitted to a hospital for treatment due to a somatic illness. The aim of the intervention is to improve the continuity of treatment and care across the transition between the in-hospital and adjoining primary care sectors.

METHODS/DESIGN

The trial is a longitudinal multisite randomized controlled trial with two arms (care as usual and intersectoral care management). Inclusion criteria at the time of hospital admission due to a somatic illness are age 70+ years, cognitive impairment (Mini Mental State Examination, MMSE ≤26), living at home, and written informed consent. Each participant will have a baseline assessment at the hospital and two follow-up assessments at home (3 and 12 months after discharge). The estimated sample size is n = 398 people with cognitive inmpairement plus their respective informal caregivers (where available). In the intersectoral care management group, specialized care managers will develop, implement, and monitor individualized treatment and care based on comprehensive assessments of the unmet needs of the patients and their informal caregivers. These assessments will occur at the hospital and in participants' homes. Primary outcomes are (1) activities of daily living, (2) readmission to the hospital, and (3) institutionalization. Secondary outcomes include (a) frailty, (b) delirium, (c) quality of life, (d) cognitive status, (e) behavioral and psychological symptoms of dementia, (f) utilization of services, and (g) informal caregiver burden.

DISCUSSION

In the event of proving efficacy, this trial will deliver a proof of concept for implementation into routine care. The cost-effectiveness analyses as well as an independent process evaluation will increase the likelihood of meeting this goal. The trial will enable an in-depth analysis of mediating and moderating effects for different health outcomes at the interface between hospital care and primary care. By highlighting treatment and care, the study will provide insights into unmet needs at the time of hospital admission, and the opportunities and barriers to meeting those needs during the hospital stay and after discharge.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT03359408 ; December 2, 2017.

[Prevalence of dementia in people with a migration background in Germany]

BACKGROUND

In Germany the number of people with a migration background was 16.5 million people in 2013 with 9% being older than 65 years. In this population utilization of health services is low, especially in older people, although they often display worse health outcomes. Little is known about the number of people with dementia and migration background in Germany and their distribution on the state level, resulting in a challenge that is barely assessable for the healthcare system.

OBJECTIVE

The depiction of the prevalence of dementia in people with a migration background for Germany and the individual federal states.

METHOD

The number of people with a migration background and dementia living in Germany and the individual federal states was estimated for different ethnic groups using country and state-specific data on the population, dementia frequency and age-specific prevalence.

RESULTS

Out of 1.86 million people with a migration background who are 65 years or older, approximately 96,500 persons (5.2%) have dementia. The majority are of European (84,490), more specifically Polish (13,960), Italian (8920) and Turkish (8840) heritage. North Rhine-Westphalia (26,000), Baden-Wuerttemberg (18,080) and Bavaria (16,710) are presumed to show the highest rates of people affected.

CONCLUSION

In Germany people with a migration background and dementia represent a large target group for health care; however, the numbers and ethnic populations affected differ considerably between states. These analyses can be used for state-specific healthcare planning of culture-specific and culture-sensitive services and care so that specific healthcare improvements can be achieved.

Quality of life in persons with dementia using regional dementia care network services in Germany: a one-year follow-up study

Background

The majority of individuals with dementia live in the community; thus, regional dementia care networks are becoming increasingly more important for the provision of care. To date, four different types of dementia care networks have been identified in Germany (stakeholder, organisation, hybrid, mission); however, the effect on the quality of life of persons with dementia using such network services has not yet been examined. Moreover, the possible differences in the effect on the quality of life among the four types of dementia care networks have not been investigated. Therefore, the aim of the present study was to describe the changes over time in the quality of life of persons with dementia, assessing the association with the different types of dementia care networks.

Methods

Within the DemNet-D study, face-to-face interviews with persons with dementia and their primary caregivers were conducted to collect data of typical outcome parameters, such as quality of life (Quality of Life Alzheimers Disease: QoL-AD), sociodemographic data, social index (Scheuch−Winkler), depression (Geriatric Depression Scale: GDS), challenging behaviour (Cohen−Mansfield Agitation Inventory: CMAI), capacities of daily living (Instrumental Activity of Daily Living: IADL), impairment due to dementia (FAST), and caregiver burden. In addition to these parameters, the differences in quality of life scores among the four types of dementia care networks were analysed using multi-level analysis.

Results

In total, 407 persons with dementia (79.1 years; 60.1% female) and their caregivers were included in the analysis. Over 75% of the persons with dementia showed moderate to (very) severe impairments of dementia and at least one challenging behaviour. At baseline, 60.6% had a low social index. Quality of life was stable over one-year on a level slightly above average (baseline 29.1; follow-up 28.7). Multi-level analyses (p <  0.001; R² = 0.183) show that persons with dementia with higher QoL-AD scores at baseline were associated with a decline at follow-up. No significant differences among the types of dementia care networks were found.

Conclusion

Users of dementia care network services showed a stable QoL-AD score over time at a level slightly above average, indicating no decrease or worsening over time as expected. Therefore, dementia care network services can be considered as a beneficial model of care in terms of the quality of life of persons with dementia, regardless of their special organisational type.