The effects of acute illness on ADL decline over 1 year in frail older adults with and without cognitive impairment

Associations between inappropriate medication use and (instrumental) activities of daily living in geriatric rehabilitation inpatients: RESORT study

BACKGROUND

Inappropriate medication use can affect functional independence in older adults.

AIMS

The aim of the study is to examine associations between potentially inappropriate medication use and Activities of Daily Living (ADL) and Instrumental Activities of Daily Living (IADL) in geriatric rehabilitation inpatients.

METHODS

A longitudinal, prospective, observational study was undertaken at a teaching hospital. Potentially inappropriate medications (PIMs) and potential prescribing omissions (PPOs) were measured at acute admission, and at admission and discharge from geriatric rehabilitation. Associations between PIM and PPO use and ADL and IADL scores were examined at admission to geriatric rehabilitation, discharge and 3-month post-discharge.

RESULTS

A total of 693 inpatients were included. At the 3-month post-discharge, PPOs were associated with lower IADL scores (incident rate ratio = 0.868, 95% CI 0.776-0.972). There were no significant associations between PIMs and PPOs use at admission to geriatric rehabilitation with longitudinal changes of ADLs and IADLs from geriatric rehabilitation admission to 3-month post-discharge Renal PIMs were associated with higher IADL scores at 3-month post-discharge (incidence rate ratio = 1.750, 95% CI 1.238-2.474). At 3-month post-discharge, PPOs involving vaccinations were associated with a lower IADL score (incident risk ratio = 0.844, 95% CI 0.754-0.944).

CONCLUSIONS

Inappropriate medication use involving PPOs was associated with lower IADL scores at 3-month post-discharge from geriatric rehabilitation but not with ADL scores. Greater attention is needed in reducing PPOs in geriatric rehabilitation inpatients that can potentially impact IADLs. In the community, health professionals need to be vigilant about assessing how older patients' physical functioning may be affected by inappropriate medication prescribing.

Improvement in Activities of Daily Living during a Nursing Home Stay and One-Year Mortality among Older Adults with Sepsis

BACKGROUND/OBJECTIVE

To describe the recovery of activities of daily living (ADLs) during a skilled nursing facility (SNF) stay and the association with 1-year mortality after SNF discharge among Medicare beneficiaries treated in intensive care for sepsis.

DESIGN

Retrospective cohort study.

SETTING

Skilled nursing facilities in the United States.

PARTICIPANTS

Medicare fee-for-service beneficiaries admitted to an SNF within 3 days of discharge from a hospitalization that included an intensive care unit (ICU) stay for sepsis between January 1, 2013, and September 30, 2015 (N = 59,383).

MEASUREMENTS

Data from the Minimum Data Set (MDS) were used to calculate a total score for seven ADLs. Improvement was determined by comparing the total ADL scores from the first and last MDS assessments of the SNF stay. Proportional hazard models were used to estimate the association between improvement in ADL function and 1-year mortality after SNF discharge.

RESULTS

Approximately 58% of SNF residents had any improvement in ADL function. Residents who had improvement in ADL function had 0.72 (95% confidence interval (CI) = 0.69-0.74) lower risk for mortality following SNF discharge than residents who did not improve. Residents who improved 1-3 points (hazard ratio (HR) = 0.82, 95% CI = 0.79-0.84) and four or more points (HR = 0.57, 95% CI = 0.55-0.60) in ADL function had significantly lower mortality risk than residents who did not improve.

CONCLUSION

Older adults treated in an ICU with sepsis can improve in ADL function during an SNF stay. This improvement is associated with lower 1-year mortality risk after SNF discharge. These findings provide evidence that ADL recovery during an SNF stay is associated with better health outcomes for older adults who have survived an ICU stay for sepsis.

The association between ward staffing levels, mortality and hospital readmission in older hospitalised adults, according to presence of cognitive impairment: a retrospective cohort study

BACKGROUND

Lower nurse staffing levels are associated with increased hospital mortality. Older patients with cognitive impairments (CI) have higher mortality rates than similar patients without CI and may be additionally vulnerable to low staffing.

OBJECTIVES

To explore associations between registered nurse (RN) and nursing assistant (NA) staffing levels, mortality and readmission in older patients admitted to general medical/surgical wards.

RESEARCH DESIGN

Retrospective cohort.

PARTICIPANTS

All unscheduled admissions to an English hospital of people aged ≥75 with cognitive screening over 14 months.

MEASURES

The exposure was defined as deviation in staffing hours from the ward daily mean, averaged across the patient stay. Outcomes were mortality in hospital/within 30 days of discharge and 30-day re-admission. Analyses were stratified by CI.

RESULTS

12,544 admissions were included. Patients with CI (33.2%) were exposed to similar levels of staffing as those without. An additional 0.5 RN hours per day was associated with 10% reduction in the odds of death overall (odds ratio 0.90 [95% CI 0.84-0.97]): 15% in patients with CI (OR 0.85 [0.74-0.98]) and 7% in patients without (OR 0.93 [0.85-1.02]). An additional 0.5 NA hours per day was associated with a 15% increase in mortality in patients with no impairment. Readmissions decreased by 6% for an additional 0.5 RN hours in patients with CI.

CONCLUSIONS

Although exposure to low staffing was similar, the impact on mortality and readmission for patients with CI was greater. Increased mortality with higher NA staffing in patients without CI needs exploration.

Length of hospital stay is associated with a decline in activities of daily living in hemodialysis patients: a prospective cohort study

Background

The impact of length of hospital stay on activities of daily living (ADLs) has not specifically been investigated among dialysis patients. Therefore, we attempt to verify the association between the length of hospital stay and the decline in ADLs among hemodialysis patients.

Methods

This prospective cohort study used data from the Japanese Dialysis Outcomes and Practice Patterns Study (J-DOPPS). We included 2442 hemodialysis patients aged ≥40 years from the J-DOPPS phase V (2012–2015) and subsequently excluded those who had already lost basic activities of daily living (BADLs) as demonstrated by dependency in at least three of the five BADLs at baseline and for whom changes in ADLs had been evaluated for less than 90 days. The main exposure was the cumulative length of hospital stay during the follow-up period. The primary outcomes were a decline in at least one of the five BADLs and eight instrumental activities of daily living (IADLs). We compared risk ratios (RRs) for 30-day increments for hospital stays with 10-year increments for age and having diabetes.

Results

A total of 849 patients were included in the statistical analysis. The cumulative length of hospital stay was significantly associated with a risk of decline in ADLs (adjusted RRs [95% confidence intervals] per 30-day increments: 1.42 [1.15 to 1.75] for BADLs, 1.38 [1.13 to 1.68] for IADLs). The adjusted RRs [95% CI] for 10-year increments in age were 1.20 [0.96 to 1.50] and 1.21 [1.00 to 1.47]. The adjusted RRs [95% CI] for having diabetes were 1.36 [0.97 to 1.91] for BADLs and 1.38 [1.04 to 1.84] for IADLs.

Conclusion

The impact of a 30-day increment in the cumulative length of hospital stay on the decline in ADLs was comparable to that of a 10-year increase in age and having diabetes.

Keys to staying sharp: A randomized clinical trial of piano training among older adults with and without mild cognitive impairment

BACKGROUND

The prevalence of dementia, the most expensive medical condition (Kirschstein, 2000 and Hurd et al., 2013 [1,2]), and its precursor, mild cognitive impairment (MCI) are increasing [3]. Finding effective intervention strategies to prevent or delay dementia is imperative to public health. Prior research provides compelling evidence that central auditory processing (CAP) deficits are a risk factor for dementia [4-6]. Grounded in the information degradation theory [7, 8], we hypothesize that improving brain function at early perceptual levels (i.e., CAP) may be optimal to attenuate cognitive and functional decline and potentially curb dementia prevalence. Piano training is one avenue to enhance cognition [9-13] by facilitating CAP at initial perceptual stages [14-18].

OBJECTIVES

The Keys To Staying Sharp study is a two arm, randomized clinical trial examining the efficacy of piano training relative to music listening instruction to improve CAP, cognition, and everyday function among older adults. In addition, the moderating effects of MCI status on piano training efficacy will be examined and potential mediators of intervention effects will be explored.

HYPOTHESES

We hypothesize that piano training will improve CAP and cognitive performance, leading to functional improvements. We expect that enhanced CAP will mediate cognitive gains. We further hypothesize that cognitive gains will mediate functional improvements.

METHOD

We plan to enroll 360 adults aged 60 years and older who will be randomized to piano training or an active control condition of music listening instruction and complete pre- and immediate post- assessments of CAP, cognition, and everyday function.

Outcomes of hospital in the home treatment of acute decompensated congestive cardiac failure compared to traditional in-hospital treatment in older patients

OBJECTIVES

To compare the outcomes of readmission, mortality and treatment-related complications in older people treated by hospital in the home (HITH) for acute decompensated congestive cardiac failure (CCF) with those treated in hospital.

METHODS

Retrospective cohort study of patients 65 years and older treated by HITH over a 30-month period compared with age- and sex-matched patients treated in hospital.

RESULTS

There was no difference between the "HITH" and "Hospital" cohorts in mortality within 60 days of discharge (P = 0.5), time to death (P = 0.8), 30-day (P = 0.7) and 60-day (P = 0.4) readmissions, time to readmission (P = 0.9) and complication rate (P = 0.1). HITH patients had longer length of stay (P = 0.001) but lower cost per day of admission ($669.42 vs $1377.58).

CONCLUSION

In appropriately selected older patients, HITH is a safe, efficacious and cost-effective alternative to inpatient management of acute decompensated CCF.

Assessment and clinical implications of cognitive impairment in acutely ill geriatric patients using a revised simplified short-term memory recall test (STMT-R)

BACKGROUND

Cognitive dysfunction due to delirium or dementia is a common finding in acutely ill geriatric patients, but often remains undetected. A brief and sensitive clinical identification method could prevent errors or complications while evaluating the mental status of elderly patients.

AIMS

To evaluate the usefulness and clinical implications of the revised simplified short-term memory recall test (STMT-R) in geriatric patients admitted in the emergency department; with age, gender, dementia history, serum albumin, underlying diseases and clinical outcome used as comparative factors.

METHODS

Mini-mental state examination and STMT-R scores were initially compared and a positive correlation was observed (r = 0.66, p < 0.001). Subsequently, 885 inpatients aged over 50 years underwent STMT-R evaluation between October 2014 and September 2015. We considered as cognitive dysfunction STMT-R scores ≤ 4 of a maximum score of 8.

RESULTS

Among enrolled patients, 52.2% were female and the mean age was 78.9 years. There were 159 patients who were unable to complete the test (incomplete testing group). We observed cognitive dysfunction in 460 patients, while 266 did not have cognitive dysfunction. There were significant differences between those with and without cognitive dysfunction in terms of age, dementia history, underlying respiratory diseases, and hospital outcome.

CONCLUSION

Cognitive dysfunction at admission can have a negative effect on the hospital outcomes of elderly patients. Age, a history of dementia and underlying respiratory diseases may also influence cognitive functional decline.

Finding a 'new normal' following acute illness: A qualitative study of influences on frail older people's care preferences

Background:

The frail older population is growing, and many frail older people have episodes of acute illness. Patient preferences are increasingly considered important in the delivery of person-centred care and may change following acute illness.

Aim:

To explore influences on the care preferences of frail older people with recent acute illness.

Design:

Qualitative in-depth individual interviews, with thematic analysis.

Setting/participants:

Maximum variation sample of 18 patients and 7 nominated family carers from a prospective cohort study of people aged over 65, scoring ⩾5 on the Clinical Frailty Scale, and with recent acute illness, who were not receiving specialist palliative care. Median patient age was 84 (inter-quartile range 81–87), 53% female. Median frailty score 6 (inter-quartile range 5–7).

Results:

Key influences on preferences were illness and care context, particularly hospital care; adaptation to changing health; achieving normality and social context. Participants focused on the outcomes of their care; hence, whether care was likely to help them ‘get back to normal’, or alternatively ‘find a new normal’ influenced preferences. For some, acute illness inhibited preference formation. Participants’ social context and the people available to provide support influenced place of care preferences. We combined these findings to model influences on preferences.

Conclusion:

‘Getting back to normal’ or ‘finding a new normal’ are key focuses for frail older people when considering their preferences. Following acute illness, clinicians should discuss preferences and care planning in terms of an achievable normal, and carefully consider the social context. Longitudinal research is needed to explore the influences on preferences over time.

Orthostatic hypotension and physical functioning in older adults: A systematic review and meta-analysis

BACKGROUND

Orthostatic hypotension (OH) may negatively affect physical functioning and aggravate morbidities, but existing evidence is contradictory.

METHODS

MEDLINE (from 1946), PubMed (from 1966) and EMBASE databases (from 1947) were systematically searched for studies on the association of OH and physical functioning in older adults, categorized as: balance, gait characteristics, walking speed, Timed Up and Go time, handgrip strength (HGS), physical frailty, exercise tolerance, physical activity, activities of daily living (ADL), and performance on the Hoehn and Yahr scale (HY) and Unified Parkinson's Disease Rating Scale (UPDRS). Study quality was assessed using the Newcastle Ottawa Scale.

RESULTS

Forty-two studies were included in the systematic review (29,421 individuals) and 29 studies in the meta-analyses (23,879 individuals). Sixteen out of 42 studies reported a significant association of OH with worse physical functioning. Meta-analysis showed a significant association of OH with impaired balance, ADL performance and HY/UPDRS III performance, but not with gait characteristics, mobility, walking speed, TUG, HGS, physical frailty, exercise tolerance, physical activity and UPDRS II performance.

CONCLUSIONS

OH was associated with impaired balance, ADL performance and HY/UPDRS III performance, but not with other physical functioning categories. The results suggest that OH interventions could potentially improve some aspects of physical functioning.

Nursing care needs and services utilised by home-dwelling elderly with complex health problems: observational study

Background

In Norway, as in many Western countries, a shift from institutional care to home care is taking place. Our knowledge is limited regarding which needs for nursing interventions patients being cared for in their home have, and how they are met. We aimed at assessing aspects of health and function in a representative sample of the most vulnerable home-dwelling elderly, to identify their needs for nursing interventions and how these needs were met.

Methods

In this observational study we included patients aged 75+ living in their own homes in Oslo, who received daily home care, had three or more chronic diagnoses, received daily medication, and had been hospitalized during the last year. Focused attention and cognitive processing speed were assessed with the Trail Making Test A (TMT-A), handgrip strength was used as a measure of sarcopenia, mobility was assessed with the “Timed Up-and-Go” test, and independence in primary activities of daily living by the Barthel Index. Diagnoses and medication were collected from electronic medical records. For each diagnosis, medication and functional impairment, a consensus group defined which nursing service that the particular condition necessitated. We then assessed whether these needs were fulfilled for each participant.

Results

Of 150 eligible patients, 83 were included (mean age 87 years, 25% men). They had on average 6 diagnoses and used 9 daily medications. Of the 83 patients, 61 (75%) had grip strength indicating sarcopenia, 27 (33%) impaired mobility, and 69 (83%) an impaired TMT-A score. Median amount of home nursing per week was 3.6 h (interquartile range 2.6 to 23.4). Fulfilment of pre-specified needs was >60% for skin and wound care in patients with skin diseases, observation of blood glucose in patients taking antidiabetic drugs, and in supporting food intake in patients with eating difficulties. Most other needs as defined by the consensus group were fulfilled in <10% of the patients.

Conclusions

We identified a very frail group of home-dwelling patients. For this group, resources for home nursing should probably be used in a more flexible and pro-active way to aim for preserving functional status, minimize symptom burden, and prevent avoidable hospitalisations.

Improved Functional Performance in Geriatric Patients During Hospital Stay

OBJECTIVE

The aim of this work was to evaluate the time course of changes in strength and functional performance in elderly hospitalized medical patients.

DESIGN

This was a prospective observational study in elderly medical patients of age 65 years or older at a geriatric department.Measurements were obtained on days 2 to 4, day 5 to 8, and days 9 to 13. Functional performance was measured with De Morton Mobility Index (DEMMI) test and a 30-second chair stand test (30-s CST). Muscular strength was measured with handgrip strength. Activity level was determined with accelerometry (ActivPAL).

RESULTS

Results in DEMMI and 30-s CST gradually improved (P < 0.05), whereas handgrip strength remained unchanged (P > 0.05). Larger functional improvements were observed in patients with "high" compared to "low" and "moderate" activity level (P < 0.05). Changes in DEMMI score correlated with changes in 30-s CST (P < 0.05); however, changes in DEMMI score and 30-s CST were more likely to occur in patients with a low versus high functional level, respectively.

CONCLUSIONS

Functional performance of the lower extremities in geriatric patients improves moderately over the time of a hospital stay of less than 14 days, with larger improvements in patients with high activity level. The DEMMI test and the 30-s CST seem to be complementary to each other when evaluating functional changes in a geriatric hospital population.

TO CLAIM CME CREDITS

Complete the self-assessment activity and evaluation online at http://www.physiatry.org/JournalCME CME OBJECTIVES: Upon completion of this article, the reader should be able to (1) describe changes in mobility and muscle strength of geriatric patients during a hospital stay of less than 14 days, (2) understand the significance of physical activity during hospital admission in geriatric patients, and (3) discuss the potential limitations of measures for assessing mobility and lower extremity strength status and change during a hospital admission.

LEVEL

Advanced ACCREDITATION: The Association of Academic Physiatrists is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.The Association of Academic Physiatrists designates this activity for a maximum of 1.5 AMA PRA Category 1 Credit(s)™. Physicians should only claim credit commensurate with the extent of their participation in the activity.

Dementia in the acute hospital: the prevalence and clinical outcomes of acutely unwell patients with dementia

BACKGROUND

Studies have demonstrated that a significant minority of older persons presenting to acute hospital services are cognitively impaired; however, the impact of dementia on long-term outcomes is less clear.

AIM

To evaluate the prevalence of dementia, both formally diagnosed and hitherto unrecognised in a cohort of acutely unwell older adults, as well as its impact on both immediate outcomes (length of stay and in-hospital mortality) and 12-month outcomes including readmission, institutionalisation and death.

DESIGN

Prospective observational study.

METHODS

190 patients aged 70 years and over, presenting to acute hospital services underwent a detailed health assessment including cognitive assessment (standardised Mini Mental State Examination, AD8 and Confusion Assessment Method for the Intensive Care Unit). Patients or informants were contacted directly 12 months later to compile 1-year outcome data. Dementia was defined as a score of 2 or more on the AD8 screening test.

RESULTS

Dementia was present in over one-third of patients (73/190). Of these patients, 36% (26/73) had a prior documented diagnosis of dementia with the remaining undiagnosed before presentation. The composite outcome of death or readmission to hospital within the following 12 months was more likely to occur in patients with dementia (73% (53/73) vs. 58% (68/117), P = 0.043). This finding persisted after controlling for age, gender, frailty status and medical comorbidities, including stroke and heart disease.

CONCLUSION

A diagnosis of dementia confers an increased risk of either death or further admission within the following 12 months, highlighting the need for better cognitive screening in the acute setting, as well as targeted intervention such as comprehensive geriatric assessment.

The Impact of a Home-Based Computerized Cognitive Training Intervention on Fall Risk Measure Performance in Community Dwelling Older Adults, a Pilot Study

OBJECTIVES

Cognitive intervention studies have reported improvements in various domains of cognition as well as a transfer effect of improved function post training. Despite the availability of web based cognitive training programs, most intervention studies have been performed under the supervision of researchers. Therefore, the purpose of this study was to first, examine the feasibility of a six week home based computerized cognitive training (CCT) program in a group of community dwelling older adults and, second, to determine if a CCT program which focused on set shifting, attention, and visual spatial ability impacted fall risk measure performance.

DESIGN

This pilot study used a pretest/posttest experimental design with randomization by testing site to an intervention or control group.

PARTICIPANTS

Community dwelling older adults (mean age = 74.6 years) participated in either the control (N=25) or the intervention group (N=19).

INTERVENTION

Intervention group subjects participated in 6 weeks of home based CCT 3x/week for an average of 23 minutes/session, using an online CCT program.

MEASUREMENTS

Comparisons of mean scores on three measures of physical function (usual gait speed, five times sit to stand, timed up and go) were completed at baseline and week 7.

RESULTS

Following the completion of an average of 18 sessions of CCT at home with good adherence (86%) and retention (92%) rates, a statistically significant difference in gait speed was found between groups with an average improvement of 0.14 m/s in the intervention group.

CONCLUSION

A home based CCT program is a feasible approach to targeting cognitive impairments known to influence fall risk and changes in gait in older adults.

Activity of daily living trajectories surrounding acute hospitalization of long-stay nursing home residents

OBJECTIVES

To explore patterns of change in nursing home (NH) residents' activities of daily living (ADLs), particularly surrounding acute hospital stays.

DESIGN

Longitudinal study using Medicare and Minimum Data Set (MDS) assessments.

SETTING

National sample of long-stay NH residents.

PARTICIPANTS

NH residents who were hospitalized for the seven most-common inpatient diagnoses (N = 40,128). Each hospital admission was at least 90 days after any prior hospitalization and had at least two preceding MDS assessments.

MEASUREMENTS

The MDS ADL long-form score, a simple sum of seven self-care variables coded from 0 (independent) to 4 (totally dependent) was used to indicate resident ADL function. Scores ranged from 0 to 28, with higher scores indicating greater impairment. A linear mixed model describing ADL trajectories was jointly estimated with time-to-event models for mortality and hospital readmission.

RESULTS

Before hospitalization, the most common trajectory was stable (53.7%), with 27.5% of residents worsening and 18.8% improving. ADL function after hospital discharge was most often characterized as stable (43.1%) or worsening (39.2%). Mortality (20.3%) was higher for those with worsening prehospital ADL function (28.9%) than for those with stable (19.1%) or improving (11.3%) trajectories. Hospital diagnosis was associated with amount of ADL worsening and rate of subsequent ADL change. Most residents with the best initial function continued to worsen after hospital discharge. Cognitive impairment was associated with poorer ADL function and accelerated worsening of ADLs.

CONCLUSION

For many long-stay NH residents, substantial and sustained ADL worsening accompanies acute hospitalization, so acute hospitalization presents an opportunity to revisit care goals; the results of the current study can help inform decision-making.

Measuring levels of person-centeredness in acute care of older people with cognitive impairment: evaluation of the POPAC scale

BACKGROUND

Person-centeredness is increasingly advocated in the literature as a gold-standard, best practice concept in health services for older people. This concept describes care that incorporates individual and multidimensional needs, personal biography, subjectivity and interpersonal relationships. However, acute in-patient hospital services have a long-standing biomedical tradition that may contrast with person-centred care. Since few tools exist that enable measurements of the extent to which acute in-patient hospital services are perceived as being person-centred, this study aimed to translate the English version of the Person-centred care of older people with cognitive impairment in acute care scale (POPAC) to Swedish, and evaluate its psychometric properties in a sample of acute hospital staff.

METHODS

The 15-item POPAC was translated, back-translated and culturally adjusted, and distributed to a cross-sectional sample of Swedish acute care staff (n = 293). Item performance was evaluated through assessment of item means, internal consistency by Cronbach's alpha on total and on subscale levels; temporal stability was assessed through Pearson's product correlation and intra-class correlation between test and retest scores. Confirmatory factor analysis was used to explore model fit.

RESULTS

The results indicate that the Swedish version POPAC provides a tentatively construct-valid and reliable contribution to measuring the extent to which acute in-patient hospital services have processes and procedures that can facilitate person-centred care of older patients with cognitive impairment. However, some questions remain regarding the dimensionality of POPAC.

CONCLUSIONS

POPAC provides a valuable contribution to the quest of improving acute care for older patients with cognitive impairment by enabling measures and subsequent accumulation of internationally comparable data for research and practice development purposes. POPAC can be used to highlight strengths and areas for improvements in care practice for older patients, and to illuminate aspects that risk being overlooked in busy acute hospital settings.

Physical activity and brain function in older adults at increased risk for Alzheimer's disease

Leisure-time physical activity (PA) and exercise training are known to help maintain cognitive function in healthy older adults. However, relatively little is known about the effects of PA on cognitive function or brain function in those at increased risk for Alzheimer's disease through the presence of the apolipoproteinE epsilon4 (APOE-ε4) allele, diagnosis of mild cognitive impairment (MCI), or the presence of metabolic disease. Here, we examine the question of whether PA and exercise interventions may differentially impact cognitive trajectory, clinical outcomes, and brain structure and function among individuals at the greatest risk for AD. The literature suggests that the protective effects of PA on risk for future dementia appear to be larger in those at increased genetic risk for AD. Exercise training is also effective at helping to promote stable cognitive function in MCI patients, and greater cardiorespiratory fitness is associated with greater brain volume in early-stage AD patients. In APOE-ε4 allele carriers compared to non-carriers, greater levels of PA may be more effective in reducing amyloid burden and are associated with greater activation of semantic memory-related neural circuits. A greater research emphasis should be placed on randomized clinical trials for exercise, with clinical, behavioral, and neuroimaging outcomes in people at increased risk for AD.

A qualitative analysis of an advanced practice nurse-directed transitional care model intervention

PURPOSE

The purpose of this study was to describe barriers and facilitators to implementing a transitional care intervention for cognitively impaired older adults and their caregivers lead by advanced practice nurses (APNs).

DESIGN AND METHODS

APNs implemented an evidence-based protocol to optimize transitions from hospital to home. An exploratory, qualitative directed content analysis examined 15 narrative case summaries written by APNs and fieldnotes from biweekly case conferences.

RESULTS

Three central themes emerged: patients and caregivers having the necessary information and knowledge, care coordination, and the caregiver experience. An additional category was also identified, APNs going above and beyond.

IMPLICATIONS

APNs implemented individualized approaches and provided care that exceeds the type of care typically staffed and reimbursed in the American health care system by applying a Transitional Care Model, advanced clinical judgment, and doing whatever was necessary to prevent negative outcomes. Reimbursement reform as well as more formalized support systems and resources are necessary for APNs to consistently provide such care to patients and their caregivers during this vulnerable time of transition.

The relationship between intervening hospitalizations and transitions between frailty states

BACKGROUND

Frailty among older persons is a dynamic process, characterized by frequent transitions between frailty states over time. We performed a prospective longitudinal study to evaluate the relationship between intervening hospitalizations and these transitions.

METHODS

We studied 754 nondisabled community-living persons, aged 70 years or older. Frailty, assessed every 18 months for 108 months, was defined on the basis of muscle weakness, exhaustion, low physical activity, shrinking, and slow walking speed. Participants were classified as frail if they met three or more of these criteria, prefrail if they met one or two of the criteria, or nonfrail if they met none of the criteria. Hospitalizations were ascertained every month for a median of 108 months.

RESULTS

The exposure rates (95% confidence interval) of hospitalization per 1,000 months, based on frailty status at the start of each 18-month interval, were 19.7 (16.2-24.0) nonfrail, 32.9 (29.8-36.2) prefrail, and 57.2 (52.9-63.1) frail. The likelihood of transitioning from states of greater frailty to lesser frailty (ie, recovering) was consistently lower based on exposure to intervening hospitalizations, with adjusted hazard ratios per each hospitalization ranging from 0.46 (95% confidence interval: 0.21-1.03) for the transition from frail to nonfrail states to 0.52 (95% confidence interval: 0.42-0.65) for the transition from prefrail to nonfrail states. Hospitalization had more modest and less consistent effects on transitions from states of lesser frailty to greater frailty. Nonetheless, transitions from nonfrail to frail states were uncommon in the absence of a hospitalization.

CONCLUSIONS

Recovery from prefrail and frail states is substantially diminished by intervening hospitalizations. These results provide additional evidence highlighting the adverse consequences of hospitalization in older persons.

Reducing "iatrogenic disability" in the hospitalized frail elderly

BACKGROUND

Hospitalization is the first cause of functional decline in the elderly: 30 to 60% of elderly patients lose some independence in basic activities of daily living (ADL) during a stay in hospital. This loss of independence results from the acute condition that led to admission, but is also related to the mode of management.

OBJECTIVE

This paper is a review of the literature on functional decline in elderly hospitalized patients. It is the first stage in a project aiming to prevent dependence that is induced during the course of care.

METHODS

During a 2-day workshop in Monaco, a task force of 20 international experts discussed and defined the concept of "iatrogenic disability".

RESULTS

1- "Iatrogenic disability" was defined by the task force as the avoidable dependence which often occurs during the course of care. It involves three components that interact and have a cumulative effect: a) the patient's pre-existing frailty, b) the severity of the disorder that led to the patient's admission, and lastly c) the hospital structure and the process of care. 2- The prevention of "iatrogenic disability" involves successive stages. - becoming aware that hospitalization may induce dependence. Epidemiological studies have identified at-risk populations by the use of composite scores (HARP, ISAR, SHERPA, COMPRI, etc). - considering that functional decline is not a fatality. Quality references have already been defined. Interventions to prevent dependence in targeted populations have been set up: simple geriatric consultation teams, single-factor interventions (aimed for example at mobility, delirium, iatrogenic disorders) or multidomain interventions (such as GEM and ACE units, HELP, Fast Track, NICHE). These interventions are essentially centered on the patient's frailty and have limited results, as they take little account of the way the institution functions, which is not aimed at prevention of functional decline. The process of care reveals shortcomings: lack of geriatric knowledge, inadequate evaluation and management of functional status. The group suggests that interventions must not only identify at-risk patients so that they may benefit from specialized management, but they must also target the hospital structure and the process of care. This requires a graded "quality approach" and rethinking of the organization of the hospital around the elderly person.

Risk factors of functional decline during hospitalization in the oldest old

BACKGROUND AND AIMS

The number of hospital admissions of the elderly is increasing and hospitalization often leads to functional decline. The aim of this study was to identify major risk factors for functional decline in the hospitalized oldest old.

METHODS

Prospective, observational, non-randomized study of patients aged >/=80 years, admitted for at least two days to the University Department of Geriatric Medicine of Torino, Italy, between November 2003 and November 2004. For detection of functional decline, the ADL scale was used, referring to the number of dependent ADL.

RESULTS

At discharge, ADL mean scores were significantly higher than on admission (2.5+/-2 vs 2.3+/-1.9, p<0.001). 23.9% of the sample lost at least one ADL function during hospitalization, and 19.2% were transferred to long-term care, compared with 5.4% of those with no functional decline. Length of hospitalization, neoplasm, low level of albumin and high number of drugs prescribed were associated with functional decline. At multivariate analysis, only in-hospital stay was an independent risk factor for functional decline (RR 1.1 per day of hospitalization, CI 1.03-1.14).

CONCLUSIONS

Hospitalization of the oldest old increases the risk of functional decline, especially if prolonged. It is important to identify patients at high risk for functional decline after hospital admission.

Factors associated with recovery of prehospital function among older persons admitted to a nursing home with disability after an acute hospitalization

BACKGROUND

The objective of this study was to identify the factors associated with recovery of prehospital function among older persons admitted to a nursing home with disability after an acute hospitalization.

METHODS

The analytic sample included 292 participants of an ongoing cohort study who had one or more admissions to a nursing home with disability after an acute hospitalization during nearly 10 years of follow-up, yielding a total of 364 "index" nursing home admissions. Information on nursing home admissions, hospitalizations, and disability in essential activities of daily living was ascertained during monthly telephone interviews. Data on potential predictors of functional recovery were collected during comprehensive assessments, which were completed every 18 months for 90 months. Participants were considered to have recovered if they were discharged home within 6 months of their nursing home admission at (or above) their prehospital level of function.

RESULTS

Recovery of prehospital function was observed for 115 (31.6%) of the 364 index nursing home admissions. In the multivariate analysis, the strongest associations were observed for the best category of performance, relative to the poorest category, for gross motor coordination (hazard ratio [HR] 13.5, 95% confidence interval [CI] 4.02-45.0) and manual dexterity (HR 10.0, 95% CI 2.94-34.3). Only two other factors were independently associated with recovery of prehospital function: not cognitively impaired (HR 3.0, 95% CI 1.46-6.14) and no significant weight loss (HR 1.96, 95% CI 1.06-3.63).

CONCLUSIONS

In the setting of an acute hospitalization leading to a nursing home admission with disability, the likelihood of recovering prehospital function is low. The factors associated with recovery include faster performance on tests of gross motor coordination and manual dexterity and the absence of cognitive impairment and significant weight loss.

Program of all-inclusive care (PACE): past, present, and future

From modest beginnings in 1973 to over 60 programs nationwide, the PACE concept has proven the value of integrated, interdisciplinary-based care for frail older adults. The evolution of PACE and its regulatory and reimbursement model have changed over time, but the principals of care have remained unchanged. Nationally PACE programs are dealing with some of the same challenges they had 30 years ago and yet PACE programs continue to expand and provide care to an ever wider distribution of populations. The looming issue of ever-growing health care expenditures represents another opportunity for PACE to demonstrate its value while providing a level of quality beyond what could normally be provided by typical Medicare and Medicaid payments for similar conditions and patient characteristics. The future for PACE includes a number of possibilities including flexibility in financing and reimbursement, design changes to work with community-based physicians, potential eligibility adjustments, and growth of rural PACE. The PACE model has clearly demonstrated that in a debilitated, frail population in whom health care expenses would be expect to be high, a combination of team care, managed health care services, and care coordination can lead to both improved health outcomes and reduced expenses over time.

A cognitive training program based on principles of brain plasticity: results from the Improvement in Memory with Plasticity-based Adaptive Cognitive Training (IMPACT) study

OBJECTIVES

To investigate the efficacy of a novel brain plasticity-based computerized cognitive training program in older adults and to evaluate the effect on untrained measures of memory and attention and participant-reported outcomes.

DESIGN

Multisite randomized controlled double-blind trial with two treatment groups.

SETTING

Communities in northern and southern California and Minnesota.

PARTICIPANTS

Community-dwelling adults aged 65 and older (N=487) without a diagnosis of clinically significant cognitive impairment.

INTERVENTION

Participants were randomized to receive a broadly-available brain plasticity-based computerized cognitive training program (intervention) or a novelty- and intensity-matched general cognitive stimulation program modeling treatment as usual (active control). Duration of training was 1 hour per day, 5 days per week, for 8 weeks, for a total of 40 hours.

MEASUREMENTS

The primary outcome was a composite score calculated from six subtests of the Repeatable Battery for the Assessment of Neuropsychological Status that use the auditory modality (RBANS Auditory Memory/Attention). Secondary measures were derived from performance on the experimental program, standardized neuropsychological assessments of memory and attention, and participant-reported outcomes.

RESULTS

RBANS Auditory Memory/Attention improvement was significantly greater (P=.02) in the experimental group (3.9 points, 95% confidence interval (CI)=2.7-5.1) than in the control group (1.8 points, 95% CI=0.6-3.0). Multiple secondary measures of memory and attention showed significantly greater improvements in the experimental group (word list total score, word list delayed recall, digits backwards, letter-number sequencing; P<.05), as did the participant-reported outcome measure (P=.001). No advantage for the experimental group was seen in narrative memory.

CONCLUSION

The experimental program improved generalized measures of memory and attention more than an active control program.

Predicting change in functional status over quarterly intervals for older adults enrolled in the PACE community-based long-term care program

BACKGROUND AND AIMS

Many frail older adults experience multiple changes in activities of daily living (ADL) functioning over the course of a year. Accurate predictions of ADL status over quarterly intervals may improve the precision of care planning for older adults who seek long-term care in the community. The study sought to develop and validate a model that predicts older adults' ADL status over quarterly intervals.

METHODS

The study included 3127 enrollees from 11 Program of All Inclusive Care for the Elderly (PACE) sites. Nurses assessed ADL status quarterly. Potential predictors included baseline assessment of age, sex, race, and living situation and quarterly assessments of prior functioning, co-morbidities, prior hospitalizations, and mental status.

RESULTS

Change in level of functioning occurred for 30% of quarterly observations. Predictors of functioning at the end of a quarter were prior ADL change, prior hospitalization, living with others, impaired mental status, cancer, dementia, coronary artery disease, congestive heart failure and chronic obstructive pulmonary disease. When the model was applied to the validation observations, 93% of predictions were within one level and 72% of the predictions were the same level of ADL functioning observed at the end of the quarter.

CONCLUSIONS

In a sample of community-living ADL-disabled older adults, changes in functional status over a quarter were common and associated with functional and health status at the beginning of the quarter. Further validation of the model may result in an index that helps clinicians better predict future ADL needs of community-living older adults who need long-term care.

A randomized controlled trial on early physiotherapy intervention versus usual care in acute care unit for elderly: potential benefits in light of dietary intakes

OBJECTIVE

To evaluate effects of early intensive physiotherapy during acute illness on post hospitalization activity daily living autonomy (ADL).

DESIGN

Prospective randomized controlled trial of intensive physiotherapy rehabilitation on day 1 to 2 after admission until clinical stability or usual care.

SETTING

acute care geriatric medicine ward.

PATIENTS

A total of 76 acutely ill patients, acutely bedridden or with reduced mobility but who were autonomous for mobility within the previous 3 months. Patients in palliative care or with limiting mobility pathology were excluded. Mean age was 85.4 (SD 6.6) years.

MEASUREMENTS

At admission, at clinical stability and one month later: anthropometry, energy and protein intakes, hand grip strength, ADL scores, and baseline inflammatory parameters. An exploratory principal axis analysis was performed on the baseline characteristics and general linear models were used to explore the course of ADL and nutritional variables.

RESULTS

A 4-factor solution was found explaining 71.7% of variance with a factor "nutrition", a factor "function" (18.8% of variance) for ADL, handgrip strength, bedridden state, energy and protein intakes, serum albumin and C-reactive protein concentrations; a factor "strength" and a fourth factor . During follow-up, dietary intakes, handgrip strength, and ADL scores improved but no changes occurred for anthropometric variables. Intervention was associated only with an increase in protein intake. Better improvement in ADL was found in intervention group when model was adjusted on "function" factor items.

CONCLUSION

Physical intervention programs should be proposed according to nutritional intakes with the aim of preventing illness induced disability.

Treatment strategy and risk of functional decline and mortality after nursing-home acquired lower respiratory tract infection: two prospective studies in residents with dementia

BACKGROUND

Although lower respiratory tract infections (LRI) cause considerable morbidity and mortality among nursing home residents with dementia, the effects of care and treatment are largely unknown. Few large prospective studies have been conducted.

METHODS

We pooled data from two large prospective cohort studies in 61 Dutch nursing homes and 36 nursing homes in the state of Missouri, United States. We included 551 US residents and 381 Dutch residents with dementia and LRI. Main outcome measures were 3-month mortality and decline in activities of daily living (ADL) function after 3 months compared with pre-illness status. Using multivariable multinomial logistic regression to control for confounding, we assessed associations of restraint use and antibiotic type (oral compared with parenteral), with outcomes of lower respiratory tract infection (LRI). Survival without ADL decline was the reference category.

RESULTS

After multivariable adjustment, restraint use was associated with ADL decline (OR 1.9, 95% CI 1.1-3.3). Oral antibiotics were not associated with 3-month mortality (OR 0.83; 95% CI 0.56-1.2). Severe dementia was the strongest independent predictor of decline; mortality was most strongly associated with male gender.

CONCLUSIONS

Among Dutch and US nursing home residents with dementia and LRI, restrained residents suffered more decline. Parenteral antibiotic treatment was not associated with better outcome in residents at low to moderate risk of mortality. Aggressive treatment strategies may provide little benefit for the majority of nursing home residents with dementia and LRI.

Assessing neurocognitive outcomes after critical illness: are delirium and long-term cognitive impairments related?

PURPOSE OF REVIEW

Critically ill patients have a high risk of developing neurologic dysfunction including delirium and long-term cognitive impairment. In this paper we examine possible relationships between delirium and long-term cognitive impairments and explore this in the context of critical illness.

RECENT FINDINGS

Critical illness and its treatment can lead to neurologic morbidity including neuropathological abnormalities, delirium, and cognitive impairments. The association between delirium and long-term cognitive impairments has been shown in a number of populations. Among intensive care unit cohorts, delirium appears to be one of many possible causes of cognitive impairments and may be a leading modifiable cause. The mechanisms of both delirium and intensive care unit related cognitive impairment remain unclear, although a variety of common mechanisms have been proposed.

SUMMARY

Potential neurologic consequences of critical illness include delirium and long-term cognitive impairments. Defining the extent of their association in intensive care unit cohorts is an important research priority due to the high prevalence of delirium and persistent cognitive impairments in critically ill patients. Future research should focus on strategies for the early identification of delirium and cognitive impairments, elucidating mechanisms of brain injury, and the development and implementation of therapeutic modalities designed to prevent or decrease delirium and cognitive morbidity.

Analysis of measures of functional and cognitive ability for aging adults with cardiac and vascular disease

Baseline and follow-up assessments of functional and cognitive status are essential for aging patients who survive acute cardiac and vascular disease, as they are faced with new medications and implementing changes in lifestyle. Because declining functional and/or cognitive status will interfere with treatment regimens and taking prescribed medications, it is imperative that healthcare providers develop an understanding of approaches to functional and cognitive assessment that can be used with aging patients, selecting those most appropriate for the venue in which they practice and for their particular patient population.

Population impact of arthritis on disability in older adults

OBJECTIVE

Disability threatens the independence of older adults and has large economic and societal costs. This article examines the population impact of arthritis on disability incidence among older Americans.

METHODS

The present study used longitudinal data (1998-2000) from the Health and Retirement Study, a national probability sample of elderly Americans. Disability was defined by the inability to perform basic activities of daily living (ADL). A total of 7,758 participants ages > or =65 years with no ADL disability at baseline were included in the analyses. Multiple logistic regression was used to measure the impact of baseline arthritis (self reported) on incidence of subsequent ADL disability after controlling for baseline differences in demographics, health factors, health behaviors, and medical access.

RESULTS

Older adults who had baseline arthritis had a substantially higher incidence of ADL disability compared with those without arthritis (9.3% versus 4.5%). The strong relationship of arthritis and ADL disability was partially explained by demographic, health, behavioral, and medical access factors. However, even after adjusting for all other risk factors, arthritis remained as an independent and significant predictor for developing ADL disability (adjusted odds ratio 1.5, 95% confidence interval 1.2-1.8). Almost 1 in every 4 new cases of ADL disability was due to arthritis (adjusted population attributable fraction: 23.7%).

CONCLUSION

The high frequency of incident ADL disability attributable to arthritis points to the importance of intervention programs that address the entire spectrum of health and functional problems in persons with arthritis to prevent disability.

Elderly patients with cognitive impairment have a high risk for functional decline during hospitalization: The GIFA Study

BACKGROUND

We tested the hypothesis that cognitive impairment upon admission (CIA) and cognitive decline (CD) during hospitalization are associated with an increased risk for functional decline (FD) in older inpatients.

METHODS

The Italian Group of Pharmacoepidemiology in the Elderly (Gruppo Italiano di Farmacoepidemiologia nell'Anziano, GIFA) project was a multicenter survey of 9061 older patients admitted to Italian hospitals between 1991 and 1997. CIA was defined as a Hodkinson Abbreviated Mental Test score <7 on admission. The percentage of participants who developed FD, defined as loss of the ability to perform without help one or more activities of daily living between admission and discharge, was compared in patients who did and did not have CIA, and between those who lost at least one point in Hodkinson Abbreviated Mental Test score (CD) and those who did not.

RESULTS

Mean age was 77.4 years, and women represented 52.3% of the sample. CIA was present in 21.0% of the patients. During hospitalization, 176 patients (1.9%) experienced FD (4% of those with CIA vs 1.3% of those without CIA). In multivariate analysis, CIA was an important risk factor for FD (odds ratio 2.4; 95% confidence interval, 1.7-3.5; p <.001), independent of age, gender, comorbidity, polypharmacy, and disability on admission. CD occurred in 3.7% of the sample and was strongly associated with an increased risk for FD (odds ratio 16.0; 95% confidence interval, 10.8-23.6; p <.001).

CONCLUSIONS

Elderly patients with CIA have a higher risk for FD. New strategies should be implemented to prevent FD in patients with cognitive impairment, who account for a high percentage of older persons who are admitted to hospitals.

Functional decline in hospitalized older adults

In older adults who are hospitalized, functional decline can occur in a matter of days. This devastating outcome is a common result of the older adult's "cascade to dependency," in which normal aging changes--combined with bed rest or immobility--result in irreversible physiologic changes, poor outcomes at discharge, and for many, placement in a nursing home. Routine walking schedules, activities to prevent sensory deprivation, and timely hospital discharge are among the interventions that can help prevent functional decline.

Rates of Acute Care Admissions for Frail Older People Living with Met Versus Unmet Activity of Daily Living Needs

OBJECTIVES

To determine whether older people who do not have help for their activity of daily living (ADL) disabilities are at higher risk for acute care admissions and whether entry into a program that provides for these needs decreases this risk.

DESIGN

A longitudinal cohort study.

SETTING

Thirteen nationwide sites for the Program of All-inclusive Care for the Elderly (PACE). PACE provides comprehensive medical and long-term care to community-living older adults.

PARTICIPANTS

Two thousand nine hundred forty-three PACE enrollees with one or more ADL dependencies.

MEASUREMENTS

Unmet needs were defined as the absence of paid or unpaid assistance for ADL disabilities before PACE enrollment. Hospital admissions in the 6 months before PACE enrollment and acute admissions in the first 6 weeks and the 7th through 12th weeks after enrollment were determined.

RESULTS

Those who lived with unmet ADL needs before enrollment were more likely to have a hospital admission before PACE enrollment (odds ratio (OR) = 1.28, 95% confidence interval (CI) = 1.01-1.63) and an acute admission in the first 6 weeks after enrollment (OR = 1.45, 95% CI = 1.00-2.09) but not after 6 weeks of receiving PACE services (OR = 0.86, 95% CI = 0.53-1.40).

CONCLUSION

Frail older people who live without needed help for their ADL disabilities have higher rates of admissions while they are living with unmet ADL needs but not after their needs are met. With state governments under increasing pressure to develop fiscally feasible solutions for caring for disabled older people, it is important that they be aware of the potential health consequences of older adults living without needed ADL assistance.

Effect of hospital in the home treatment on physical and cognitive function: a randomized controlled trial

BACKGROUND

Hospitalization for acute illness is associated with higher rates of mortality and morbidity, as well as functional decline, for older patients. We have previously shown that treatment in Hospital in the Home (HITH) results in less confusion and fewer bowel and bladder problems for these patients. However, it is not clear what impact HITH has on physical and cognitive function.

METHODS

One hundred patients (mean age 70) presenting to the emergency department and assessed by a senior doctor to require admission were randomized to be treated in hospital or at home. We measured the Barthel index, Instrumental Activities of Daily Living (IADL) index, and Mental Status Questionnaire (MSQ) on admission and at discharge.

RESULTS

The HITH-treated group improved in the IADL and MSQ indices, whereas the hospital-treated group improved only in the MSQ. The improvement in IADL scores remained significant after adjusting for age, sex, living arrangements, development of confusion, and length of stay.

CONCLUSIONS

HITH offers a safe option for treatment of older patients with a functional advantage over in-hospital care.

Risk factors for functional decline in older adults with arthritis

OBJECTIVE

Functional limitation is a major factor in medical costs. This study was undertaken to evaluate the prevalence of functional limitation among adults with arthritis and the frequency of functional decline over 2 years, and to investigate factors amenable to public health intervention that predict functional decline.

METHODS

Longitudinal data (1998-2000) from a cohort of 5,715 adults ages 65 years or older with arthritis from a national probability sample were analyzed. Function was defined based on ability to perform basic activities of daily living (ADL) tasks and instrumental ADL. Adjusted odds ratios (ORs) from a multiple logistic regression model were used to estimate the associations between functional decline and comorbid conditions, health behaviors, and economic factors.

RESULTS

Overall, 19.7% of this cohort had functional limitation at baseline, including 12.9% with ADL limitations. Over the subsequent 2 years, function declined in 13.6% of those at risk. Functional decline was most frequent among women (15.0%) and minorities (18.0% Hispanics, 18.7% African Americans) with arthritis. Lack of regular vigorous physical activity, the most prevalent risk factor (64%), almost doubled the odds of functional decline (adjusted OR 1.9, 95% confidence interval 1.5-2.4) after controlling for all risk factors. It was found that if all subjects engaged in regular vigorous physical activity, the expected functional decline could be reduced as much as 32%. Other significant predictors included older age, cognitive impairment, depressive symptoms, diabetes, physical limitations, no alcohol use, stroke, and vision impairment.

CONCLUSION

Lack of regular vigorous physical activity is a potentially modifiable risk factor that could substantially reduce functional decline and associated health care costs. Prevention/intervention programs should include regular vigorous physical activity, weight maintenance, and medical intervention for health needs. (c) 2005, American College of Rheumatology.

Usefulness of a single item in a mail survey to identify persons with possible dementia: a new strategy for finding high-risk elders

The objective of this study was to examine the characteristics of elderly persons who responded positively to a question about "severe memory problems" on a mailed health questionnaire yet were missed by the existing health risk algorithm to identify vulnerable elderly persons. A total of 324,471 respondents aged 65 and older completed a primary care health status questionnaire that gathered clinical information to quickly identify members with functional impairment, multiple chronic diseases, and higher medical care needs. The respondents were part of a large, integrated, not-for-profit managed care organization that implemented a model of care for elders using a uniform risk identification method across eight regions. Respondents with severe memory problems were compared to general respondents by morbidity, geriatric syndromes, functional impairments, service utilization, sensory impairments, sociodemographic characteristics, and activities of daily living. Of the respondents, 13,902 persons (4.3%) reported severe memory problems; the existing health risk algorithm missed 47.1% of these. When severe memory problems were included in the risk algorithm, identification increased from 11% to 13%, and risk prevalence by age groups ranged from 4.4% to 40.5%; one third had severe memory problems, a finding that was fairly consistent within age groups (28.4% to 36.5%). A question about severe memory problems should be incorporated into population risk-identification techniques. While false-negative rates are unknown, the false-positive rate of a self-report mail survey appears to be minimal. Persons reporting severe memory problems clearly have multiple comorbidities, higher prevalence of geriatric syndromes, and greater functional and sensory impairments.

Barriers to excellent end-of-life care for patients with dementia

While great strides have been made recently in improving end-of-life care in the United States, people with dementia often die with inadequate pain control, with feeding tubes in place, and without the benefits of hospice care. In this paper, we discuss the most important and persistent challenges to providing excellent end-of-life care for patients with dementia, including dementia not being viewed as a terminal illness; the nature of the course and treatment decisions in advanced dementia; assessment and management of symptoms; the caregiver experience and bereavement; and health systems issues. We suggest approaches for overcoming these barriers in the domains of education, clinical practice, and public policy. As the population ages, general internists increasingly will be called upon to provide primary care for a growing number of patients dying with dementia. There are great opportunities to improve end-of-life care for this vulnerable and underserved population.