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Hinton L, Tran D, Peak K, Meyer OL, Quiñones AR. Mapping racial and ethnic healthcare disparities for persons living with dementia: A scoping review. Alzheimers Dement 2024; 20:3000-3020. [PMID: 38265164 PMCID: PMC11032576 DOI: 10.1002/alz.13612] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2023] [Revised: 08/25/2023] [Accepted: 11/25/2023] [Indexed: 01/25/2024]
Abstract
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.
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Affiliation(s)
- Ladson Hinton
- School of MedicineUniversity of CaliforniaDavisSacramentoCaliforniaUSA
| | - Duyen Tran
- School of MedicineUniversity of CaliforniaDavisSacramentoCaliforniaUSA
| | - Kate Peak
- Department of Family MedicineOregon Health & Science University (OHSU)PortlandOregonUSA
| | - Oanh L. Meyer
- School of MedicineUniversity of CaliforniaDavisSacramentoCaliforniaUSA
| | - Ana R. Quiñones
- Department of Family MedicineOregon Health & Science University (OHSU)PortlandOregonUSA
- OHSU‐PSU School of Public HealthOregon Health & Science UniversityPortlandOregonUSA
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Harrison KL, Cenzer I, Smith AK, Hunt LJ, Kelley AS, Aldridge MD, Covinsky KE. Functional and clinical needs of older hospice enrollees with coexisting dementia. J Am Geriatr Soc 2023; 71:785-798. [PMID: 36420734 PMCID: PMC10023265 DOI: 10.1111/jgs.18130] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2022] [Revised: 10/21/2022] [Accepted: 10/30/2022] [Indexed: 11/25/2022]
Abstract
BACKGROUND The Medicare Hospice Benefit increasingly serves people dying with dementia. We sought to understand characteristics, hospice use patterns, and last-month-of-life care quality ratings among hospice enrollees with dementia coexisting with another terminal illness as compared to enrollees with a principal hospice diagnosis of dementia, and enrollees with no dementia. METHODS We conducted a pooled cross-sectional study among decedent Medicare beneficiaries age 70+ using longitudinal data from the National Health and Aging Trends Study (NHATS) (last interview before death; after-death proxy interview) linked to Medicare hospice claims (2011-2017). We used unadjusted and adjusted regression analyses to compare characteristics of hospice enrollees with coexisting dementia to two groups: (1) enrollees with a principal dementia diagnosis, and (2) enrollees with no dementia. RESULTS Among 1105 decedent hospice enrollees age 70+, 40% had coexisting dementia, 16% had a principal diagnosis of dementia, and 44% had no dementia. In adjusted analyses, enrollees with coexisting dementia had high rates of needing help with 3-6 activities of daily living, similar to enrollees with principal dementia (62% vs. 67%). Enrollees with coexisting dementia had high clinical needs, similar to those with no dementia, for example, 63% versus 61% had bothersome pain. Care quality was worse for enrollees with coexisting dementia versus principal dementia (e.g., 61% vs. 79% had anxiety/sadness managed) and similar to those with no dementia. Enrollees with coexisting dementia had similar hospice use patterns as those with principal diagnoses and higher rates of problematic use patterns compared to those with no dementia (e.g., 16% vs. 10% live disenrollment, p = 0.004). CONCLUSIONS People with coexisting dementia have functional needs comparable to enrollees with principal diagnoses of dementia, and clinical needs comparable to enrollees with no dementia. Changes to hospice care models and policy may be needed to ensure appropriate dementia care.
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Affiliation(s)
- Krista L Harrison
- Division of Geriatrics, Department of Medicine, University of California San Francisco, San Francisco, California, USA
- Philip R. Lee Institute for Health Policy Studies, University of California San Francisco, San Francisco, California, USA
- Global Brain Health Institute, University of California San Francisco, San Francisco, California, USA
| | - Irena Cenzer
- Division of Geriatrics, Department of Medicine, University of California San Francisco, San Francisco, California, USA
| | - Alexander K Smith
- Division of Geriatrics, Department of Medicine, University of California San Francisco, San Francisco, California, USA
- San Francisco Veterans Affairs Medical Center, San Francisco, California, USA
| | - Lauren J Hunt
- Philip R. Lee Institute for Health Policy Studies, University of California San Francisco, San Francisco, California, USA
- Global Brain Health Institute, University of California San Francisco, San Francisco, California, USA
- Department of Physiological Nursing, University of California San Francisco, San Francisco, California, USA
| | - Amy S Kelley
- Department of Geriatrics and Palliative Medicine, Icahn School of Medicine, Mount Sinai, New York, USA
- James J. Peters Bronx VA Medical Center, Bronx, New York, USA
| | - Melissa D Aldridge
- Department of Geriatrics and Palliative Medicine, Icahn School of Medicine, Mount Sinai, New York, USA
- James J. Peters Bronx VA Medical Center, Bronx, New York, USA
| | - Kenneth E Covinsky
- Division of Geriatrics, Department of Medicine, University of California San Francisco, San Francisco, California, USA
- San Francisco Veterans Affairs Medical Center, San Francisco, California, USA
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Harrison KL, Cenzer I, Ankuda CK, Hunt LJ, Aldridge MD. Hospice Improves Care Quality For Older Adults With Dementia In Their Last Month Of Life. HEALTH AFFAIRS (PROJECT HOPE) 2022; 41:821-830. [PMID: 35666964 PMCID: PMC9662595 DOI: 10.1377/hlthaff.2021.01985] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
The Medicare hospice benefit was originally designed around a cancer disease paradigm but increasingly serves people living with dementia. At this time, almost half of all older adults receiving hospice care have dementia. Yet there is minimal evidence as to whether hospice benefits people living with dementia outside of nursing facilities. We asked whether and how the perceived quality of last-month-of-life care differed between people with and without dementia and whether hospice use among people living with dementia was associated with perceived quality of care compared with the quality of care for those who did not use hospice. We used nationally representative data from the National Health and Aging Trends Study and Medicare claims from the period 2011-17 to examine the impact of hospice enrollment on proxy perceptions of last-month-of-life care quality. Proxies of people living with dementia enrolled in hospice compared with proxies of those not enrolled more often reported care to be excellent (predicted probability: 52 percent versus 41 percent), more often reported having anxiety or sadness managed (67 percent versus 46 percent), and less often reported changes in care settings in the last three days of life (10 percent versus 25 percent). There were no differences in the impact of hospice on proxy ratings of care for people with and without dementia. Policy makers should consider these benefits when weighing changes to hospice policy and regulations that may affect people living with dementia.
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Affiliation(s)
- Krista L Harrison
- Krista L. Harrison , University of California San Francisco, San Francisco, California
| | - Irena Cenzer
- Irena Cenzer, University of California San Francisco
| | - Claire K Ankuda
- Claire K. Ankuda, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Lauren J Hunt
- Lauren J. Hunt, University of California San Francisco
| | - Melissa D Aldridge
- Melissa D. Aldridge, Icahn School of Medicine at Mount Sinai and James J. Peters Bronx Veterans Affairs Medical Center, Bronx, New York
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Yan D, Wang S, Temkin-Greener H, Cai S. HCBS Service Spending and Nursing Home Placement for Patients With Alzheimer's Disease and Related Dementias: Does Race Matter? J Appl Gerontol 2021; 41:638-649. [PMID: 34615409 DOI: 10.1177/07334648211048187] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
OBJECTIVES We examined the extent to which home and community-based services (HCBS) spending affected the likelihood of nursing home (NH) placement among black and white HCBS users with Alzheimer's disease and related dementias (ADRD). METHODS The study population included new HCBS users with ADRD between 2010 and 2013 (N = 1,046,200). RESULTS We found that a one hundred dollar increase in monthly HCBS spending was associated with a 0.3 percentage points decrease in the NH placement rate among Whites, but a 0.3 percentage points increase in the NH placement rate among Blacks. The overall NH placement rate was 68.2% and 56.7% for Whites and Blacks, respectively. DISCUSSION A higher HCBS spending was associated with a decreased likelihood of NH placements for Whites but not for Blacks. It is important to understand how states' HCBS expansion efforts influence Blacks and Whites with ADRD so that resources can be tailored to communities with different race-mix.
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Affiliation(s)
- Di Yan
- Department of Public Health Sciences, 6923University of Rochester School of Medicine and Dentistry, Rochester, NY, USA
| | - Sijiu Wang
- Department of Public Health Sciences, 123964University of Chicago, Chicago, IL, USA
| | - Helena Temkin-Greener
- Department of Public Health Sciences, 6923University of Rochester School of Medicine and Dentistry, Rochester, NY, USA
| | - Shubing Cai
- Department of Public Health Sciences, 6923University of Rochester School of Medicine and Dentistry, Rochester, NY, USA
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Yeh JC, Newman J, Main R, Hunt LJ. Improving End-of-Life Care for Persons Living With Dementia: Bereaved Caregivers' Observations and Recommendations. J Pain Symptom Manage 2021; 62:579-586. [PMID: 33556499 DOI: 10.1016/j.jpainsymman.2021.01.133] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2020] [Revised: 12/31/2020] [Accepted: 01/27/2021] [Indexed: 10/22/2022]
Abstract
CONTEXT Dementia is a terminal diagnosis that requires significant caregiving support across the trajectory of decline through to death. Experiences and perspectives from bereaved caregivers can help identify ways to improve the end-of-life care experience of persons dying with dementia. OBJECTIVES This exploratory study sought to assess satisfaction with, and elicit recommendations for improving end-of-life care experiences of decedents with dementia from the perspective of bereaved caregivers. METHODS A cross-sectional survey was conducted with caregivers of decedents with dementia (n = 53), from the San Francisco Bay Area, California. Multiple choice and open-ended questions were asked regarding end-of-life care discussions and decisions and respecting and honoring end-of-life needs and wishes. The Satisfaction with Care at the End of Life in Dementia instrument was adapted for the survey. RESULTS While approximately 75% of caregivers were satisfied with their person living with dementia's (PLWD) end-of-life care, 25% felt better care was needed. Qualitative findings revealed that gaps persist regarding communication with providers about disease progression, care continuity and coordination, and honoring death in a preferred location. While most caregivers felt ready to discuss end-of-life decisions with providers when their PLWD was near death, with retrospection, the majority would recommend that providers discuss end-of-life decisions with them during earlier stages of the disease. CONCLUSION End-of-life care for PLWD has significant room for improvement. Efforts to train healthcare providers should focus on helping them meet the complex informational, emotional, and social support needs of PLWD and their caregivers across the trajectory of decline.
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Affiliation(s)
- Jarmin C Yeh
- Institute for Health & Aging, School of Nursing, University of California, San Francisco, California, USA.
| | - Jeff Newman
- Institute for Health & Aging, School of Nursing, University of California, San Francisco, California, USA
| | - Rachel Main
- Alzheimer's Association of Northern California and Northern Nevada, San Francisco, California, USA
| | - Lauren J Hunt
- Department of Physiological Nursing, University of California, San Francisco, California, USA; San Francisco VA Health Care System, San Francisco, California, USA
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Lee HJ, Small BJ, Haley WE. Health and Well-Being in the Year before Death: The Association with Quality of Life and Care at the End-of-Life. J Aging Health 2020; 32:1475-1485. [PMID: 32618482 DOI: 10.1177/0898264320935297] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Objective: We examined whether older adults' health and well-being during their final year of life predicts end-of-life (EOL) quality of life (QOL) and quality of care (QOC). Methods: Using data from deceased participants (n = 1125) in the 2011-2015 National Health and Aging Trends Study, we performed latent class analysis to identify profiles of health and well-being, and we examined the association between these classes and EOL QOL and QOC. Results: Four classes were identified: healthy/happy (20%), frail/happy (37%), cognitively impaired/moderately distressed (27%), and highly impaired/highly distressed (16%). Persons in the highly impaired/highly distressed class showed a poorer QOL at the EOL, whereas those in the healthy/happy class reported a lower level of QOC at the EOL. Discussion: The benefits of maintaining health and well-being often carry forward to EOL. Older adults with high impairment and distress merit greater attention such as assuring care and advance care plans.
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Affiliation(s)
- Hyo Jung Lee
- 54761Nanyang Technological University, Singapore
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Luth EA, Pristavec T. Do Caregiver Experiences Shape End-of-Life Care Perceptions? Burden, Benefits, and Care Quality Assessment. J Pain Symptom Manage 2020; 59:77-85. [PMID: 31419541 PMCID: PMC6942199 DOI: 10.1016/j.jpainsymman.2019.08.012] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2019] [Revised: 08/05/2019] [Accepted: 08/08/2019] [Indexed: 11/23/2022]
Abstract
CONTEXT Researchers, hospices, and government agencies administer standardized questionnaires to caregivers for assessing end-of-life care quality. Caregiving experiences may influence end-of-life care quality reports, which have implications for caregiver outcomes, and are a clinical and policy priority. OBJECTIVES This study aims to determine whether and how caregivers' end-of-life care assessments depend on their burden and benefit perceptions. METHODS This study analyzes data from 391 caregivers in the 2011 National Study of Caregiving and their Medicare beneficiary care recipients from the 2011-2016 National Health and Aging Trends Study. Caregivers assessed five end-of-life care aspects for decedents. Logistic regression was used and predicted probabilities of caregivers positively or negatively assessing end-of-life care based on their burden and benefit experiences calculated. Analyses adjusted for caregiver and care recipient demographic and health characteristics. RESULTS No or minimal caregiving burden is associated with ≥0.70 probability of caregivers reporting they were always informed about the recipient's condition and that the dying person's care needs were always met, regardless of perceived benefits. High perceived caregiving benefit is associated with ≥0.80 probability of giving such reports, even when perceiving high burden. CONCLUSION Caregiver burden and benefit operate alongside one another regarding two end-of-life care evaluations, even when years elapse between caregiver experience reports and care recipient death. This suggests that caregiver interventions reducing burden and bolstering benefits may have a positive and lasting impact on end-of-life care assessments.
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Li J, Zhang Y, Prigerson H, Kaushal R, Casalino LP. Use of Advance Directives among Older U.S. Adults by Dementia Status: 2012-2016. J Palliat Med 2019; 22:1493-1494. [PMID: 31794364 DOI: 10.1089/jpm.2019.0371] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Jing Li
- Department of Healthcare Policy and Research, Weill Cornell Medical College, New York, New York
| | - Yongkang Zhang
- Department of Healthcare Policy and Research, Weill Cornell Medical College, New York, New York
| | - Holly Prigerson
- Department of Medicine, Weill Cornell Medical College, New York, New York
| | - Rainu Kaushal
- Department of Healthcare Policy and Research, Weill Cornell Medical College, New York, New York
| | - Lawrence P Casalino
- Department of Healthcare Policy and Research, Weill Cornell Medical College, New York, New York
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Russell D, Baik D, Jordan L, Dooley F, Hummel SL, Prigerson HG, Bowles KH, Creber RM. Factors Associated With Live Discharge of Heart Failure Patients From Hospice: A Multimethod Study. JACC-HEART FAILURE 2019; 7:550-557. [PMID: 31078473 DOI: 10.1016/j.jchf.2019.01.010] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/21/2018] [Revised: 01/20/2019] [Accepted: 01/23/2019] [Indexed: 10/26/2022]
Abstract
OBJECTIVES This study identified sociodemographic and clinical factors that predicted live discharge among home hospice patients with heart failure, and related these findings to perspectives among health care providers about challenges to caring for these patients. BACKGROUND Hospice patients with heart failure are frequently discharged from hospice before death ("live discharge"). However, little is known about the factors and circumstances associated with live discharge among patients with heart failure. METHODS Quantitative analyses of patient medical records (N = 1,498) and qualitative interviews were performed with health care providers (n = 19) at a not-for-profit hospice agency in New York City. RESULTS Thirty percent of home hospice patients with heart failure experienced a live discharge, most frequently due to 911 calls that led to acute hospitalization. The odds of acute hospitalization were higher for younger patients (age 18 to 74 years: adjusted odds ratio [AOR]: 2.10; 95% confidence interval [CI]: 1.34 to 3.28), African American (AOR: 2.06; 95% CI: 1.31 to 3.24) or Hispanic (AOR: 2.99; 95% CI: 1.99 to 4.50) patients, and higher functioning patients (Palliative Performance Scores of 50% to 70%; AOR: 5.68; 95% CI: 3.66 to 8.79). Qualitative interviews with health care providers highlighted the unique characteristics of heart failure (e.g., sudden changes in patients' condition), the importance of patients' understanding of hospice and their own prognosis, and the role of sociocultural and family context in precipitating and potentially preventing live discharge (e.g., absence of social supports in the home). CONCLUSIONS Live discharge from hospice, especially due to acute hospitalization, is common with heart failure. Greater attention is needed for patients' knowledge of and readiness for hospice care, especially among younger and diverse populations, and for factors related to the social and family context in which hospice care is provided.
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Affiliation(s)
- David Russell
- Department of Sociology, Appalachian State University, Boone, North Carolina; Center for Home Care Policy & Research, Visiting Nurse Service of New York, New York, New York.
| | - Dawon Baik
- School of Nursing, Columbia University, New York, New York
| | - Lizeyka Jordan
- Department of Sociology, Appalachian State University, Boone, North Carolina
| | - Frances Dooley
- Hospice and Palliative Care, Visiting Nurse Service of New York, New York, New York
| | - Scott L Hummel
- Frankel Cardiovascular Center, University of Michigan and Ann Arbor Veterans Affairs Health System, Ann Arbor, Michigan
| | - Holly G Prigerson
- Weill Cornell Medicine Center for Research on End-of-Life Care, New York, New York
| | - Kathryn H Bowles
- Center for Home Care Policy & Research, Visiting Nurse Service of New York, New York, New York; University of Pennsylvania, School of Nursing, Philadelphia, Pennsylvania
| | - Ruth Masterson Creber
- Department of Healthcare Research & Policy, Division of Health Informatics, Weill Cornell Medical College, New York, New York
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