Caring for patients with dementia: how good is the quality of care? Results from three health systems

Association between physician age and patterns of end-of-life care among older Americans

BACKGROUND

End-of-life (EOL) care patterns may differ by physician age given differences in how physicians are trained or changes associated with aging. We sought to compare patterns of EOL care delivered to older Americans according to physician age.

METHODS

We conducted a cross-sectional study of a 20% sample of Medicare fee-for-service beneficiaries aged ≥66 years who died in 2016-2019 (n = 487,293). We attributed beneficiaries to the physician who had >50% of primary care visits during the last 6 months of life. We compared beneficiary-level outcomes by physician age (<40, 40-49, 50-59, or ≥60) in two areas: (1) advance care planning (ACP) and palliative care; and (2) high-intensity care at the EOL.

RESULTS

Beneficiaries attributed to younger physicians had slightly higher proportions of billed ACP (adjusted proportions, 17.1%, 16.1%, 15.5%, and 14.0% for physicians aged <40, 40-49, 50-59, and ≥60, respectively; p-for-trend adjusted for multiple comparisons <0.001) and palliative care counseling or hospice use in the last 180 days of life (64.5%, 63.6%, 61.9%, and 60.8%; p-for-trend <0.001). Similarly, physicians' younger age was associated with slightly lower proportions of emergency department visits (57.4%, 57.0%, 57.4%, and 58.1%; p-for-trend <0.001), hospital admissions (51.2%, 51.1%, 51.4%, and 52.1%; p-for-trend <0.001), intensive care unit admissions (27.8%, 27.9%, 28.2%, and 28.3%; p-for-trend = 0.03), or mechanical ventilation or cardiopulmonary resuscitation (14.2, 14.9%, 15.2%, and 15.3%; p-for-trend <0.001) in the last 30 days of life, and in-hospital death (20.2%, 20.6%, 21.3%, and 21.5%; p-for-trend <0.001).

CONCLUSIONS

We found that differences in patterns of EOL care between beneficiaries cared for by younger and older physicians were small, and thus, not clinically meaningful. Future research is warranted to understand the factors that can influence patterns of EOL care provided by physicians, including initial and continuing medical education.

Implementation and review of the care ecosystem in an integrated healthcare system

BACKGROUND AND OBJECTIVES

The University of California, San Francisco Memory and Aging Center (UCSF-MAC) led the development and tested a collaborative care model delivered by lay care team navigators (CTNs) with support from a multidisciplinary team known as the Care Ecosystem (CE). We evaluated outcomes related to the feasibility of the CE in a non-academic healthcare system, including acceptability, adoption, and fidelity to the original UCSF model.

RESEARCH DESIGN AND METHODS

The CE team at HealthPartners consisted of two CTNs, a social worker, an RN, a program coordinator, and a behavioral neurologist. Intake forms were developed to collect demographic, baseline, and annual data at one year related to dementia severity and caregiver status. Experience surveys were completed at 6 and 12 months by participating caregivers. All data was entered into REDCap.

RESULTS

A total of 570 PWD-caregiver dyads were recruited into the CE: 53% PWDs female, average age 75.2 ± 9.43, 19% living within rural communities. Of the 173 dyads assessed at one year, 30% responded to the annual intake forms and 58% of responded to experience surveys. At one year, PWDs progressed in disease severity and functional impairment, although caregiver burden and mood remained unchanged. We observed a significant reduction in caregiver reported emotional challenges associated with caregiving, sleep problems, and obtaining caregiver help at one year. 86% of caregivers reported feeling supported by their CTN nearly always or quite frequently, and 88% rated the CTN as highly responsive to what was important to them.

DISCUSSION AND IMPLICATIONS

The CE was feasible and well-received within a non-academic healthcare system.

"I Hope That the People Caring for Me Know About Me": Exploring Person-Centred Care and the Quality of Dementia Care

Background

Person-centred care is at the core of high-quality dementia care but people living with dementia are often excluded from quality improvement efforts. We sought to explore person-centred care and quality of care from the perspectives of persons living with dementia in the community and their care partners.

Methods

We used a qualitative descriptive approach with in-person, semi-structured interviews with 17 participants (9 persons living with dementia and 8 care partners) from Ontario, Canada.

Results

Participants report that person-centred care is essential to the quality of dementia care. Three themes were identified that describe connections between person-centred care and quality of care: 1) "I hope that the people looking after me know about me", 2) "I just like to understand [what's happening] as we go down the road", and 3) "But the doctor doesn't even know all the resources that are available." Participants perceived that quality indicators over-emphasized technical/medical aspects of care and do not entirely capture quality of care.

Conclusions

Persons living with dementia and their care partners provide important insights into person-centredness and quality of care. Their perspectives on "quality" may differ from clinicians and researchers. Research is needed to better integrate their perspectives in quality improvement and person-centred care.

How Telemedicine Can Improve the Quality of Care for Patients with Alzheimer's Disease and Related Dementias? A Narrative Review

Background and Objectives: Dementia affects more than 55 million patients worldwide, with a significant societal, economic, and psychological impact. However, many patients with Alzheimer's disease (AD) and other related dementias have limited access to effective and individualized treatment. Care provision for dementia is often unequal, fragmented, and inefficient. The COVID-19 pandemic accelerated telemedicine use, which holds promising potential for addressing this important gap. In this narrative review, we aim to analyze and discuss how telemedicine can improve the quality of healthcare for AD and related dementias in a structured manner, based on the seven dimensions of healthcare quality defined by the World Health Organization (WHO), 2018: effectiveness, safety, people-centeredness, timeliness, equitability, integrated care, and efficiency. Materials and Methods: MEDLINE and Scopus databases were searched for peer-reviewed articles investigating the role of telemedicine in the quality of care for patients with dementia. A narrative synthesis was based on the seven WHO dimensions. Results: Most studies indicate that telemedicine is a valuable tool for AD and related dementias: it can improve effectiveness (better access to specialized care, accurate diagnosis, evidence-based treatment, avoidance of preventable hospitalizations), timeliness (reduction of waiting times and unnecessary transportation), patient-centeredness (personalized care for needs and values), safety (appropriate treatment, reduction of infection risk),integrated care (interdisciplinary approach through several dementia-related services), efficiency (mainly cost-effectiveness) and equitability (overcoming geographical barriers, cultural diversities). However, digital illiteracy, legal and organizational issues, as well as limited awareness, are significant potential barriers. Conclusions: Telemedicine may significantly improve all aspects of the quality of care for patients with dementia. However, future longitudinal studies with control groups including participants of a wide educational level spectrum will aid in our deeper understanding of the real impact of telemedicine in quality care for this population.

Program of Intensive Support in Emergency Departments for Care Partners of Cognitively Impaired Patients: Protocol for a Multisite Randomized Controlled Trial

BACKGROUND

Older adults with cognitive impairment have more emergency department visits and 30-day readmissions and are more likely to die after visiting the emergency department than people without cognitive impairment. Emergency department providers frequently do not identify cognitive impairment. Use of cognitive screening tools, along with better understanding of root causes for emergency department visits, could equip health care teams with the knowledge needed to develop individually tailored care management strategies for post-emergency department care. By identifying and directly addressing patients' and informal caregivers' (or care partners') psychosocial and health care needs, such strategies could reduce the need for repeat acute care. We have used the terms "caregiver" and "care partner" interchangeably.

OBJECTIVE

We aimed to describe the protocol for a randomized controlled trial of a new care management intervention, the Program of Intensive Support in Emergency Departments for Care Partners of Cognitively Impaired Patients (POISED) trial, compared with usual care. We described the research design, intervention, outcome measures, data collection techniques, and analysis plans.

METHODS

Emergency department patients who were aged ≥75 years and screened positive for cognitive impairment via either the Mini-Cog or the proxy-reported Short Informant Questionnaire on Cognitive Decline in the Elderly, with a planned discharge to home, were recruited to participate with their identified informal (family or friend) caregiver in the 2-site POISED randomized controlled trial at New York University Langone Health and Indiana University. The intervention group received 6 months of care management from the POISED Care Team of registered nurses and specialty-trained paraprofessionals, who perform root cause analyses, administer standardized assessments, provide advice, recommend appropriate referrals, and, when applicable, implement dementia-specific comorbid condition protocols. The control group received care as recommended at emergency department discharge (usual care) and were given information about resources for further cognitive assessment. The primary outcome is repeat emergency department use; secondary outcomes include caregiver activation for patient health care management, caregiver depression, anxiety, and experience of social support as important predisposing and time-varying enabling and need characteristics. Data were collected from questionnaires and patients' electronic health records.

RESULTS

Recruitment was conducted between March 2018 and May 2021. Study findings will be published in peer-reviewed journals and presented to peer audiences, decision makers, stakeholders, and other interested persons.

CONCLUSIONS

The POISED intervention is a promising approach to tailoring care management based on root causes for emergency department admission of patients with cognitive impairment with the aim of reducing readmissions. This trial will provide insights for caregivers and emergency department and primary care providers on appropriate, personalized, and proactive treatment plans for older adults with cognitive impairment. The findings will be relevant to audiences concerned with quality of life for individuals with cognitive impairment and their caregivers.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03325608; https://clinicaltrials.gov/ct2/show/NCT03325608.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/36607.

Prevalence of Alzheimer's disease and related dementias among veterans experiencing housing insecurity

INTRODUCTION

Housing insecure veterans are aging, but the prevalence of Alzheimer's disease and related dementias (AD/ADRD) in the population is unknown.

METHODS

We calculated the prevalence of AD/ADRD diagnoses in 2018 among veterans that experienced homelessness, were at-risk for homelessness, or were stably housed. We determined acute care (emergency department, hospitalizations, psychiatric hospitalizations), and any long-term care (nursing home, and community-based) use by housing status among veterans with an AD/ADRD diagnosis.

RESULTS

The overall prevalence of AD/ADRD diagnoses for homeless, at-risk, and stably housed veterans was 3.66%, 13.48%, and 3.04%, respectively. Housing insecure veterans with AD/ADRD used more acute care, and were more likely to have a nursing home admission compared to stably housed veterans. At risk, but not homeless veterans, were more likely to use US Department of Veterans Affairs-paid home and community-based care than stably housed veterans.

DISCUSSION

The prevalence of AD/ADRD diagnoses is greater among housing insecure veterans than stably housed veterans.

Dementia-friendly intervention for hospitalized older adults with cognitive impairments: results of the Italian Dementia-Friendly Hospital Trial (IDENTITÀ)

Objective: To evaluate whether a short training focused on improving dementia care practices of the hospital staff was able to counteract functional loss and to decrease negative outcomes at discharge among hospitalized older adults with cognitive impairment.Method: Sixty-eight hospitalized participants aged 65 and over with cognitive impairment were included in the study, allocated in the control group (n = 34) and intervention group (n = 34). The intervention consisted of a short training of the hospital staff aimed at improving the management of patients with cognitive impairment. Participants were evaluated within 48 h of hospital admission and at discharge using a battery of tests including Barthel Index, Mini-Mental State Examination, and Hospital Anxiety and Depression Scale.Results: The intervention group demonstrated shorter hospital length of stay and a maintenance of the functional status at discharge compared to the control group. We observed no differences in cognitive ability between the two groups, and a trend towards a decrease of anxious symptoms in the intervention group compared to the control group.Conclusion: The results suggest that an intervention, focused on improving dementia care practices in healthcare staff, has the potential to improve the outcomes for hospitalized older adults with cognitive impairment.

Dementia diagnosis and utilization patterns in a racially diverse population within an integrated health care delivery system

Introduction

In an effort to identify improvement opportunities for earlier dementia detection and care within a large, integrated health care system serving diverse Medicare Advantage (MA) beneficiaries, we examined where, when, and by whom Alzheimer's disease and related dementias (ADRD) diagnoses are recorded as well as downstream health care utilization and life care planning.

Methods

Patients 65 years and older, continuously enrolled in the Kaiser Foundation health plan for at least 2 years, and with a first ADRD diagnosis between January 1, 2015, and December 31, 2018, comprised the incident cohort. Electronic health record data were used to identify site and source of the initial diagnosis (clinic vs hospital-based, provider type), health care utilization in the year before and after diagnosis, and end-of-life care.

Results

ADRD prevalence was 5.5%. A total of 25,278 individuals had an incident ADRD code (rate: 1.2%) over the study period-nearly half during a hospital-based encounter. Hospital-diagnosed patients had higher comorbidities, acute care use before and after diagnosis, and 1-year mortality than clinic-diagnosed individuals (36% vs 11%). Many decedents (58%-72%) received palliative care or hospice. Of the 55% diagnosed as outpatients, nearly two-thirds were diagnosed by dementia specialists; when used, standardized cognitive assessments indicated moderate stage ADRD. Despite increases in advance care planning and visits to dementia specialists in the year after diagnosis, acute care use also increased for both clinic- and hospital-diagnosed cohorts.

Discussion

Similar to other MA plans, ADRD is under-diagnosed in this health system, compared to traditional Medicare, and diagnosed well beyond the early stages, when opportunities to improve overall outcomes are presumed to be better. Dementia specialists function primarily as consultants whose care does not appear to mitigate acute care use. Strategic targets for ADRD care improvement could focus on generating pragmatic evidence on the value of proactive detection and tracking, care planning, and the role of specialists in chronic care management.

Acceptability and Preliminary Effectiveness of a Remote Dementia Educational Training Among Primary Care Providers and Health Navigators

BACKGROUND

Optimal care can improve lives of families with dementia but remains under-implemented. Most healthcare professional training is in person, time-intensive, and does not focus on key aspects such as early detection, and cultural competency.

OBJECTIVE

We explored the acceptability and preliminary effectiveness of a training, The Dementia Update Course, which addressed these issues. We hypothesized that the training would lead to increased levels of perceived dementia care competency among key healthcare workers, namely primary care providers (PCPs) and health navigators (HNs).

METHODS

We conducted pre-post training assessments among 22 PCPs and 32 HNs. The 6.5-h training was remote, and included didactic lectures, case discussion techniques, and materials on dementia detection and care. Outcomes included two 5-point Likert scales on acceptability, eleven on perceived dementia care competency, and the three subscales of the General Practitioners Confidence and Attitude Scale for Dementia. We used paired samples t-tests to assess the mean differences in all preliminary effectiveness outcomes.

RESULTS

The training included 28.6% of PCPs and 15.6% of HNs that self-identified as non-White or Latino and 45.5% of PCPs and 21.9% of HNs who served in rural areas. PCPs (84.2%) and HNs (91.7%) reported a high likelihood to recommend the training and high satisfaction. Most preliminary effectiveness outcomes analyzed among PCPs (11/14) and all among HNs (8/8) experienced an improvement from pre- to post-training (p < 0.05).

CONCLUSION

A relatively brief, remote, and inclusive dementia training was associated with high levels of acceptability and improvements in perceived dementia care competency among PCPs and HNs.

Dementia knowledge and its demographic correlates amongst informal dementia caregivers in Singapore

Objectives: The Dementia Knowledge Assessment Scale (DKAS) is a validated assessment tool to measure dementia knowledge. However, the factor structure of the DKAS has yet to be validated in Singapore. This study aims to investigate the DKAS factor structure amongst a sample of informal dementia caregivers in Singapore, as well as their sociodemographic correlates.Methods: A total of 282 participants were evaluated on their knowledge of dementia by an interviewer administering the DKAS. Confirmatory factor analysis (CFA) of factor models proposed by previous study yielded poor fit for our sample. Thus, an exploratory factor analysis (EFA) was conducted. Multiple linear regression was then performed to examine the sociodemographic correlates of DKAS factors.Results: EFA revealed a 23-item 3-factor model - 'misconceptions about dementia' (MD), 'caregiving considerations towards dementia' (CD) and 'dementia symptoms' (DS). Being a male caregiver and having lower educational levels were associated with poorer scores on MD and CD.Conclusion: A 3-factor model of the DKAS was found to be more appropriate with the sample in this study. Findings from this study suggests the need for more dementia literacy intervention for caregivers of dementia patients in Singapore, especially for male caregivers and those of lower education levels.

Frontotemporal Dementia Knowledge Scale: Development and Preliminary Psychometric Properties

OBJECTIVE

Frontotemporal dementia (FTD) accounts for ∼10% of dementia cases and is the most common cause of early-onset dementia. However, no well-validated instrument currently exists to measure knowledge about FTD. In this study, we used systematic scale development procedures to create a scale to measure knowledge of FTD based on a contemporary understanding of the disease.

METHODS

Standard scale development methods were used to create items and evaluate their psychometric properties. A total of 72 health care professionals and 102 caregivers of people with FTD responded to items measuring FTD knowledge, general dementia knowledge, crystallized intelligence, experience with FTD, and demographic information.

RESULTS

The Frontotemporal Dementia Knowledge Scale (FTDKS) contains 18 items that cover key, basic knowledge about FTD in the domains of risk factors, symptoms, course, caregiving, and treatment. The scale uses a 4-point True/False format with a Don't Know option and takes ∼5 minutes to complete. In the current sample the FTDKS had good psychometric properties in terms of reliability and validity.

IMPLICATIONS

The FTDKS can be used with health care professionals and caregivers of people with FTD to assess their knowledge about the disease. The scale may be useful to evaluate knowledge in clinical care and educational program contexts.

Extent of and influences on knowledge of Alzheimer's disease among undergraduate medical students

Background:

Alzheimer's disease (AD) is a major health problem, which is of increasing concern because of rising yearly incidence and estimated cost. Early diagnosis and treatment is essential to manage AD effectively and improve the outcomes. Inadequate knowledge can delay the diagnosis. General practitioners should play a more effective role in the identification and diagnosis of AD, and medical education is key to solving this issue.

Objectives:

This study aimed to assess the knowledge of undergraduate medical students and to identify the factors that influenced their knowledge.

Methods:

This study used a quantitative cross-sectional evaluation of 327 Saudi Arabian medical students from the first and final years in Riyadh, Saudi Arabia, who participated in an online survey via email between March and May 2018. Knowledge of AD was assessed using the 12-item AD Knowledge Test for Health Professionals from the University of Alabama at Birmingham (UAB ADKT). General linear models were used to identify the most significant influence on AD knowledge scores.

Results:

Only 10.73% of first-year and 33.33% of final-year students scored ≥ 50% on the UAB ADKT. Students pursuing specialties related to AD (adult neurology, geriatrics, or psychiatry) and students aged ≥ 27 years had higher scores (P < 0.05).

Conclusion:

Undergraduate medical students lacked proper knowledge of AD, suggesting that improvements in education programs can help. Future studies are needed to assess the quality and effectiveness of AD education in the curriculum of Saudi medical schools.

National Trends in Potentially Preventable Hospitalizations of Older Adults with Dementia

BACKGROUND/OBJECTIVES

Dementia is associated with higher healthcare expenditures, in large part due to increased hospitalization rates relative to patients without dementia. Data on contemporary trends in the incidence and outcomes of potentially preventable hospitalizations of patients with dementia are lacking.

DESIGN

Retrospective cohort study using the National Inpatient Sample from 2012 to 2016.

SETTING

U.S. acute care hospitals.

PARTICIPANTS

A total of 1,843,632 unique hospitalizations of older adults (aged ≥65 years) with diagnosed dementia.

MEASUREMENTS

Annual trends in the incidence of hospitalizations for all causes and for potentially preventable conditions including acute ambulatory care sensitive conditions (ACSCs), chronic ACSCs, and injuries. In-hospital outcomes including mortality, discharge disposition, and hospital costs.

RESULTS

The survey weighted sample represented an estimated 9.27 million hospitalizations for patients with diagnosed dementia (mean [standard deviation] age = 82.6 [6.7] years; 61.4% female). In total, 3.72 million hospitalizations were for potentially preventable conditions (40.1%), 2.07 million for acute ACSCs, .76 million for chronic ACSCs, and .89 million for injuries. Between 2012 and 2016, the incidence of all-cause hospitalizations declined from 1.87 million to 1.85 million per year (P = .04) while the incidence of potentially preventable hospitalizations increased from .75 million to .87 million per year (P < .001), driven by an increased number of hospitalizations of community-dwelling older adults. Among patients with dementia hospitalized for potentially preventable conditions, inpatient mortality declined from 6.4% to 6.1% (P < .001), inflation-adjusted median costs increased from $7,319 to $7,543 (P < .001), and total annual costs increased from $7.4 to $9.3 billion. Although 86.0% of hospitalized patients were admitted from the community, only 32.7% were discharged to the community.

CONCLUSION

The number of potentially preventable hospitalizations of older adults with dementia is increasing, driven by hospitalizations of community-dwelling older adults. Improved strategies for early detection and goal-directed treatment of potentially preventable conditions in patients with dementia are urgently needed. J Am Geriatr Soc 68:2240-2248, 2020.

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

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

Modelling care quality for patients after a transient ischaemic attack within the US Veterans Health Administration

Objective

Timely preventive care can substantially reduce risk of recurrent vascular events or death after a transient ischaemic attack (TIA). Our objective was to understand patient and facility factors influencing preventive care quality for patients with TIA in the US Veterans Health Administration (VHA).

Methods

We analysed administrative data from a retrospective cohort of 3052 patients with TIA cared for in the emergency department (ED) or inpatient setting in 110 VHA facilities from October 2010 to September 2011. A composite quality indicator (QI score) pass rate was constructed from four process-related quality measures—carotid imaging, brain imaging, high or moderate potency statin and antithrombotic medication, associated with the ED visit or inpatient admission after the TIA. We tested a multilevel structural equation model where facility and patient characteristics, inpatient admission, and neurological consultation were predictors of the resident’s composite QI score.

Results

Presenting with a speech deficit and higher Charlson Comorbidity Index (CCI) were positively related to inpatient admission. Being admitted increased the likelihood of neurology consultation, whereas history of dementia, weekend arrival and a higher CCI score made neurological consultation less likely. Speech deficit, higher CCI, inpatient admission and neurological consultation had direct positive effects on the composite quality score. Patients in facilities with fewer full-time equivalent neurology staff were less likely to be admitted or to have a neurology consultation. Facilities having greater organisational complexity and with a VHA stroke centre designation were more likely to provide a neurology consultation.

Conclusions

Better TIA preventive care could be achieved through increased inpatient admissions, or through enhanced neurology and other care resources in the ED and during follow-up care.

Health Care Utilization and Cost Outcomes of a Comprehensive Dementia Care Program for Medicare Beneficiaries

IMPORTANCE

An estimated 4 to 5 million Americans have Alzheimer disease or another dementia.

OBJECTIVE

To determine the health care utilization and cost outcomes of a comprehensive dementia care program for Medicare fee-for-service beneficiaries.

DESIGN, SETTING, AND PARTICIPANTS

In this case-control study, we used a quasiexperimental design to compare health care utilization and costs for 1083 Medicare fee-for-service beneficiaries enrolled in the University of California Los Angeles Health System Alzheimer and Dementia Care program between July 1, 2012, and December 31, 2015, with those of 2166 similar patients with dementia not participating in the program. Patients in the comparison cohort were selected using the zip code of residence as a sampling frame and matched with propensity scores, which included demographic characteristics, comorbidities, and prior-year health care utilization. We used Medicare claims data to compare utilization and cost outcomes for the 2 groups.

INTERVENTIONS

Patients in the dementia care program were comanaged by nurse practitioners and physicians, and the program consisted of structured needs assessments of patients and their caregivers, creation and implementation of individualized dementia care plans with input from primary care physicians, monitoring and revising care plans, referral to community organizations for dementia-related services and support, and access to a clinician for assistance and advice 24 hours per day, 7 days per week.

MAIN OUTCOMES AND MEASURES

Admissions to long-term care facilities; average difference-in-differences per quarter over the 3-year intervention period for all-cause hospitalization, emergency department visits, 30-day hospital readmissions, and total Medicare Parts A and B costs of care. Program costs were included in the cost estimates.

RESULTS

Program participants (n = 382 men, n = 701 women; mean [SD] age, 82.10 [7.90] years; age range 54-101 years) were less likely to be admitted to a long-term care facility (hazard ratio, 0.60; 95% CI, 0.59-0.61) than those not participating in the dementia care program (n = 759 men, n = 1407 women; mean [SD] age, 82.42 [8.50] years; age range, 34-103 years). There were no differences between groups in terms of hospitalizations, emergency department visits, or 30-day readmissions. The total cost of care to Medicare, excluding program costs, was $601 less per patient per quarter (95% CI, -$1198 to -$5). After accounting for the estimated program costs of $317 per patient per quarter, the program was cost neutral for Medicare, with an estimated net cost of -$284 (95% CI, -$881 to $312) per program participant per quarter.

CONCLUSIONS AND RELEVANCE

Comprehensive dementia care may reduce the number of admissions to long-term care facilities, and depending on program costs, may be cost neutral or cost saving. Wider implementation of such programs may help people with dementia stay in their communities.

Reaching Out to Rural Caregivers and Veterans with Dementia Utilizing Clinical Video-Telehealth

Context: A clinical video telehealth (CVT) program was implemented to improve access and quality of dementia care to patients and their caregivers in rural areas. The program was offered as part of an established dementia clinic/geriatric primary care clinic in collaboration with five community-based outpatient clinics (CBOC’s) affiliated with the Tennessee Valley Healthcare System (TVHS) in middle Tennessee. Telehealth support was provided by a physician–social worker team visit. Methods: Telehealth training and equipment were provided to clinic personnel, functioning part-time with other collateral clinical duties. Patients and caregivers were referred by primary care providers and had an average of one to two CVT encounters originating at their local CBOC lasting 20 to 30 min. Clinical characteristics and outcomes of patients and caregivers receiving CVT support were collected by retrospective electronic medical record (EMR) review. Results: Over a 3-year period 45 CVT encounters were performed on patient–caregiver dyads, followed for a mean of 15 (1–36) months. Some 80% patients had dementia confirmed and 89% of these had serious medical comorbidities, took an average of eight medications, and resided at a distance of 103 (76–148) miles from the medical center. Dementia patients included 33% with late stage dementia, 25% received additional care from a mental health provider, 23% took antipsychotic medications, 19% transitioned to a higher level of care, and 19% expired an average of 10.2 months following consultation. Significant caregiver distress was present in 47% of family members. Consult recommendations included 64% community-based long-term care services and supports (LTSS), 36% medications, and 22% further diagnostic testing. Acceptance of the CVT encounter was 98%, with 8770 travel miles saved. Conclusions: CVT is well received and may be helpful in providing dementia care and supporting dementia caregivers to obtain LTSS for high-need older adults in rural areas.

Acceptability and Results of Dementia Screening Among Older Adults in the United States

OBJECTIVES

To measure older adults acceptability of dementia screening and assess screening test results of a racially diverse sample of older primary care patients in the United States.

DESIGN

Cross-sectional study of primary care patients aged 65 and older.

SETTING

Urban and suburban primary care clinics in Indianapolis, Indiana, in 2008 to 2009.

PARTICIPANTS

Nine hundred fifty-four primary care patients without a documented diagnosis of dementia.

MEASUREMENTS

Community Screening Instrument for Dementia, the Mini-Mental State Examination, and the Telephone Instrument for Cognitive Screening.

RESULTS

Of the 954 study participants who consented to participate, 748 agreed to be screened for dementia and 206 refused screening. The overall response rate was 78.4%. The positive screen rate of the sample who agreed to screening was 10.2%. After adjusting for demographic differences the following characteristics were still associated with increased likelihood of screening positive for dementia: age, male sex, and lower education. Patients who believed that they had more memory problems than other people of their age were also more likely to screen positive for dementia.

CONCLUSION

Age and perceived problems with memory are associated with screening positive for dementia in primary care.

Health Services Utilization in Older Adults with Dementia Receiving Care Coordination: The MIND at Home Trial

OBJECTIVE

To investigate effects of a novel dementia care coordination program on health services utilization.

DATA SOURCES/STUDY SETTING

A total of 303 community-dwelling adults aged ≥70 with a cognitive disorder in Baltimore, Maryland (2008-2011).

STUDY DESIGN

Single-blind RCT evaluating efficacy of an 18-month care coordination intervention delivered through community-based nonclinical care coordinators, supported by an interdisciplinary clinical team.

DATA COLLECTION/EXTRACTION METHODS

Study partners reported acute care/inpatient, outpatient, and home- and community-based service utilization at baseline, 9, and 18 months.

PRINCIPAL FINDINGS

From baseline to 18 months, there were no significant group differences in acute care/inpatient or total outpatient services use, although intervention participants had significantly increased outpatient dementia/mental health visits from 9 to 18 months (p = .04) relative to controls. Home and community-based support service use significantly increased from baseline to 18 months in the intervention compared to control (p = .005).

CONCLUSIONS

While this dementia care coordination program did not impact acute care/inpatient services utilization, it increased use of dementia-related outpatient medical care and nonmedical supportive community services, a combination that may have helped participants remain at home longer. Future care model modifications that emphasize delirium, falls prevention, and behavior management may be needed to influence inpatient service use.

Consistency of dementia caregiver intervention classification: an evidence-based synthesis

BACKGROUND

There are many systematic reviews and meta-analyses (SRs) of interventions for family caregivers of persons with Alzheimer's disease or a related dementia. A challenge when synthesizing the efficacy of dementia caregiver interventions is the potential discrepancy in how they are categorized. The objective of this study was to systematically examine inconsistencies in how dementia caregiver interventions are classified.

METHODS

We searched Ovid Medline®, Ovid PsycINFO®, Ovid Embase®, and the Cochrane Library to identify previous SRs published and indexed in bibliographic databases through January 2015. Following a graphical network analysis, open-coding of classification definitions was conducted. A descriptive analysis was then completed to examine classification consistency of individual interventions across SR grouping labels.

RESULTS

Twenty-three SRs were identified. A graphical network analysis revealed a significant amount of overlap in individual studies included across SRs, but stark differences in how reviews labeled or categorized them. The qualitative content analysis identified seven themes; one of these, content of the intervention, was used to compare classification consistency. When subjecting the classification of interventions to descriptive empirical analysis, extensive inconsistency was apparent.

CONCLUSIONS

The substantial inconsistency in how dementia caregiver interventions are classified across SRs has hindered the science and practice of dementia caregiver interventions. Specifically, accurate reporting of intervention components and SRs would allow for more precise assessments of efficacy as well as a fuller determination of how caregiver interventions can best yield benefits for caregivers and persons with dementia.

Carers: The navigators of the maze of care for people with dementia—A qualitative study

Background

Dementia is a challenge in our society, with individuals accessing services across multiple settings. Carers are navigating and delivering care services in the home. This research sought to investigate the experiences of people with dementia and their carers when transitioning home from hospital.

Methods

This study used a qualitative descriptive design, employing in-depth interviews with 30 carers recruited through networks known to one state branch of Alzheimer’s Australia. Emerging themes were validated in one focus group.

Results

During the hospital stay carers experienced a paradox: being required to deliver care yet perceiving that they were being ignored in regard to decisions about care. The time in hospital was considered by some carers to be stressful, as they were concerned about the safety of the person with dementia. Many reported that discharge home was rarely planned and coordinated. Returning home carers found re-establishing and/or accessing new services challenging, with available services often inappropriate to need.

Conclusion

The paradox of the care experience in the acute setting, whereby the carer was either invited, or sought, to deliver care, yet was excluded in staff decisions about that care, challenges the current communication and coordination of care. For people with dementia and their carers, there is a need for a coordinated seamless service that enables continued unbroken care and support from acute care to home. Carers also need support navigating the wide range of services available and importantly both carers and care providers may need to understand service boundaries.

Recommendations

This study highlights the need to acknowledge the expertise of the carer, and their need for support. Enabling a smooth discharge from hospital and support to navigate care access in the community is paramount. These experiences provide insight into gaps in service provision and modifying existing services may lead to improved experiences.

Quality of Care Provided by a Comprehensive Dementia Care Comanagement Program

Multiple studies have shown that quality of care for dementia in primary care is poor, with physician adherence to dementia quality indicators (QIs) ranging from 18% to 42%. In response, the University of California at Los Angeles (UCLA) Health System created the UCLA Alzheimer's and Dementia Care (ADC) Program, a quality improvement program that uses a comanagement model with nurse practitioner dementia care managers (DCM) working with primary care physicians and community-based organizations to provide comprehensive dementia care. The objective was to measure the quality of dementia care that nurse practitioner DCMs provide using the Assessing Care of Vulnerable Elders (ACOVE-3) and Physician Consortium for Performance Improvement QIs. Participants included 797 community-dwelling adults with dementia referred to the UCLA ADC program over a 2-year period. UCLA is an urban academic medical center with primarily fee-for-service reimbursement. The percentage of recommended care received for 17 dementia QIs was measured. The primary outcome was aggregate quality of care for the UCLA ADC cohort, calculated as the total number of recommended care processes received divided by the total number of eligible quality indicators. Secondary outcomes included aggregate quality of care in three domains of dementia care: assessment and screening (7 QIs), treatment (6 QIs), and counseling (4 QIs). QIs were abstracted from DCM notes over a 3-month period from date of initial assessment. Individuals were eligible for 9,895 QIs, of which 92% were passed. Overall pass rates of DCMs were similar (90-96%). All counseling and assessment QIs had pass rates greater than 80%, with most exceeding 90%. Wider variation in adherence was found among QIs addressing treatments for dementia, which patient-specific criteria triggered, ranging from 27% for discontinuation of medications associated with mental status changes to 86% for discussion about acetylcholinesterase inhibitors. Comprehensive dementia care comanagement with a nurse practitioner can result in high quality of care for dementia, especially for assessment, screening, and counseling. The effect on treatment QIs is more variable but higher than previous reports of physician-provided dementia care.

Case Finding of Mild Cognitive Impairment and Dementia and Subsequent Care; Results of a Cluster RCT in Primary Care

PURPOSE

Despite a call for earlier diagnosis of dementia, the diagnostic yield of case finding and its impact on the mental health of patients and relatives are unclear. This study assessed the effect of a two-component intervention of case finding and subsequent care on these outcomes.

METHODS

In a cluster RCT we assessed whether education of family physicians (FPs; trial stage 1) resulted in more mild cognitive impairment (MCI) and dementia diagnoses among older persons in whom FPs suspected cognitive decline and whether case finding by a practice nurse and the FP (trial stage 2) added to this number of diagnoses. In addition, we assessed mental health effects of case finding and subsequent care (trial stage 2). FPs of 15 primary care practices (PCPs = clusters) judged the cognitive status of all persons ≥ 65 years. The primary outcome, new MCI and dementia diagnoses by FPs after 12 months as indicated on a list, was assessed among all persons in whom FPs suspected cognitive impairment but without a formal diagnosis of dementia. The secondary outcome, mental health of patients and their relatives, was assessed among persons consenting to participate in trial stage 2. Trial stage 1 consisted of either intervention component 1: training FPs to diagnose MCI and dementia, or control: no training. Trial stage 2 consisted of either intervention component 2: case finding of MCI and dementia and care by a trained nurse and the FP, or control: care as usual.

RESULTS

Seven PCPs were randomized to the intervention; eight to the control condition. MCI or dementia was diagnosed in 42.3% (138/326) of persons in the intervention, and in 30.5% (98/321) in the control group (estimated difference GEE: 10.8%, OR: 1.51, 95%-CI 0.60-3.76). Among patients and relatives who consented to stage 2 of the trial (n = 145; 25%), there were no differences in mental health between the intervention and control group.

CONCLUSIONS

We found a non-significant increase in the number of new MCI diagnoses. As we cannot exclude a clinically relevant effect, a larger study is warranted to replicate ours.

TRIAL REGISTRATION

Nederlands Trial Register NTR3389.

Potentially Unsafe Activities and Living Conditions of Older Adults with Dementia

OBJECTIVES

To examine the prevalence of dementia in the absence of a reported dementia diagnosis and whether potentially unsafe activities and living conditions vary as a function of dementia diagnosis status in a nationally representative sample of older adults.

DESIGN

Observational cohort study.

SETTING

Community.

PARTICIPANTS

Medicare beneficiaries aged 65 and older enrolled in the National Health and Aging Trends Study (N = 7,609).

MEASUREMENTS

Participants were classified into four groups based on self-report of dementia diagnosis, proxy screening interview, and cognitive testing: probable dementia with reported dementia diagnosis (n = 457), probable dementia without reported dementia diagnosis (n = 581), possible dementia (n = 996), or no dementia (n = 5,575). Potentially unsafe activities (driving, preparing hot meals, managing finances or medications, attending doctor visits alone) and living conditions (falls, living alone, and unmet needs) were examined according to dementia status subgroups in stratified analyses and multivariate models, adjusting for sociodemographic factors, medical comorbidities, and physical capacity.

RESULTS

The prevalence of driving (22.9%), preparing hot meals (31.0%), managing finances (21.9%), managing medications (36.6%), and attending doctor visits alone (20.6%) was lowest in persons with probable dementia; however, but in persons with probable dementia, the covariate-adjusted rates of driving, preparing hot meals, managing finances, managing medications, and attending doctor visits alone were significantly higher in those without reported dementia diagnosis than in those with reported diagnosis (all odds ratios ≥2.00, all P < .01).

CONCLUSION

Older adults with probable dementia who are not aware of a dementia diagnosis are more likely to report engaging in potentially unsafe behaviors. Understanding the prevalence of potentially unsafe activities and living conditions can help clinicians focus safety screening and counseling in older adults with diagnosed or suspected dementia.

Unmet needs of caregivers of individuals referred to a dementia care program

OBJECTIVES

To characterize caregiver strain, depressive symptoms, and self-efficacy for managing dementia-related problems and the relationship between these and referring provider type.

DESIGN

Cross-sectional observational cohort.

SETTING

Urban academic medical center.

PARTICIPANTS

Caregivers of community-dwelling adults with dementia referred to a dementia care management program.

MEASUREMENTS

Caregivers were surveyed and completed the Patient Health Questionnaire (PHQ-9) about themselves; the Modified Caregiver Strain Index; the Neuropsychiatric Inventory Questionnaire, which measures patient symptom severity and related caregiver distress; and a nine-item caregiver self-efficacy scale developed for the study.

RESULTS

Of 307 patient-caregiver dyads surveyed over a 1-year period, 32% of caregivers reported confidence in managing dementia-related problems, 19% knew how to access community services to help provide care, and 28% agreed that the individual's provider helped them work through dementia care problems. Thirty-eight percent reported high levels of caregiver strain, and 15% reported moderate to severe depressive symptoms. Caregivers of individuals referred by geriatricians more often reported having a healthcare professional to help work through dementia care problems than those referred by internists, family physicians, or other specialists, but self-efficacy did not differ. Low caregiver self-efficacy was associated with higher caregiver strain, more caregiver depressive symptoms, and caring for an individual with more-severe behavioral symptoms.

CONCLUSION

Most caregivers perceived inadequate support from the individual's provider in managing dementia-related problems, reported strain, and had low confidence in managing caregiving. New models of care are needed to address the complex care needs of individuals with dementia and their caregivers.

The influence of sleep disruption and pain perception on indicators of quality of life in individuals living with dementia at home

This cross-sectional study evaluated the influence of sleep quality and pain perceptions on different dimensions of quality of life in community-dwelling persons with dementia. Evaluations of pain were collected using Visual Analog Scale (VAS), sleep disruption using Pittsburg Sleep Quality Index (PSQI) items, and quality of life indicators using the DemQOL-Proxy in 88 persons with dementia and their family caregivers. Lower overall quality of life was associated with the presence of pain and symptoms of sleep disruption when controlling for mental status, age, and number of health conditions. Pain and sleep symptoms were differentially associated with different aspects of QoL. As symptoms negatively impact quality of life but are modifiable, better clinical procedures are needed to prevent and also identify and treat symptoms of pain and sleep disturbance in community-dwelling persons with dementia.

Dementia Services Mini-Screen: a simple method to identify patients and caregivers in need of enhanced dementia care services

OBJECTIVE

Improving dementia care in health systems requires estimates of need in the population served. We explored whether dementia-specific service needs and gaps for patients and caregivers could be predicted by simple information readily captured in routine care settings.

METHOD

Primary family caregivers (n = 215) rated their own current stress, challenging patient behaviors, and prior-year needs and gaps in 16 medical and psychosocial services. These were evaluated with other patient and caregiver characteristics in multivariate regressions to identify unique predictors of service needs and gaps.

RESULTS

Caregiver stress and patient behavior problems together accounted for an average of 24% of the whole-sample variance in total needs and gaps. All other variables combined (comorbid chronic disease, dementia severity, age, caregiver relationship, and residence) accounted for a mean of 3%, with none yielding more than 4% in any equation. We combined stress and behavior problem indicators into a simple screen. In early/mild dementia dyads (n = 111) typical in primary care settings, the screen identified gaps in total (84%) and psychosocial (77%) care services for high stress/high behavior problem dyads vs. 25% and 23%, respectively, of low stress/low behavior problem dyads. Medical care gaps were dramatically higher in high stress/high behavior problem dyads (66%) than all others (12%).

CONCLUSION

The Dementia Services Mini-Screen is a simple tool that could help clinicians and health systems rapidly identify dyads needing enhanced dementia care, track key patient and caregiver outcomes of interventions, and estimate population needs for new service development.

Correlates of quality of life for individuals with dementia living at home: the role of home environment, caregiver, and patient-related characteristics

OBJECTIVES

To examine prevalence of modifiable risk factors and their contribution to patient quality of life (QoL) as rated by dementia patients and family caregivers.

DESIGN

Cross-sectional.

SETTING

Home environment.

PARTICIPANTS

88 patients and their caregivers.

MEASUREMENTS

Modifiable characteristics of home environments, patients, and caregivers were observed or obtained through interview. Demographics and ratings of patients' QoL were obtained from patients and caregivers.

RESULTS

Patients had mean Mini-mental Status Examination (MMSE) score = 17.7 ± 4.6, (range: 10-28) on an average 7.7 ± 2.4 neuropsychiatric behaviors, 6.0 ± 3.1 health conditions and moderate functional challenges; 70.7% (N = 58) had fall risk; 60.5% (N = 52) had sleep problems at least once weekly; and 42.5% (N = 37) had pain. An average of 8.1 ± 5.2 home hazards and 5.4 ± 4.1 adaptations were observed; 51.7% had unmet device/navigation needs. Patients' and caregivers' QoL ratings were unrelated to MMSE; and patients' self-rated QoL was higher than rated by caregivers. Number of health conditions and unmet device/navigation needs were inversely associated with patient self-rated QoL, and number of health conditions, frequency of behaviors, and level of negative communications were inversely associated with caregiver's assessment of patient QoL. Positive endorsement of caregiving was positively associated with caregiver's appraisal of patient QoL. Other factors were unrelated.

CONCLUSIONS

Most patients lived at home with high fall risk, unmanaged behavioral symptoms, pain, sleep disturbances, environmental challenges, and multiple hazards. Except for health, factors associated with lower QoL differed for patients and caregivers. Results suggest need to improve QoL by addressing modifiable risk factors and tailoring interventions to patient and caregiver perspectives.

Understanding diagnosis and management of dementia and guideline implementation in general practice: a qualitative study using the theoretical domains framework

Background

Dementia is a growing problem, causing substantial burden for patients, their families, and society. General practitioners (GPs) play an important role in diagnosing and managing dementia; however, there are gaps between recommended and current practice. The aim of this study was to explore GPs’ reported practice in diagnosing and managing dementia and to describe, in theoretical terms, the proposed explanations for practice that was and was not consistent with evidence-based guidelines.

Methods

Semi-structured interviews were conducted with GPs in Victoria, Australia. The Theoretical Domains Framework (TDF) guided data collection and analysis. Interviews explored the factors hindering and enabling achievement of 13 recommended behaviours. Data were analysed using content and thematic analysis. This paper presents an in-depth description of the factors influencing two behaviours, assessing co-morbid depression using a validated tool, and conducting a formal cognitive assessment using a validated scale.

Results

A total of 30 GPs were interviewed. Most GPs reported that they did not assess for co-morbid depression using a validated tool as per recommended guidance. Barriers included the belief that depression can be adequately assessed using general clinical indicators and that validated tools provide little additional information (theoretical domain of ‘Beliefs about consequences’); discomfort in using validated tools (‘Emotion’), possibly due to limited training and confidence (‘Skills’; ‘Beliefs about capabilities’); limited awareness of the need for, and forgetting to conduct, a depression assessment (‘Knowledge’; ‘Memory, attention and decision processes’). Most reported practising in a manner consistent with the recommendation that a formal cognitive assessment using a validated scale be undertaken. Key factors enabling this were having an awareness of the need to conduct a cognitive assessment (‘Knowledge’); possessing the necessary skills and confidence (‘Skills’; ‘Beliefs about capabilities’); and having adequate time and resources (‘Environmental context and resources’).

Conclusions

This is the first study to our knowledge to use a theoretical approach to investigate the barriers and enablers to guideline-recommended diagnosis and management of dementia in general practice. It has identified key factors likely to explain GPs’ uptake of the guidelines. The results have informed the design of an intervention aimed at supporting practice change in line with dementia guidelines, which is currently being evaluated in a cluster randomised trial.

Implementation of advanced practice nurse clinic for management of behavioral symptoms in dementia: A dyadic intervention (innovative practice)

Behavioral symptoms are common in all types of dementia and often result in significant caregiver stress and illness, institutionalization of the patient, and reduced quality of life for the patient and caregiver. Health care practitioners often lack the expertise or time to adequately assess behavioral symptoms or counsel caregivers about interventions. Our goal was to implement a specialty clinic managed by advanced practice nurses to assess and manage behavioral symptoms associated with dementia. The clinic evaluations consisted of an assessment of the patient by the Nurse Practitioner during the time that the family caregiver(s) was interviewed by the Clinical Nurse Specialist and focused on an assessment of the cognitive and functional abilities of the patient, identification of triggers for the problematic behaviors, and assessment of caregiver coping. We evaluated 66 dyads since implementation in February 2010. The patients were primarily female, Caucasian, 74.3 years of age with Alzheimer’s disease. The majority of caregivers were spouses ( n = 44) followed by adult children ( n = 20) and then siblings ( n = 2). Targeted interventions were developed and caregiver counseling, support, and education were an integral part of the consultation and included written information, video instruction, and internet resources. Evaluations indicated caregivers and referring providers found the appointment helpful in managing behavioral symptoms and caregiver stress.

Quality improvement in neurology: dementia management quality measures

Professional and advocacy organizations have long urged that dementia should be recognized and properly diagnosed. With the passage of the National Alzheimer's Project Act in 2011, an Advisory Council for Alzheimer's Research, Care, and Services was convened to advise the Department of Health and Human Services. In May 2012, the Council produced the first National Plan to address Alzheimer's disease, and prominent in its recommendations is a call for quality measures suitable for evaluating and tracking dementia care in clinical settings. Although other efforts have been made to set dementia care quality standards, such as those pioneered by RAND in its series Assessing Care of Vulnerable Elders (ACOVE), practitioners, healthcare systems, and insurers have not widely embraced implementation. This executive summary (full manuscript available at www.neurology.org) reports on a new measurement set for dementia management developed by an interdisciplinary Dementia Measures Work Group (DWG) representing the major national organizations and advocacy organizations concerned with the care of individuals with dementia. The American Academy of Neurology (AAN), the American Geriatrics Society, the American Medical Directors Association, the American Psychiatric Association, and the American Medical Association-convened Physician Consortium for Performance Improvement led this effort. The ACOVE measures and the measurement set described here apply to individuals whose dementia has already been identified and properly diagnosed. Although similar in concept to ACOVE, the DWG measurement set differs in several important ways; it includes all stages of dementia in a single measure set, calls for the use of functional staging in planning care, prompts the use of validated instruments in patient and caregiver assessment and intervention, highlights the relevance of using palliative care concepts to guide care before the advanced stages of illness, and provides evidence-based support for its recommendations and guidance on the selection of instruments useful in tracking patient-centered outcomes. It also specifies annual reassessment and updating of interventions and care plans for dementia-related problems that affect families and other caregivers as well as individuals with dementia. Here, a brief synopsis of why major reforms in healthcare design and delivery are needed to achieve substantive improvements in the quality of care is first provided, and then the final measures approved for publication, dissemination, and implementation are listed.

Under-provision of medical care for vascular diseases for people with dementia in primary care: a cross-sectional review

BACKGROUND

Vascular diseases contribute to the causation and progression of clinical dementia.

AIM

To evaluate the quality of medical care for vascular diseases provided to people with dementia, the patient and practice characteristics that influence quality, and to compare care with that provided to those without dementia.

DESIGN AND SETTING

Observational, cross-sectional review of primary care records of people with dementia from 52 general practices from five primary care trusts in the UK, and comparison with publicly available summary data on patients without dementia.

METHOD

A total of 700 patients with ≥1 diagnosed vascular disease or risk factor were identified from dementia registers. Quality of care was measured on 30 indicators from the UK Quality and Outcomes Framework (QOF) for hypertension, coronary heart disease, stroke, diabetes mellitus, atrial fibrillation, heart failure, and smoking. Overall quality of vascular care was calculated for each patient with dementia.

RESULT

Level of care received by people with dementia was significantly lower compared with those without dementia for 22 of 30 (73%) indicators; most notably for measurement processes such as peripheral pulses check and neuropathy testing for diabetes, and cholesterol measures for stroke. Among people with dementia, women, those in care homes, and those with fewer comorbid physical conditions and medications were associated with lower scores for overall quality of vascular care.

CONCLUSION

The quality of medical care provided to people with dementia with regard to vascular diseases is not concordant with quality, as defined by the QOF. Research is needed to improve access to high-quality care.

The University of California at Los Angeles Alzheimer's and Dementia Care program for comprehensive, coordinated, patient-centered care: preliminary data

Dementia is a chronic disease that requires medical and social services to provide high-quality care and prevent complications. As a result of time constraints in practice, lack of systems-based approaches, and poor integration of community-based organizations (CBOs), the quality of care for dementia is poorer than that for other diseases that affect older persons. The University of California at Los Angeles (UCLA) Alzheimer's and Dementia Care (UCLA ADC) program partners with CBOs to provide comprehensive, coordinated, patient-centered care for individuals with Alzheimer's disease and other dementias. The goals of the program are to maximize function, independence, and dignity; minimize caregiver strain and burnout; and reduce unnecessary costs. The UCLA ADC program consists of five core components: recruitment and a dementia registry, structured needs assessments of individuals in the registry and their caregivers, creation and implementation of individualized dementia care plans based on needs assessments and input from the primary care physicians, monitoring and revising care plans as needed, and around-the-clock access for assistance and advice. The program uses a comanagement model with a nurse practitioner Dementia Care Manager working with primary care physicians and CBOs. Based on the first 150 individuals served, the most common recommendations in the initial care plans were referrals to support groups (73%) and Alzheimer's Association Safe Return (73%), caregiver training (45%), and medication adjustment (41%). The program will be evaluated on its ability to achieve the triple aim of better care for individuals, better health for populations, and lower costs.

Quality improvement in neurology: dementia management quality measures (executive summary)

This article represents the efforts of an interdisciplinary work group, the Dementia Measures Work Group (DWG), composed of representatives of diverse national organizations who convened specifically to define optimal standards of dementia care for individual practitioners as well as multidisciplinary teams. The DWG measurement set includes all stages of dementia in a single measure set, calls for the use of functional staging in planning care, prompts the use of validated instruments in patient and caregiver assessment and intervention, highlights the relevance of using palliative care concepts to guide care prior to the advanced stages of illness, and provides evidence-based support for its recommendations and guidance on the selection of instruments for tracking patient-centered outcomes. In addition, it specifies annual reassessment and updating of interventions and care plans for dementia-related problems that affect families and other caregivers as well as patients.

Health care experiences of people with dementia and their caregivers: a meta-ethnographic analysis of qualitative studies

BACKGROUND

Understanding the health care experience of people with dementia and their caregivers is becoming increasingly important given the growing number of affected individuals. We conducted a systematic review of qualitative studies that examined aspects of the health care experience of people with dementia and their caregivers to better understand ways to improve care for this population.

METHODS

We searched the electronic databases MEDLINE, Embase, PsychINFO and CINAHL to identify relevant articles. We extracted key study characteristics and methods from the included studies. We also extracted direct quotes from the primary studies, along with the interpretations provided by authors of the studies. We used meta-ethnography to synthesize the extracted information into an overall framework. We evaluated the quality of the primary studies using the Consolidated Criteria for Reporting Qualitative Research (COREQ) checklist.

RESULTS

In total, 46 studies met our inclusion criteria; these involved 1866 people with dementia and their caregivers. We identified 5 major themes: seeking a diagnosis; accessing supports and services; addressing information needs; disease management; and communication and attitudes of health care providers. We conceptualized the health care experience as progressing through phases of seeking understanding and information, identifying the problem, role transitions following diagnosis and living with change.

INTERPRETATION

The health care experience of people with dementia and their caregivers is a complex and dynamic process, which could be improved for many people. Understanding these experiences provides insight into potential gaps in existing health services. Modifying existing services or implementing new models of care to address these gaps may lead to improved outcomes for people with dementia and their caregivers.

United States medical students' knowledge of Alzheimer disease

PURPOSE

A knowledge gap exists between general physicians and specialists in diagnosing and managing Alzheimer disease (AD). This gap is concerning due to the estimated rise in prevalence of AD and cost to the health care system. Medical school is a viable avenue to decrease the gap, educating future physicians before they specialize. The purpose of this study was to assess the knowledge level of students in their first and final years of medical school.

METHODS

Fourteen participating United States medical schools used e-mail student rosters to distribute an online survey of a quantitative cross-sectional assessment of knowledge about AD; 343 students participated. Knowledge was measured using the 12-item University of Alabama at Birmingham AD Knowledge Test for Health Professionals. General linear models were used to examine the effect of demographic variables and previous experience with AD on knowledge scores.

RESULTS

Only 2.5% of first year and 68.0% of final year students correctly scored ten or more items on the knowledge scale. Personal experience with AD predicted higher knowledge scores in final year students (P= 0.027).

CONCLUSION

Knowledge deficiencies were common in final year medical students. Future studies to identify and evaluate the efficacy of AD education programs in medical schools are warranted. Identifying and disseminating effective programs may help close the knowledge gap.

Collaborative care management reduces disparities in dementia care quality for caregivers with less education

OBJECTIVES

To examine educational gradients in dementia care and whether the effect of a dementia collaborative care management intervention varied according to the educational attainment of the informal caregiver.

DESIGN

Analysis of data from a cluster-randomized controlled trial.

SETTING

Eighteen clinics in three healthcare organizations in southern California.

PARTICIPANTS

Dyads of Medicare recipients aged 65 and older with a diagnosis of dementia and an eligible caregiver.

INTERVENTION

Collaborative care management for dementia.

MEASUREMENTS

Caregiver educational attainment, adherence to four dimensions of guideline-recommended processes of dementia care (assessment, treatment, education and support, and safety) before and after the intervention, and the adjusted intervention effect (IE) for each dimension stratified according to caregiver education. Each IE was estimated by subtracting the difference between pre- and postintervention scores for the usual care participants from the difference between pre- and postintervention scores in the intervention participants.

RESULTS

At baseline, caregivers with lower educational attainment provided poorer quality of dementia care for the Treatment and Education dimensions than those with more education, but less-educated caregivers had significantly more improvement after the intervention on the assessment, treatment, and safety dimensions. The IEs for those who had not graduated from high school were 44.4 for the assessment dimension, 36.9 for the treatment dimension, and 52.7 for the safety dimension, versus 29.5, 15.7, and 40.9 respectively, for college graduates (P < .001 for all three).

CONCLUSIONS

Collaborative care management was associated with smaller disparities in dementia care quality between caregivers with lower educational attainment and those with more education.

Nonpharmacologic management of behavioral symptoms in dementia

Behavioral symptoms such as repetitive speech, wandering, and sleep disturbances are a core clinical feature of Alzheimer disease and related dementias. If untreated, these behaviors can accelerate disease progression, worsen functional decline and quality of life, cause significant caregiver distress, and result in earlier nursing home placement. Systematic screening for behavioral symptoms in dementia is an important prevention strategy that facilitates early treatment of behavioral symptoms by identifying underlying causes and tailoring a treatment plan. First-line nonpharmacologic treatments are recommended because available pharmacologic treatments are only modestly effective, have notable risks, and do not effectively treat some of the behaviors that family members and caregivers find most distressing. Examples of nonpharmacologic treatments include provision of caregiver education and support, training in problem solving, and targeted therapy directed at the underlying causes for specific behaviors (eg, implementing nighttime routines to address sleep disturbances). Based on an actual case, we characterize common behavioral symptoms and describe a strategy for selecting evidence-based nonpharmacologic dementia treatments. Nonpharmacologic management of behavioral symptoms in dementia can significantly improve quality of life and patient-caregiver satisfaction.

Predictors of acceptance of offered care management intervention services in a quality improvement trial for dementia

OBJECTIVE

Care management approaches have been proven to improve outcomes for patients with dementia and their family caregivers (dyads). However, acceptance of services in these programs is incomplete, impacting effectiveness. Acceptance may be related to dyad as well as healthcare system characteristics, but knowledge about factors associated with program acceptance is lacking. This study investigates patient, caregiver, and healthcare system characteristics associated with acceptance of offered care management services.

METHODS

This study analyzed data from the intervention arm of a cluster randomized controlled trial of a comprehensive dementia care management intervention. There were 408 patient-caregiver dyads enrolled in the study, of which 238 dyads were randomized to the intervention. Caregiver, patient, and health system factors associated with participation in offered care management services were assessed through bivariate and multivariate regression analyses.

RESULTS

Out of the 238 dyads, 9 were ineligible for this analysis, leaving data of 229 dyads in this sample. Of these, 185 dyads accepted offered care management services, and 44 dyads did not. Multivariate analyses showed that higher likelihood of acceptance of care management services was uniquely associated with cohabitation of caregiver and patient (p < 0.001), lesser severity of dementia (p = 0.03), and higher patient comorbidity (p = 0.03); it also varied across healthcare organization sites.

CONCLUSIONS

Understanding factors that influence care management participation could result in increased adoption of successful programs to improve quality of care. Using these factors to revise both program design as well as program promotion may also benefit external validity of future quality improvement research trials.

Quality of care provided to people with dementia: utilisation and quality of the annual dementia review in general practice

BACKGROUND

Primary care services are often the main healthcare service for people with dementia; as such, good-quality care at this level is important.

AIM

To measure the quality of care provided to people with dementia in general practice using routinely collected data, and to explore associated patient and practice factors.

DESIGN AND SETTING

Observational, cross-sectional review of medical records from general practices (n = 52) in five primary care trusts.

METHOD

A total of 994 people with dementia were identified from dementia registers. An unweighted quality-of-care score was constructed using information collected in the annual dementia review, together with pharmacological management of cognitive and non-cognitive symptoms. Multilevel modelling was carried out to identify factors associated with quality-of-care scores.

RESULTS

In total, 599 out of 745 (80%) patients with dementia had received an annual dementia review; however, a social care review or discussion with carers was evident in just 305 (51%) and 367 (61%) of those 599 cases, respectively. Despite high prevalence of vascular disease, over a quarter (n = 259, 26%) of all patients with dementia were prescribed antipsychotics; only 57% (n = 148) of these had undergone medication review in the previous 6 months. Those with vascular dementia who were registered with single-handed practices received poorer quality of care than those registered with practices that had more than one GP.

CONCLUSION

Although the number of people with dementia with a record of an annual dementia review is high, the quality of these reviews is suboptimal. The quality score developed in this study could be used as one source of data to identify weaknesses in practice activity that need to be corrected, and so would be of value to commissioners and regulators, as well as practices themselves.

Building capacity and resilience in the dementia care workforce: a systematic review of interventions targeting worker and organizational outcomes

BACKGROUND

Dementia increasingly impacts every health and social care system in the world. Preparing the dementia care workforce is therefore paramount, particularly in light of existing problems of staff retention and turnover. Training interventions will need to increase worker and organizational capacity to deliver effective patient care. It is not clear which training interventions best enhance workers' capacity. A review of the evidence for dementia care training interventions to enhance worker capacity and facilitate organizational change is presented.

METHODS

A systematic literature review was conducted. All selected randomized intervention studies aimed to enhance some aspect of dementia care worker or workforce capacity such as knowledge of dementia, psychological well-being, work performance, and organizational factors such as retention or service delivery in dementia care.

RESULTS

Seventy-four relevant studies were identified, but only six met inclusion criteria for the review. The six studies selected focused on worker and organizational outcomes in dementia care. All interventions were multi-component with dementia education or instructional training most commonly adopted. No interventions were found for the community setting. Variable effects were found for intervention outcomes and methodological concerns are raised.

CONCLUSION

The rigor of scientific research in training interventions that aim to build capacity of dementia care workers is poor and a strong need exists for evaluation and delivery of such interventions in the community sphere. Wider domains of interest such as worker psychological health and well-being need to be examined further, to understand capacity-building in the dementia care workforce.

Implementing innovative models of dementia care: The Healthy Aging Brain Center

BACKGROUND

Recent randomized controlled trials have demonstrated the effectiveness of the collaborative dementia care model targeting both the patients suffering from dementia and their informal caregivers.

OBJECTIVE

To implement a sustainable collaborative dementia care program in a public health care system in Indianapolis.

METHODS

We used the framework of Complex Adaptive System and the tool of the Reflective Adaptive Process to translate the results of the dementia care trial into the Healthy Aging Brain Center (HABC).

RESULTS

Within its first year of operation, the HABC delivered 528 visits to serve 208 patients and 176 informal caregivers. The mean age of HABC patients was 73.8 (standard deviation, SD 9.5), 40% were African-Americans, 42% had less than high school education, 14% had normal cognitive status, 39% received a diagnosis of mild cognitive impairment, and 46% were diagnosed with dementia. Within 12 months of the initial HABC visit, 28% of patients had at least one visit to an emergency room (ER) and 14% were hospitalized with a mean length of stay of five days. The rate of a one-week ER revisit was 14% and the 30-day rehospitalization rate was 11%. Only 5% of HABC patients received an order for neuroleptics and only 16% had simultaneous orders for both definite anticholinergic and anti-dementia drugs.

CONCLUSION

The tools of 'implementation science' can be utilized to translate a health care delivery model developed in the research laboratory to a practical, operational, health care delivery program.

Support groups for dementia caregivers--predictors for utilisation and expected quality from a family caregiver's point of view: a questionnaire survey part I*

Background

Support groups have proved to be effective in reducing the burden on family caregivers of dementia patients. Nevertheless, little is known about the factors that influence utilisation or quality expectations of family caregivers. These questions are addressed in the following paper.

Methods

The cross-sectional study was carried out as an anonymous written survey of family caregivers of dementia patients in Germany. Qualitative and quantitative data from 404 caregivers were analysed using content analysis and binary logistic regression analysis.

Results

The only significant predictor for utilisation is assessing how helpful support groups are for the individual care situation. Family caregivers all agree that psycho-educative orientation is a priority requirement.

Conclusions

In order to increase the rate of utilisation, family caregivers must be convinced of the relevant advantages of using support groups. Support groups which offer an exchange of experiences, open discussion, information and advice meet the requirements of family caregivers.

Counselling for dementia caregivers-predictors for utilization and expected quality from a family caregiver's point of view

Caregiver counselling has proved to be effective in reducing the burden of family caregivers of dementia patients. Nevertheless, little is known about the influencing factors for utilization and quality expectations of family caregivers. In this article, we address the following questions on the theoretical base of the Andersen/Newman model: Which variables of the care situation, the caregivers and their attitudes act as predictors for the utilization of caregiver counselling? What are the views of caregivers about the quality of caregiver counselling? The cross-sectional study was carried out as an anonymous written survey of family caregivers of dementia patients in four regions, both urban and rural, of Germany. Quantitative and qualitative data from 404 family caregivers were analysed using binary logistic regression analysis and qualitative content analysis, respectively. The only significant predictor for utilization is the assessment of how helpful caregiver counselling is for the individual care situation. In the sensitivity analysis 'accessibility of caregiver counselling' was additionally predictive for usage. Family caregivers most frequently expressed a wish for advice about further 'support offers' by qualified counsellors. In order to increase the rate of utilization, family caregivers must be convinced of the relevant advantages of using caregiver counselling. Counselling services should provide information about further support offers and give practical help in filling out application forms.

When help becomes a hindrance: mental health referral systems as barriers to care for primary care physicians treating patients with Alzheimer's disease

OBJECTIVES

To describe structural barriers to mental health specialists and consequences of these barriers to care for patients with dementia and neuropsychological symptoms and their primary care physicians (PCPs).

DESIGN

Cross-sectional qualitative interview study of PCPs.

SETTING

Physicians' offices, primarily managed care.

PARTICIPANTS

Forty PCPs in Northern California.

MEASUREMENTS

Open-ended interviews lasted 30-60 minutes. The interview guide covered clinician background, practice setting, clinical care of a particular patient, and general approach to managing patients with Alzheimer disease or related dementias.Interviews were transcribed and themes reflecting referrals identified.

RESULTS

Ninety-three percentage of the PCPs described problematic access to and communication with mental health specialists (in particular psychiatrists and neuropsychologists) as impediments to effective care for dementia patients. Thematic analysis identified structural barriers to mental health referrals ranging from problems with managed care and reimbursement policies to lack of trained providers and poor geographic distribution of specialists. Structural barriers compromised care for patients with dementia because the barriers limited PCP treatment options, and resources, impacted office staff and time with other patients, impeded and delayed care, and fostered poor communication and lack of coordinated care. Negative consequences for PCPs included increased frustration,conflict, and burnout.

CONCLUSION

PCPs viewed problems created by onerous referral systems, such as mental health carve outs, as particularly burdensome for elderly patients with comorbid dementia and neuropsychiatric problems. These problems were cited by PCPs across different types of practice settings. PCPs managed treatment of neurobehavioral symptoms as best they could despite lack of specialist support.