National Trends in Potentially Preventable Hospitalizations of Older Adults with Dementia

The effects of a facilitator-enabled online multicomponent iSupport for dementia programme: A multicentre randomised controlled trial

BACKGROUND

Multicomponent interventions with carers of people with dementia demonstrate positive effects on the health and quality of life for carers and care recipients. The World Health Organization's iSupport for Dementia is an evidence-based online psychoeducation programme for carers. However, the programme was mainly implemented as a self-learning tool which might have limited its positive effects on carers and care recipients. Evidence for online multicomponent interventions with carers that incorporates the iSupport programme remains unknown.

OBJECTIVES

This study aimed to partner with health and social care organisations to evaluate the effects of a facilitator-enabled online multicomponent Chinese iSupport programme, which included psychoeducation using the iSupport programme, facilitator-enabled carer support groups and access to care services.

DESIGN

A multicentre randomised controlled trial.

SETTINGS AND PARTICIPANTS

Participants were family carers in Australia and greater China. We recruited participants to the study from 1st November 2021 to 30th June 2022.

METHODS

The intervention group received the Chinese iSupport programme delivered online. The intervention lasted for 6 months. Our primary outcome was carers' quality of life. Our secondary outcomes were carers' self-efficacy, social support, distress reactions to changed behaviours, care recipients' frequency of changed behaviours, quality of life, unplanned hospital admissions, emergency department presentations and permanent admissions to nursing homes. The outcomes were measured at baseline (T0), 6 months (T1) and 9 months (T2). We applied a multivariate mixed effect linear regression model to capture the group effect, time effect and their interaction.

RESULTS

In total, 266 eligible family carers agreed to participate and were randomly assigned to an intervention group (n = 131) or a usual care group (n = 135). Most carers were women with a mean age of 53 years. The intervention group showed a statistically significant higher score of mental-health-related quality of life (mean difference = 4.1, 95 % CI: 1.5, 6.8, p = 0.002), self-efficacy in controlling upsetting thoughts (mean difference = 7.1, 95 % CI: 2.2, 12.0, p = 0.005) and lower score of distress reactions to changed behaviours (mean difference = -0.1, 95 % CI: -0.3, -0.03, p = 0.012) than the usual care group at T1.

CONCLUSION

The facilitator-enabled online multicomponent Chinese iSupport programme demonstrated positive effects for carers on mental health-related quality of life, controlling upsetting thoughts and distress reactions to changed behaviours of people with dementia.

TRIAL REGISTRATION

This study is registered in the Australia New Zealand Clinical Trials Registry on 12th March 2021 (ACTRN12621000276853).

TWEETABLE ABSTRACT

The facilitator-enabled online multicomponent Chinese iSupport programme improved family carers' mental health-related quality of life, control of upsetting thoughts and distress reactions to changed behaviours of people with dementia.

Fragmented Readmissions From a Nursing Facility in Medicare Beneficiaries

Over one-third of Medicare beneficiaries discharged to nursing facilities require readmission. When those readmissions are to a different hospital than the original admission, or "fragmented readmissions," they carry increased risks of mortality and subsequent readmissions. This study examines whether Medicare beneficiaries readmitted from a nursing facility are more likely to have a fragmented readmission than beneficiaries readmitted from home among a 2018 cohort of Medicare beneficiaries, and examined whether this association was affected by a diagnosis of Alzheimer's Disease (AD). In fully adjusted models, readmissions from a nursing facility were 19% more likely to be fragmented (AOR 1.19, 95% CI 1.16, 1.22); this association was not affected by a diagnosis of AD. These results suggest that readmission from nursing facilities may contribute to care fragmentation for older adults, underscoring it as a potentially modifiable pre-hospital risk factor for fragmented readmissions.

Hospital admissions for dementia in the Brazilian public health system over the last decade

OBJECTIVE

The rise in dementia prevalence, particularly in lower- and middle-income countries (LMIC), places a significant burden on healthcare systems. However, comprehensive data on dementia hospital admissions are scarce.

METHODS

We analyzed admission rates for dementia, cost of hospital admissions, lengths of hospital stay, and in-hospital deaths in 2010 and 2019 in Brazil.

RESULTS

Admission rates declined from 19.7/100,000 inhabitants in 2010 to 14.6/100,000 in 2019. In-hospital mortality increased from 3.9% in 2010 to 8.8% in 2019, particularly for short-term stays. Although 9.6% of hospital admissions occurred in regions with lower economic power in 2010 and 10.4% in 2019, these regions had higher mortality, reaching 4.3% of in-hospital deaths in 2010 and 9.3% in 2019.

CONCLUSION

The observed trends, alongside sex and regional disparities, underscore the need for targeted investment in healthcare infrastructure and training to improve dementia care in LMIC.

Highlights

The rate of hospital admissions for dementia was similar in 2010 and 2019 in Brazil.The cost per hospital admission in 2010 decreased by 38.5% compared with 2019.There was an increase in short-term hospital stays for dementia in 2019 compared to 2010, accompanied by an increase in mortality rates for these short-term stays.While hospital admissions for dementia decreased in men and increased in women, the in-hospital mortality due to dementia increased for both sexes.

Ascertaining Out-of-Pocket Costs of Dementia Care: Feasibility Study of a Web-Based Weekly Survey

BACKGROUND

Caring for a family member living with dementia is costly. A major contributor to care demands, and therefore to the costs, are the behavioral symptoms of dementia. Here, we examine the feasibility of ascertaining costs related to caregiving from weekly web-based surveys collected during a telehealth-based behavioral intervention study-Support via Technology: Living and Learning with Advancing Alzheimer Disease.

OBJECTIVE

This study aims to determine the feasibility and acceptability of using a web-based weekly survey to capture real-time data on out-of-pocket caregiving expenses and time commitments associated with dementia care. To examine relationships between behavioral symptoms, care partner reactivity, burden, and out-of-pocket dementia care costs.

METHODS

Feasibility was measured by accrual, retention, and data completion by participating care partners. Behavioral symptoms, care partner reactivity, and burden were collected before and after the intervention from 13 care partners. Weekly web-based surveys queried Support via Technology: Living and Learning with Advancing Alzheimer Disease care partners about their out-of-pocket costs associated with care-related activities. The surveys included questions on out-of-pocket costs care partners incurred from hospitalizations and emergency department use, primary care provider visits, use of paid in-home care or respite services, use of prescription medications, and use of over-the-counter medications. The surveys also queried the amount of time care partners devoted to these specific care-related activities.

RESULTS

Out-of-pocket costs of dementia care were collected via a web-based weekly survey for up to 18 months. In-home assistance was the most frequently reported type of out-of-pocket care expense and the costliest. care partners who paid for in-home assistance or respite reported more behavioral and psychological symptoms of dementia behaviors, higher reactivity, and higher burden than those who did not.

CONCLUSIONS

This novel web-based weekly survey-based approach offers lessons for designing and implementing future cost-focused studies and care partner-supportive telehealth-based interventions for Alzheimer disease and related dementias (ADRD). The results correspond with the existing understanding of ADRD in that high family-related out-of-pocket costs are a typical part of the caregiving experience, and those costs likely increase with dementia severity. The results may also offer potential insights to health systems and policy makers as they seek to implement telehealth-based and related interventions that seek to better support people living with ADRD and their family care partners.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04335110; https://clinicaltrials.gov/ct2/show/NCT04335110.

Needs of family caregivers of hospitalised adults with dementia during care transitions: a qualitative study in a US Department of Veterans Affairs Hospital

OBJECTIVE

To identify the needs of caregivers of hospitalised adults with dementia in the hospital and during care transitions.

DESIGN

Pragmatic qualitative inquiry with semi-structured interviews.

SETTING

Michael E. DeBakey Veterans Affairs Medical Center in Houston, Texas, USA.

PARTICIPANTS

12 family caregivers (family member (n=11); friend (n=1)) and 15 health professionals (hospital medicine physicians (n=4), inpatient nurse case managers (n=2), social workers (n=4), outpatient geriatrics providers (n=2), a primary care provider (n=1), geriatric psychiatrists (n=2)) were interviewed. Caregivers were recruited while their care recipient was hospitalised and were interviewed at least 2 weeks after the care recipient was discharged from the hospital. Health professionals were eligible for the study if they provided care to patients with dementia in the inpatient or outpatient setting.

RESULTS

Four recommendations emerged from the analysis: (1) engage caregivers as partners in the care team, (2) provide dementia-specific information and training, (3) connect caregivers to home and community-based services and (4) provide care navigation and support for the caregiver posthospitalisation.

CONCLUSIONS

Hospital care transitions are challenging for caregivers of hospitalised adults living with dementia. Care transition interventions designed to support caregivers with tailored, dementia-specific information and services are needed.

Association between days spent at home and functional status and health among persons living with dementia

BACKGROUND

Many persons living with dementias (PLWD) prefer to remain at home as long as possible, and days spent at home (DAH)-defined as the time an individual spends outside of healthcare facilities-has emerged as a person-centred outcome measure in this population. We examined the association between DAH and functional status and health among PLWD.

METHODS

Utilizing a nationally representative cohort of individuals age 65 and older in the United States with dementia from the 2010-2018 Health and Retirement Study (HRS), we assessed the relationship between an ordinal categorical DAH variable and number of activities of daily living (ADLs) (range 0-10; 10 being independent), mobility (0-5; 5 being mobile), and self-rated health (SRH) (0-4; 4 being excellent), controlling for patient characteristics. DAH was defined as the number of self-reported days spent outside a hospital or nursing home in the time between survey waves, typically 730 days.

RESULTS

We identified 3002 participants (4192 observations, average 1.4 observations per participant). The mean DAH was 704.4 days (SD 10.8 days) and 64.9% spent all days at home (i.e. 730 days). A 2-week decrease in DAH was associated with a lower ADL score by 0.32 points (95% confidence internal [CI]: 0.24-0.40, P-for-trend<0.001), a lower mobility score by 0.18 points (95% CI: 0.13-0.22, P-for-trend<0.001), and a lower SRH by 0.05 points (95% CI: 0.02-0.08, P-for-trend<0.001).

CONCLUSION

We demonstrate that DAH is positively associated with important patient-reported outcomes among the dementia population, strengthening the argument for considering DAH as a meaningful outcome measure for PLWD.

Dementia severity at incident diagnosis in a population representative sample of older Americans

INTRODUCTION

We provide the first analysis of distribution of dementia severity at incident diagnosis for a population representative sample of older Americans.

METHODS

Using data from the Aging, Demographics, and Memory Study (ADAMS), the Health Retirement Study (HRS), and traditional Medicare claims, we estimated the Clinical Dementia Rating Scale for ADAMS respondents and applied parameter estimates to predict dementia severity for HRS respondents with claims-based incident dementia diagnosis.

RESULTS

Seventy percent of older adults received a dementia diagnosis of mild cognitive impairment or mild dementia (early stages). Fewer individuals were diagnosed at early stages in years 2000 to 2008 (65%) compared to years 2009 to 2016 (76%). About 72% of non-Hispanic white persons were diagnosed at early stages, compared to 63% non-Hispanic black and 59% Hispanic persons. More males than females were diagnosed at early stages (75% vs 67%).

DISCUSSION

These data linkages allow population surveillance of early and equitable dementia detection in the older US population to assess clinical and policy levers to improve detection.

Highlights

For the US population 70 and older, 30% were diagnosed with dementia at a moderate or severe stage.Fewer were diagnosed at early stages in years 2000 to 2008 compared to 2009 to 2016 (65% vs 76%).A total of 72% of white persons were diagnosed at early stages, compared to 63% black and 59% Hispanic persons.More males than females were diagnosed at early stages (75% vs 67%).High wealth and education level were associated with diagnosis at early stages disease.

Racial/Ethnic Disparities in Hospital Readmission and Frequent Hospitalizations Among Medicare Beneficiaries With Alzheimer's Disease and Related Dementia: Traditional Medicare Versus Medicare Advantage

OBJECTIVES

Examine racial/ethnic disparities in 30-day readmission and frequent hospitalizations among Medicare beneficiaries with dementia in traditional Medicare (TM) versus Medicare Advantage (MA).

METHODS

In this case-control study, we used 2018-2019 TM and MA claims data. Participants included individuals 65+ with 2 years of continuous enrollment, diagnosis of dementia, a minimum of 4 office visits in 2018, and at least 1 hospitalization in 2019, (cases: TM [n = 36,656]; controls: MA [n = 29,366]). We conducted matching based on health-need variables and applied generalized linear models adjusting for demographics, health-related variables, and healthcare encounters.

RESULTS

TM was associated with higher odds of 30-day readmission (OR = 1.07 [CI: 1.02 to 1.12]) and frequent hospitalizations (OR = 1.10 [CI: 1.06 to 1.14]) compared to MA. Hispanic and Black enrollees in TM had higher odds of frequent hospitalizations compared with Hispanic and Black enrollees in MA, respectively (OR = 1.35 [CI: 1.19 to 1.54]) and (OR = 1.26 [CI: 1.13 to 1.40]). MA was associated with lower Hispanic-White and Black-White disparities in frequent hospitalizations by 5.8 (CI: -0.09 to -0.03) and 4.4 percentage points (PP; CI: -0.07 to -0.02), respectively. For 30-day readmission, there was no significant difference between Black enrollees in TM and MA (OR = 1.04 [CI: 0.92 to 1.18]), but Hispanic enrollees in TM had higher odds of readmission than Hispanics in MA (OR = 1.23 [CI: 1.06 to 1.43]). MA was associated with a lower Hispanic-White disparity in readmission by 1.9 PP (CI: -0.004 to -0.01).

DISCUSSION

MA versus TM was associated with lower risks of 30-day readmission and frequent hospitalizations. Moreover, MA substantially reduced Hispanic-White and Black-White disparities in frequent hospitalizations compared with TM.

Is Electronic Information Exchange Associated With Lower 30-Day Readmission Charges Among Medicare Beneficiaries?

OBJECTIVE

Fragmented readmissions, when admission and readmission occur at different hospitals, are associated with increased charges compared with nonfragmented readmissions. We assessed if hospital participation in health information exchange (HIE) was associated with differences in total charges in fragmented readmissions.

DATA SOURCE

Medicare Fee-for-Service Data, 2018.

STUDY DESIGN

We used generalized linear models with hospital referral region and readmission month fixed effects to assess relationships between information sharing (same HIE, different HIEs, and no HIE available) and total charges of 30-day readmissions among fragmented readmissions; analyses were adjusted for patient-level clinical/demographic characteristics and hospital-level characteristics.

DATA EXTRACTION METHODS

We included beneficiaries with a hospitalization for acute myocardial infarction, congestive heart failure, chronic obstructive pulmonary disease, syncope, urinary tract infection, dehydration, or behavioral issues with a 30-day readmission for any reason.

PRINCIPAL FINDINGS

In all, 279,729 admission-readmission pairs were included, 27% of which were fragmented (n=75,438); average charges of fragmented readmissions were $64,897-$71,606. Compared with fragmented readmissions where no HIE was available, the average marginal effects of same-HIE and different-HIE admission-readmission pairs were -$2329.55 (95% CI: -7333.73, 2674.62) and -$3905.20 (95% CI: -7592.85, -307.54), respectively. While the average marginal effects of different-HIE pairs were lower than those for no-HIE fragmented readmissions, the average marginal effects of same-HIE and different-HIE pairs were not significantly different from each other.

CONCLUSIONS

There were no statistical differences in charges between fragmented readmissions to hospitals that share an HIE or that do not share an HIE compared with hospitals with no HIE available.

Colonoscopy Utilization in Elderly Patients with Dementia: Characteristics, Complications, and Charges in a National Matched-Cohort Analysis

BACKGROUND

It is projected that the elderly population will continue to increase. Many will develop chronic conditions such as dementia.

AIMS

Our aims are to describe the utilization of colonoscopy among patients with dementia and compare outcomes in those with and without dementia.

METHODS

This population-based analysis utilized the National Inpatient Sample (NIS) during 2019. Patients with dementia over the age of 60 years receiving colonoscopy were identified utilizing ICD-10 codes. Logistic regression was used for propensity score matching between the comparison groups. A Greedy one-to-one matching algorithm was utilized along with standardized mean differences to assess balance. Mcnemar test, signed rank sum, and paired t-test were used to compare the outcomes.

RESULTS

Initially, 50,692 patients without dementia were compared with 4323 patients with dementia. Patients with dementia were more likely to be female, older, less likely White, had lower income, and more likely to be on Medicare. In the matched comparison (4176 in each group), complication analysis showed that patients with dementia did not have higher colonoscopy-related complications. They did have higher rates of other complications including renal/AKI (p = 0.0042), pulmonary/pneumonia (p = 0.003), cerebrovascular accidents (p = 0.0063), and sepsis (< 0.0001). Patients with dementia were also less likely to have routine discharges (< 0.0001), had longer hospital stays (< 0.0001), and higher hospital costs (< 0.0001).

CONCLUSIONS

Elderly patients with dementia have similar colonoscopy-related complications as patients without dementia. However, they do have higher complications in general. The decision whether to perform colonoscopy in this patient population is multifactorial. A careful assessment of a dementia patient's history can help with this decision.

Association of Comorbidity With Healthcare Utilization in People Living With Dementia, 2010-2019: A Population-Based Cohort Study

Evidence on the healthcare utilization associated with comorbidity in people with dementia is lacking in Chinese societies. This study aimed to quantify healthcare utilization associated with comorbidity that is common in people living with dementia. We conducted a cohort study using population-based data from Hong Kong public hospitals. Individuals aged 35+ with a dementia diagnosis between 2010 and 2019 were included. Among 88,151 participants, people with at least two comorbidities accounted for 81.2%. Estimates from negative binomial regressions showed that compared to those with one or no comorbid condition other than dementia, adjusted rate ratios of hospitalizations among individuals with six or seven and eight or more conditions were 1.97 [98.75% CI, 1.89-2.05] and 2.74 [2.63-2.86], respectively; adjusted rate ratios of Accident and Emergency department visits among individuals with six or seven and eight or more conditions were 1.53 [1.44-1.63] and 1.92 [1.80-2.05], respectively. Comorbid chronic kidney diseases were associated with the highest adjusted rate ratios of hospitalizations (1.81 [1.74-1.89]), whereas comorbid chronic ulcer of the skin was associated with the highest adjusted rate ratios of Accident and Emergency department visits (1.73 [1.61-1.85]). Healthcare utilization for individuals with dementia differed substantially by both the number of comorbid chronic conditions and the presence of some specific comorbid conditions. These findings further highlight the importance of taking account of multiple long-term conditions in tailoring the care approach and developing healthcare plans for people with dementia.

Prevalence and general characteristics of dementia: a nationwide population-based study of electronic health records in Türkiye

Background/aim

Türkiye is a country with an increasing life expectancy and an older adult population in parallel with the rest of the world. Several national small-scale studies were performed regarding the prevalence and characteristics of dementia in Türkiye, and the results of these studies differ from each other. We aimed to determine the prevalence of dementia in Türkiye to present the demographic characteristics, the frequency of use of health services, and the management of dementia.

Materials and methods

Patients aged 65 years and over with a diagnosis of any type of dementia between January 1, 2019, and December 31, 2020, were retrospectively screened from the electronic health records of the Ministry of Health using ICD-10 codes.

Results

In 2019, the total number of dementia cases identified in individuals aged 65 years and older was 247,727, of whom 150,529 (60.8%) were women. In 2020, the total number of dementia cases identified in this age group was 233,949, with 142,878 (61.1%) of these cases being women. The rate of patients admitted to the emergency department was 72.3% and 66.2% of all dementia patients in 2019 and 2020, respectively. In terms of the use of outpatient clinics, most patients with dementia were admitted to neurology (71.0% in 2019 and 62.4% in 2020). The geriatric medicine outpatient clinic was the least used by patients with dementia both in 2019 and 2020.

Conclusion

The prevalence of patients living with dementia in Türkiye is lower than the global average. This suggests that most dementia cases are overlooked, highlighting the need to raise dementia awareness both in the community and among primary health care providers who frequently encounter older individuals. The study is significant in that it is the first to show the nationwide frequency of dementia in Türkiye.

Trends and Factors Associated With Extremity Fractures and Post-Acute Care Utilization of Nevada Older Adults: Insights of Age-Friendly State Planning in U.S

Along with the trend of a steady utilization decline in the U.S. nursing home beds, post-acute care (PAC) utilization at the skilled nursing facilities has declined. This study was a cross-sectional, retrospective review of hospital discharge-based claim data. We evaluate the factors associated with utilizing post-acute care at rehabilitation facilities among those with extremity fractures in the state of Nevada. All Nevada hospital discharges of aged ≥65 years with extremity fractures between 2018 and 2021 were divided to post-acute care locations by (1) rehabilitation facilities (skilled nursing facility and inpatient rehabilitation facility) and (2) homes (with and without services). PAC utilization at facilities declined from 55.1% in 2018 to 49.7% in 2021 (P < .001). In response, PAC utilization at homes continuously upwards, particularly, homes with services from 18.8% in 2018 to 24.5% in 2021 (P < .001). Older age, female, lower extremity fractures, comorbidities, and Medicare beneficiaries were associated with higher probabilities of utilizing post-acute rehabilitation facilities. Racial minorities, COVID-19 pandemic, upper extremities, Medicaid beneficiaries, rural hospitals, and prolonged hospital length of stay were associated with lower probabilities of PAC utilization at facilities. Caregiver burdens and workforce training is urgently warranted to respond to this utilization shift. Effective geriatrics workforce training might advance care efficiency of older adults with extremity fractures and guide to the insights of establishing the age-friendly state of Nevada in response to this utilization shift trends.

Data-Driven Analytics to Discover APRN's Impact on Nursing Home Hospitalization: Causal Discovery Analysis

OBJECTIVES

Research shows advanced practice registered nurses (APRNs) embedded in nursing homes (NHs) reduce resident hospitalizations. However, the specific APRN activities that reduce hospitalizations have not been adequately investigated. This study aims to identify the causal links between APRN activities and NHs resident hospitalization. The study also examined relationships among other variables, including advanced directives, clinical diagnosis, and length of hospitalization.

DESIGN

Secondary data analysis.

SETTING AND PARTICIPANTS

Residents of NHs participating in the Missouri Quality Initiative for Nursing Homes, 2016-2019.

METHODS

We performed a secondary analysis of data from the Missouri Quality Initiative for Nursing Homes Intervention using causal discovery analysis, a machine learning, data-driven technique to determine causal relationships across data. The resident roster and INTERACT resident hospitalization datasets were combined to create the final dataset. Variables in the analysis model were divided into before and after hospitalization. Expert consensus was used to validate and interpret the outcomes.

RESULTS

The research team analyzed 1161 hospitalization events and their associated NH activities. APRNs evaluated NH residents before a transfer, expedited follow-up nursing assessments, and authorized hospitalization when necessary. No significant causal relationships were found between APRN activities and the clinical diagnosis of a resident. The analysis also showed multifaceted relationships related to having advanced directives and duration of hospitalization.

CONCLUSIONS AND IMPLICATIONS

This study demonstrated the importance of APRNs embedded in NHs to improve resident outcomes. APRNs in NHs can facilitate communication and collaboration among the nursing team, leading to early identification and treatment for resident status changes. APRNs can also initiate more timely transfers by reducing the need for physician authorization. These findings emphasize the crucial role of APRNs in NHs and suggest that budgeting for APRN services may be an effective strategy to reduce hospitalizations. Additional findings regarding advance directives are discussed.

Understanding the role of psychiatrists in the diagnosis and management of mild cognitive impairment and mild Alzheimer's disease dementia: a cross-sectional survey

BACKGROUND

Alzheimer's disease (AD) is a progressive neurological disorder and the most common cause of dementia. The clinical continuum of AD ranges from asymptomatic disease to mild cognitive impairment (MCI), followed by AD dementia, categorized as mild, moderate, or severe. Almost one-third of patients suspected of having MCI or mild AD dementia are referred to specialists including psychiatrists. We sought to better understand the role that psychiatrists play in the diagnosis, treatment, and management of patients with all-cause MCI or mild AD dementia.

METHODS

We conducted an anonymous, online survey among physicians in the United States between February 4, 2021, and March 1, 2021. We surveyed psychiatrists, primary care physicians (PCPs), geriatricians, and neurologists who treat patients with all-cause MCI or mild AD dementia.

RESULTS

A total of 301 physicians participated in the survey, 50 of whom were psychiatrists. Of their patients with all-cause MCI or mild AD dementia, psychiatrists reported personally diagnosing two-thirds (67%). Psychiatrists used various methods to diagnose MCI or mild AD dementia including mental status testing (94%), review of patient medical history (86%), and neurological exams (61%). Upon diagnosis, psychiatrists reported most commonly discussing treatments (86%), management strategies (80%), disease progression (72%), and etiology of MCI or mild AD dementia (72%) with their patients. Most psychiatrists surveyed (82%) reported receiving advanced formal training in MCI and AD dementia care, primarily via residency training (38%), continuing medical education (22%) or fellowship (18%). Additionally, almost all psychiatrists (92%) reported receiving referrals for ongoing management of patients with MCI or mild AD dementia, primarily from PCPs or neurologists. However, only 46% of psychiatrists viewed themselves as the coordinator of care for their patients with MCI or mild AD dementia.

CONCLUSIONS

Many psychiatrists indicated that they were well-informed about MCI and AD dementia and have a strong interest in providing care for these patients. They can provide timely and accurate diagnosis of clinical MCI and mild AD dementia and develop optimal treatment plans for patients. Although many psychiatrists consider other physicians to be the care coordinators for patients with MCI and mild AD dementia, psychiatrists can play a key role in diagnosing and managing patients with MCI and mild AD dementia.

Exploring the role of a facilitator in supporting family carers when embedding the iSupport for Dementia programme in care services: A qualitative study

AIMS

To explore stakeholders' perceptions of a facilitator's role in supporting carers when embedding iSupport for Dementia psychoeducation program, in care services.

METHODS

A qualitative descriptive study design was applied. Data were collected from workshops and interviews with carers of people living with dementia (PLWD)and with health and social care professionals from two tertiary hospitals and two community aged care organisations across three Australian states between October 2021 and March 2022. A thematic analysis was used to analyse data. The COREQ guideline was followed to report our findings.

RESULTS

A total of 30 family carers and 45 health and social care professionals participated in the study. Three main themes and seven subthemes were identified from the data. We described the main themes as (1) the facilitator's role at the time of dementia diagnosis, (2) the facilitator's role throughout the everyday dementia care journey and (3) the facilitator's role during transition moments.

CONCLUSIONS

Caring for family members with dementia is demanding and stressful for carers. Embedding a facilitator-enabled iSupport for Dementia program in hospital and community aged care settings has the potential to mitigate sources of stress associated with care recipient factors, carer factors and care service factors, and improve the health and well-being of carers and those for whom they care.

RELEVANCE TO CLINICAL PRACTICE

Our findings will inform the establishment of iSupport facilitators appointed by dementia care providers in hospital and community care settings and help determine their roles and responsibilities in delivering the iSupport program. Our findings relate to nurse-led and coordinated dementia care in hospital and community aged care settings.

PATIENT OR PUBLIC CONTRIBUTION

This study was co-designed with stakeholders from two aged care organisations and two tertiary hospitals. The study participants were staff employed by these organisations and carers of PLWD who were service users.

Examining the Use of Text Messages Among Multidisciplinary Care Teams to Reduce Avoidable Hospitalization of Nursing Home Residents with Dementia: Protocol for a Secondary Analysis

BACKGROUND

Reducing avoidable nursing home (NH)-to-hospital transfers of residents with Alzheimer disease or a related dementia (ADRD) has become a national priority due to the physical and emotional toll it places on residents and the high costs to Medicare and Medicaid. Technologies supporting the use of clinical text messages (TMs) could improve communication among health care team members and have considerable impact on reducing avoidable NH-to-hospital transfers. Although text messaging is a widely accepted mechanism of communication, clinical models of care using TMs are sparsely reported in the literature, especially in NHs. Protocols for assessing technologies that integrate TMs into care delivery models would be beneficial for end users of these systems. Without evidence to support clinical models of care using TMs, users are left to design their own methods and protocols for their use, which can create wide variability and potentially increase disparities in resident outcomes.

OBJECTIVE

Our aim is to describe the protocol of a study designed to understand how members of the multidisciplinary team communicate using TMs and how salient and timely communication can be used to avert poor outcomes for NH residents with ADRD, including hospitalization.

METHODS

This project is a secondary analysis of data collected from a Centers for Medicare & Medicaid Services (CMS)-funded demonstration project designed to reduce avoidable hospitalizations for long-stay NH residents. We will use two data sources: (1) TMs exchanged among the multidisciplinary team across the 7-year CMS study period (August 2013-September 2020) and (2) an adapted acute care transfer tool completed by advanced practice registered nurses to document retrospective details about NH-to-hospital transfers. The study is guided by an age-friendly model of care called the 4Ms (What Matters, Medications, Mentation, and Mobility) framework. We will use natural language processing, statistical methods, and social network analysis to generate a new ontology and to compare communication patterns found in TMs occurring around the time NH-to-hospital transfer decisions were made about residents with and without ADRD.

RESULTS

After accounting for inclusion and exclusion criteria, we will analyze over 30,000 TMs pertaining to over 3600 NH-to-hospital transfers. Development of the 4M ontology is in progress, and the 3-year project is expected to run until mid-2025.

CONCLUSIONS

To our knowledge, this project will be the first to explore the content of TMs exchanged among a multidisciplinary team of care providers as they make decisions about NH-to-hospital resident transfers. Understanding how the presence of evidence-based elements of high-quality care relate to avoidable hospitalizations among NH residents with ADRD will generate knowledge regarding the future scalability of behavioral interventions. Without this knowledge, NHs will continue to rely on ineffective and outdated communication methods that fail to account for evidence-based elements of age-friendly care.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/50231.

An integrative review of measures of transitions and care coordination for persons living with dementia and their caregivers

Introduction

High rates of hospital visits and readmissions are common among persons living with dementia, resulting in frequent transitions in care and care coordination. This paper identifies and evaluates existing measures of transitions and care coordination for persons living with dementia and their caregivers.

Methods

This integrative review builds off a prior review using a systematic search of online databases (PubMed, EBSCO, CINAHL, PsycInfo, and Scopus) to identify records and locate reports (or articles) that use measures of care transitions and care coordination. Identified measures were compared to the Alzheimer's Association's Dementia Care Practice Recommendations to evaluate strengths and weaknesses of the measure in this population, such as if measures were person- and family-centered.

Results

Seventy-one reports using measures of transitions in care and care coordination for persons living with dementia and their caregivers were identified. There were multiple measures identified in some reports. Three main areas of measures were classified into: identification of the population (3 measures, 8 reports), transitional care and care coordination delivery (14 measures, 17 reports), and transitional care and care coordination outcomes (e.g., health-care use, cost, and mortality; 17 measures, 60 reports). A strength of the three main areas of measures was that a portion of the measures were person- and family-centered. Variability in the operational definitions of some measures and time intensiveness of collecting the measure (e.g., number of items, the time it takes to complete the items) were common weaknesses.

Discussion

Transitions and care coordination measures are varied across studies targeted at persons living with dementia and their caregivers. Existing measures focus heavily on outcomes, specifically health-care resource use, and cost, rather than the elements of transitional care or care coordination. Future measure development focused on care transitions and service coordination is needed.

Association Between Weight Status and Rate of Cognitive Decline: China Health and Nutrition Survey 1997-2018

BACKGROUND

There is a close relationship between weight status and cognitive impairment in older adults. This study examined the association between weight status and the trajectory of cognitive decline over time in a population-based cohort of older adults in China.

METHODS

We used data from adults aged ≥55 years participating in the China health and nutrition survey (1997-2018). Underweight (body mass index [BMI] ≤ 18.5 kg/m2), normal weight (18.5-23 kg/m2), overweight (23-27.5 kg/m2), and obesity (BMI ≥ 27.5 kg/m2) were defined using the World Health Organization Asian cutpoints. Global cognition was estimated every 2-4 years through a face-to-face interview using a modified telephone interview for cognitive status (scores 0-27). The association between BMI and the rate of global cognitive decline, using a restricted cubic spline for age and age category, was examined with linear mixed-effects models accounting for correlation within communities and individuals.

RESULTS

We included 5 992 adults (53% female participants, mean age of 62 at baseline). We found differences in the adjusted rate of global cognitive decline by weight status (p = .01 in the cubic spline model). Models were adjusted for sex, marital status, current employment status, income, region, urbanization, education status, birth cohort, leisure activity, smoking status, and self-reported diagnosis of hypertension, diabetes, or Myocardial Infarction (MI)/stroke. In addition, significant declines by age in global cognitive function were found for all weight status categories except individuals with obesity.

CONCLUSIONS

In a cohort of adults in China, cognitive decline trajectory differed by weight status. A slower rate of change was observed in participants classified as having obesity.

New psychotropic medication use among Medicare beneficiaries with dementia after hospital discharge

BACKGROUND

Hospitalizations among people with dementia (PWD) may precipitate behavioral changes, leading to the psychotropic medication use despite adverse outcomes and limited efficacy. We sought to determine the incidence of new psychotropic medication use among community-dwelling PWD after hospital discharge and, among new users, the proportion with prolonged use.

METHODS

This was a retrospective cohort study using a 20% random sample of Medicare claims in 2017, including hospitalized PWD with traditional and Part D Medicare who were 68 years or older. The primary outcome was incident prescribing at discharge of psychotropics including antipsychotics, sedative-hypnotics, antiepileptics, and antidepressants. This was defined as new prescription fills (i.e., from classes not used in 180 days preadmission) within 7 days of hospital or skilled nursing facility discharge. Prolonged use was defined as the proportion of new users who continued to fill newly prescribed medications beyond 90 days of discharge.

RESULTS

The cohort included 117,022 hospitalized PWD with a mean age of 81 years; 63% were female. Preadmission, 63% were using at least 1 psychotropic medication; 10% were using medications from ≥3 psychotropic classes. These included antidepressants (44% preadmission), antiepileptics (29%), sedative-hypnotics (21%), and antipsychotics (11%). The proportion of PWD discharged from the hospital with new psychotropics ranged from 1.9% (antipsychotics) to 2.9% (antiepileptics); 6.6% had at least one new class started. Among new users, prolonged use ranged from 36% (sedative-hypnotics) to 63% (antidepressants); across drug classes, prolonged use occurred in 51%. Predictors of newly initiated psychotropics included length of stay (≥median vs.

CONCLUSIONS

Hospitalized PWD have a high prevalence of preadmission psychotropic medication use; against this baseline, discharge from the hospital with new psychotropics is relatively uncommon. Nevertheless, prolonged use of newly initiated psychotropics occurs in a substantial proportion of this population.

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Key Words

• dementia
• hospitalization
• prescribing
• psychotropics

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MESH Headings

• Humans
• Female
• Aged
• United States
• Aged, 80 and over
• Male
• Patient Discharge
• Retrospective Studies
• Anticonvulsants/therapeutic use
• Dementia/drug therapy
• Medicare
• Psychotropic Drugs/therapeutic use
• Antipsychotic Agents/therapeutic use
• Antidepressive Agents/therapeutic use
• Hospitals
• Hypnotics and Sedatives/therapeutic use

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Grants

• K12 HS026383 AHRQ HHS
• L30 AG074160 NIA NIH HHS
• R24 AG064025 NIA NIH HHS
• K24 AG049057 NIA NIH HHS
• R35 AG071916 NIA NIH HHS
• R03 AG064373 NIA NIH HHS
• T32 AG000212 NIA NIH HHS
• P01 AG066605 NIA NIH HHS
• K01 AG073532 NIA NIH HHS
• P30 AG044281 NIA NIH HHS
• R03 AG078804 NIA NIH HHS

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Affiliation(s)

Matthew E Growdon Division of Geriatrics, University of California, San Francisco, California, USA Geriatrics, Palliative, and Extended Care Service Line, San Francisco VA Medical Center, San Francisco, California, USA
Siqi Gan Division of Geriatrics, University of California, San Francisco, California, USA Northern California Institute for Research and Education, San Francisco, California, USA
Kristine Yaffe Mental Health, San Francisco VA Medical Center, San Francisco, California, USA Department of Epidemiology and Biostatistics, University of California, San Francisco, California, USA Departments of Neurology and Psychiatry, University of California, San Francisco, California, USA
Alexandra K Lee Division of Geriatrics, University of California, San Francisco, California, USA Geriatrics, Palliative, and Extended Care Service Line, San Francisco VA Medical Center, San Francisco, California, USA
Timothy S Anderson Division of General Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
Ulrike Muench Department of Social and Behavioral Sciences, School of Nursing, University of California, San Francisco, California, USA
W John Boscardin Division of Geriatrics, University of California, San Francisco, California, USA Department of Epidemiology and Biostatistics, University of California, San Francisco, California, USA
Michael A Steinman Division of Geriatrics, University of California, San Francisco, California, USA Geriatrics, Palliative, and Extended Care Service Line, San Francisco VA Medical Center, San Francisco, California, USA

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Supervised, Self-Administered Tablet-Based Cognitive Assessment in Neurodegenerative Disorders and Stroke

INTRODUCTION

As the population ages, the prevalence of cognitive impairment is expanding. Given the recent pandemic, there is a need for remote testing modalities to assess cognitive deficits in individuals with neurological disorders. Self-administered, remote, tablet-based cognitive assessments would be clinically valuable if they can detect and classify cognitive deficits as effectively as traditional in-person neuropsychological testing.

METHODS

We tested whether the Miro application, a tablet-based neurocognitive platform, measured the same cognitive domains as traditional pencil-and-paper neuropsychological tests. Seventy-nine patients were recruited and then randomized to either undergo pencil-and-paper or tablet testing first. Twenty-nine age-matched healthy controls completed the tablet-based assessments. We identified Pearson correlations between Miro tablet-based modules and corresponding neuropsychological tests in patients and compared scores of patients with neurological disorders with those of healthy controls using t tests.

RESULTS

Statistically significant Pearson correlations between the neuropsychological tests and their tablet equivalents were found for all domains with moderate (r > 0.3) or strong (r > 0.7) correlations in 16 of 17 tests (p < 0.05). All tablet-based subtests differentiated healthy controls from neurologically impaired patients by t tests except for the spatial span forward and finger tapping modules. Participants reported enjoyment of the tablet-based testing, denied that it provoked anxiety, and noted no preference between modalities.

CONCLUSIONS

This tablet-based application was found to be widely acceptable to participants. This study supports the validity of these tablet-based assessments in the differentiation of healthy controls from patients with neurocognitive deficits in a variety of cognitive domains and across multiple neurological disease etiologies.

The Impact of Health Information Exchange on In-Hospital and Postdischarge Mortality in Older Adults with Alzheimer Disease Readmitted to a Different Hospital Within 30 Days of Discharge: Cohort Study of Medicare Beneficiaries

BACKGROUND

Although electronic health information sharing is expanding nationally, it is unclear whether electronic health information sharing improves patient outcomes, particularly for patients who are at the highest risk of communication challenges, such as older adults with Alzheimer disease.

OBJECTIVE

To determine the association between hospital-level health information exchange (HIE) participation and in-hospital or postdischarge mortality among Medicare beneficiaries with Alzheimer disease or 30-day readmissions to a different hospital following an admission for one of several common conditions.

METHODS

This was a cohort study of Medicare beneficiaries with Alzheimer disease who had one or more 30-day readmissions in 2018 following an initial admission for select Hospital Readmission Reduction Program conditions (acute myocardial infarction, congestive heart failure, chronic obstructive pulmonary disease, and pneumonia) or common reasons for hospitalization among older adults with Alzheimer disease (dehydration, syncope, urinary tract infection, or behavioral issues). Using unadjusted and adjusted logistic regression, we examined the association between electronic information sharing and in-hospital mortality during the readmission or mortality in the 30 days following the readmission.

RESULTS

A total of 28,946 admission-readmission pairs were included. Beneficiaries with same-hospital readmissions were older (aged 81.1, SD 8.6 years) than beneficiaries with readmissions to different hospitals (age range 79.8-80.3 years, P<.001). Compared to admissions and readmissions to the same hospital, beneficiaries who had a readmission to a different hospital that shared an HIE with the admission hospital had 39% lower odds of dying during the readmission (adjusted odds ratio [AOR] 0.61, 95% CI 0.39-0.95). There were no differences in in-hospital mortality observed for admission-readmission pairs to different hospitals that participated in different HIEs (AOR 1.02, 95% CI 0.82-1.28) or to different hospitals where one or both hospitals did not participate in HIE (AOR 1.25, 95% CI 0.93-1.68), and there was no association between information sharing and postdischarge mortality.

CONCLUSIONS

These results indicate that information sharing between unrelated hospitals via a shared HIE may be associated with lower in-hospital, but not postdischarge, mortality for older adults with Alzheimer disease. In-hospital mortality during a readmission to a different hospital was higher if the admission and readmission hospitals participated in different HIEs or if one or both hospitals did not participate in an HIE. Limitations of this analysis include that HIE participation was measured at the hospital level, rather than at the provider level. This study provides some evidence that HIEs can improve care for vulnerable populations receiving acute care from different hospitals.

Dementia-related agitation: a 6-year nationwide characterization and analysis of hospitalization outcomes

OBJECTIVES

To characterize all hospitalizations held in mainland Portugal (2010-2015) with dementia-related agitation based on International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) coding, and to investigate whether there is a relationship between agitation and hospitalization outcomes.

METHODS

A retrospective observational study was conducted using an administrative dataset containing data from all mainland Portuguese public hospitals. Only hospitalization episodes for patients aged over 65 years who have received a dementia diagnosis ascertained by an ICD-9-CM code of dementia with behavioral disturbance (294.11 and 294.21) and dementia without behavioral disturbance (294.10 and 294.20) were selected. Episodes were further grouped according to the presence of an agitation code. For each episode, demographic data and hospitalization outcomes, including length of stay (LoS), in-hospital mortality, discharge destination and all-cause hospital readmissions, were sourced from the dataset. Comparative analyses were performed and multivariable logistic methods were used to estimate the adjusted associations between agitation (exposure) and outcomes.

RESULTS

Overall, 53,156 episodes were selected, of which 6,586 had an agitation code. These were mostly related to male, younger inpatients (mean 81.19 vs. 83.29 years, p < 0.001), had a higher comorbidity burden, stayed longer at the hospital (median 9.00 vs. 8.00 days, p < 0.001) and frequently ended being transferred to another facility with inpatient care. Agitation was shown to independently increase LoS (aOR = 1.385; 95%CI:1.314-1.461), but not the risk of a fatal outcome (aOR = 0.648; 95%CI:0.600-0.700).

CONCLUSION

These results support the importance of detecting and managing agitation early on admission, since its prompt management may prevent lengthy disruptive hospitalizations.

Clinical Quality Indicators for Monitoring Hospitalizations Among Older People with Dementia Accessing Aged Care Services

BACKGROUND

There is a need for clinical quality indicators (CQIs) that can be applied to dementia quality registries to monitor care outcomes for people with Alzheimer's disease and other forms of dementia.

OBJECTIVE

To develop tertiary and primary care-based dementia CQIs for application to clinical registries for individuals with dementia accessing aged care services and determine 1) annual trends in CQI incidence between 2011-2012 and 2015-2016, 2) associated factors, and 3) geographic and facility variation in CQI incidence.

METHODS

This retrospective repeated cross-sectional study included non-Indigenous individuals aged 65-105 years who lived with dementia between July 2008-June 2016, were assessed for government-funded aged care services, and resided in New South Wales or Victoria (n = 180,675). Poisson or negative binomial regression models estimated trends in annual CQI incidence and associated factors. Funnel plots examined CQI variation.

RESULTS

Between 2011-2012 and 2015-2016, CQI incidence increased for falls (11.0% to 13.9%, adjusted incidence rate ratio (aIRR) 1.05 (95% CI 1.01-1.06)) and delirium (4.7% to 6.7%, aIRR 1.09 (95% CI 1.07-1.10)), decreased for unplanned hospitalizations (28.7% to 27.9%, aIRR 0.99 (95% CI 0.98-0.99)) and remained steady for fracture (6.2% to 6.5%, aIRR 1.01 (95% CI 0.99-1.01)) and pressure injuries (0.5% to 0.4%, aIRR 0.99 (95% CI 0.96-1.02)). Being male, older, having more comorbidities and living in a major city were associated with higher CQI incidence. Considerable geographical and facility variation was observed for unplanned hospitalizations and delirium CQIs.

CONCLUSIONS

The CQI results highlighted considerable morbidity. The CQIs tested should be considered for application in clinical quality registries to monitor dementia care quality.

Association of Diagnosed Dementia with Post-discharge Mortality and Readmission Among Hospitalized Medicare Beneficiaries

BACKGROUND

Patients with dementia are frequently hospitalized and may face barriers in post-discharge care.

OBJECTIVE

To determine whether patients with dementia have an increased risk of adverse outcomes following discharge.

DESIGN

Retrospective cohort study.

SUBJECTS

Medicare beneficiaries hospitalized in 2016.

MAIN MEASURES

Co-primary outcomes were mortality and readmission within 30 days of discharge. Multivariable logistic regression models were estimated to assess the risk of each outcome for patients with and without dementia accounting for demographics, comorbidities, frailty, hospitalization factors, and disposition.

KEY RESULTS

The cohort included 1,089,109 hospitalizations of which 211,698 (19.3%) were of patients with diagnosed dementia (median (IQR) age 83 (76-89); 61.5% female) and 886,411 were of patients without dementia (median (IQR) age 76 (79-83); 55.0% female). At 30 days following discharge, 5.7% of patients with dementia had died compared to 3.1% of patients without dementia (adjusted odds ratio (aOR) 1.21; 95% CI 1.17 to 1.24). At 30 days following discharge, 17.7% of patients with dementia had been readmitted compared to 13.1% of patients without dementia (aOR 1.02; CI 1.002 to 1.04). Dementia was associated with an increased odds of readmission among patients discharged to the community (aOR 1.07, CI 1.05 to 1.09) but a decreased odds of readmission among patients discharge to nursing facilities (aOR 0.93, CI 0.90 to 0.95). Patients with dementia who were discharged to the community were more likely to be readmitted than those discharged to nursing facilities (18.9% vs 16.0%), and, when readmitted, were more likely to die during the readmission (20.7% vs 4.4%).

CONCLUSIONS

Diagnosed dementia was associated with a substantially increased risk of mortality and a modestly increased risk of readmission within 30 days of discharge. Patients with dementia discharged to the community had particularly elevated risk of adverse outcomes indicating possible gaps in post-discharge services and caregiver support.

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.

Rural and urban disparities in potentially preventable hospitalizations among US patients with Alzheimer's Disease and Related Dementias: Evidence of hospital-based telehealth and enabling services

We examined urban and rural disparities in potentially preventable hospitalizations (PPHs) among US patients with Alzheimer's Disease and Related Dementias (ADRD) and the use of telehealth post-discharge and enabling services as mediators. We merged 2017 100% Medicare Fee-For-Service (FFS) claims with the Medicare Beneficiary Summary File, along with population and hospital-based characteristics. Logistic regression models were employed to examine differences in PPHs by telehealth and enabling services. The rates of PPHs related to acute and chronic conditions for patients with ADRD living in rural and micropolitan areas were significantly higher compared to patients with ADRD in urban areas. Telehealth post-discharge combined with enabling services significantly decreased the odds of PPHs associated with acute (OR: 0.93, 95% CI: 0.89-0.98, P-value <0.01) and chronic conditions (OR: 0.96, 95% CI: 0.92-1.00, P-value = 0.07). In addition, telehealth post-discharge combined with enabling services significantly decreased the odds of PPHs in patients with ADRD in rural (acute PPHs OR: 0.56, 95% CI: 0.41-0.77, P-value <0.01; chronic PPHs OR: 0.73, 95% CI: 0.55-0.97, P-value = 0.03) and micropolitan (acute PPHs OR: 0.65, 95% CI: 0.57-0.73, P-value <0.01; chronic PPHs OR: 0.83, 95% CI: 0.74-0.93, P-value <0.01) areas. Our results suggest that the combinations of telehealth post-discharge and enabling services are important interventions in helping to reduce preventable hospitalizations among patients with ADRD living in rural and micropolitan areas.

Characteristics of elderspeak communication in hospital dementia care: Findings from The Nurse Talk observational study

BACKGROUND

Elderspeak communication is typically viewed as patronizing and infantilizing by older adults and can lead to resistive behaviors in persons living with dementia. Little is known about the presence of elderspeak communication in hospitals in the United States. Understanding this phenomenon in the hospital setting is needed in order to improve hospital dementia care.

OBJECTIVES

The purpose of the Nurse Talk study was to (1) describe attributes of elderspeak use in hospital dementia care and to (2) determine what characteristics are associated with nursing staff use of elderspeak communication with hospitalized patients with dementia.

DESIGN

A cross-sectional observational study design was used to collect and analyze audio-recordings of nursing staff during care for hospitalized patients with dementia.

SETTING

Three hospital units in one Midwestern university hospital in the United States.

PARTICIPANTS

A convenience sample of 53 staff nurses and nursing assistants that provided direct care to 16 patients with mild or more severe dementia recruited from October 2019 through mid-March 2020.

METHODS

Eighty-eight care encounters were audio-recorded and coded for elderspeak communication using the Iowa Coding of Elderspeak scheme to determine the frequency and characteristics of elderspeak communication. A linear mixed effects model was used to determine what characteristics were associated with elderspeak and the frequency of elderspeak use by nursing staff to hospitalized patients with dementia.

RESULTS

Over a quarter (28.7%) of all nursing staff speech directed towards patients with dementia constituted elderspeak and nearly all (96.6%) care encounters included some elderspeak. Particularly common attributes of elderspeak were minimizing words and mitigating expressions, childish terms and phrases, and collective pronoun substitution. A statistically significant interaction was identified between staff role and age (95% CI: -0.02, -0.00, p = .008) in predicting the frequency of elderspeak use, indicating that elderspeak was used more often by older staff nurses, whereas the age of nursing assistants remained constant across elderspeak use. Statically significant effects for delirium and length of stay were also demonstrated. Elderspeak use was 12.5% higher with patients with delirium (95% CI: 0.02, 0.23, p = .025) and increased 1.5% for each additional day the patient with dementia was hospitalized (95% CI: 0.00, 0.03, p = .035).

CONCLUSIONS

Elderspeak is present and pervasive in the acute care setting. Interventions targeted towards older staff nurses and nursing staff from hospital units that care for patients with delirium and longer lengths of stay are needed.

TWEETABLE ABSTRACT

This study identified that nursing staff are frequently using elderspeak (infantilizing speech) with hospitalized patients with dementia. @claireshaw_phd @IowaNursing.

Cultural adaptation of World Health Organization iSupport for Dementia program for Chinese-Australian caregivers

BACKGROUND

Home-based dementia care is common in the Chinese-Australian community. However, dementia education programs for Chinese-Australians in the language of their choice are scarce. The World Health Organization has developed iSupport for Dementia, an online education program for informal caregivers. Cultural adaptation of the program for Chinese-Australian caregivers is an opportunity to address this gap in caregiver support.

AIM

The aims of the study were (1) to understand stakeholders' perspectives on the cultural and linguistic appropriateness of the Chinese iSupport for Dementia content and design and (2) to explore factors affecting the future implementation of the Chinese iSupport program in Australia.

METHODS

A qualitative descriptive design was applied to address the aims of the study. Focus group discussions with Chinese-Australian caregivers and community aged care workers were conducted to collect data. Thematic analysis was used to analyse data.

RESULTS

In total, six focus groups were conducted with 18 Chinese-Australian caregivers and 17 care workers. Six themes were identified and described as follows: (1) appropriateness of the Chinese iSupport content; (2) acceptability of the online Chinese iSupport design; (3) motivations to engage in the iSupport program; (4) desire to interact with peers and professional facilitators; (5) concerns about program accessibility; and (6) the need to extend the iSupport program to care workers.

CONCLUSIONS

Engagement with Chinese-Australian caregivers and care workers will inform further revisions of the Chinese iSupport program contents to ensure the program is culturally congruent to Chinese-Australian caregivers. Factors affecting the implementation of the program identified in the study will be considered in the intervention phase of the program.

Creating 'Partnership in iSupport program' to optimise family carers' impact on dementia care: a randomised controlled trial protocol

Background

The majority of people with dementia are cared for by their family members. However, family carers are often unprepared for their caring roles, receiving less education and support compared with professional carers. The consequences are their reduced mental and physical health and wellbeing, and that of care recipients. This study protocol introduces the ‘Partnership in iSupport program’ that includes five interventional components: managing transitions, managing dementia progression, psychoeducation, carer support group and feedback on services. This health services research is built on family carer and dementia care service provider partnerships. The aims of the study are to evaluate the effectiveness, cost-effectiveness and family carers’ experiences in the program.

Methods

A multicentre randomised controlled trial will be conducted with family carers of people living with dementia from two tertiary hospitals and two community aged care providers across three Australian states. The estimated sample size is 185 family carers. They will be randomly assigned to either the intervention group or the usual care group. Outcomes are measurable improvements in quality of life for carers and people with dementia, caregiving self-efficacy, social support, dementia related symptoms, and health service use for carers and their care recipients. Data will be collected at three time points: baseline, 6 months and 12 months post-initiation of the intervention.

Discussion

This is the first large randomised controlled trial of a complex intervention on health and social care services with carers of people living with dementia in real-world practice across hospital and community aged care settings in three Australian states to ascertain the effectiveness, cost-effectiveness and carers’ experiences of the innovative program. We expect that this study will address gaps in supporting dementia carers in health and social care systems while generating new knowledge of the mechanisms of change in the systems. Findings will strengthen proactive health management for both people living with dementia and their carers by embedding, scaling up and sustaining the ‘Partnership in iSupport program’ in the health and social care systems.

Trial registration

The Australian New Zealand Clinical Trials Registry (ANZCTR). ACTRN12622000199718. Registered February 4^th, 2022.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-022-08148-2.

Elderspeak communication and pain severity as modifiable factors to rejection of care in hospital dementia care

Background

Rejection of care (RoC) occurs when persons living with dementia (PLWD) withstand or oppose the efforts of their caregiver. Improvements in hospital dementia care are needed, and one way to address this need is by identifying factors that lead to RoC, particularly those that are modifiable. Elderspeak communication is an established antecedent to RoC among PLWD in nursing homes. The purpose of this study was to extend these results to acute care settings by determining the impact of elderspeak communication by nursing staff on RoC by hospitalized PLWD.

Methods

Care encounters between nursing staff and PLWD were audio‐recorded, transcribed verbatim, and coded for semantic, pragmatic, and prosodic features of elderspeak. RoC behaviors was scored in real‐time using the Resistiveness to Care Scale. A Bayesian repeated‐measures hurdle model was used to evaluate the association between elderspeak and both the presence and severity of RoC.

Results

Eighty‐eight care encounters between 16 PLWD and 53 nursing staff were audio‐recorded for elderspeak and scored for RoC. Nearly all (96.6%) of the encounters included some form of elderspeak. Almost half of the care encounters (48.9%) included RoC behaviors. A 10% decrease in elderspeak was associated with a 77% decrease in odds of RoC (OR = 0.23, 95% CI = 0.03, 0.68) and a 16% decrease (eβ= 0.84, CI = 0.73, 0.96) in the severity of RoC. A one‐unit decrease in pain severity was associated with 73% reduced odds of RoC (OR = 0.27, CI = 0.12, 0.45) and a 28% decrease (eβ= 0.72, CI = 0.64, 0.80) in the severity of RoC.

Conclusions

Both elderspeak by nursing staff and RoC by PLWD are present and pervasive in acute care. Pain and elderspeak are two modifiable factors of RoC in hospitalized PLWD. Person‐centered interventions are needed that address communication practices and pain management for hospitalized PLWD.

Incidence of potentially disruptive medical and social events in older adults with and without dementia

BACKGROUND

Potentially disruptive medical, surgical, and social events-such as pneumonia, hip fracture, and widowhood-may accelerate the trajectory of decline and impact caregiving needs in older adults, especially among people with dementia (PWD). Prior research has focused primarily on nursing home residents with dementia. We sought to assess the incidence of potentially disruptive events in community-dwelling people with and without dementia.

METHODS

Retrospective cohort study of participants aged 65+ enrolled in the Health and Retirement Study between 2010 and 2018 (n = 9346), including a subset who were married-partnered at baseline (n = 5105). Dementia was defined with a previously validated algorithm. We calculated age-adjusted and gender-stratified incidence per 1000 person-years and incidence rate ratios of: 1) hospitalization for pneumonia, 2) hip fracture, and 3) widowhood in people with and without dementia.

RESULTS

PWD (n = 596) were older (mean age 84 vs. 75) and a higher proportion were female (67% vs. 57%) than people without dementia (PWoD) (n = 8750). Age-adjusted incidence rates (per 1000 person-years) of pneumonia were higher in PWD (113.1; 95% CI 94.3, 131.9) compared to PWoD (62.1; 95% CI 54.7, 69.5), as were hip fractures (12.3; 95% CI 9.1, 15.6 for PWD compared to 8.1; 95% CI 6.9, 9.2 in PWoD). Point estimates of widowhood incidence were slightly higher for PWD (25.3; 95% CI 20.1, 30.5) compared to PWoD (21.9; 95% CI 20.3, 23.5), but differences were not statistically significant. The association of dementia with hip fracture-but not pneumonia or widowhood-was modified by gender (male incidence rate ratio [IRR] 2.24, 95% CI 1.34, 3.75 versus female IRR 1.31 95% CI 0.92,1.86); interaction term p = 0.02).

CONCLUSIONS

Compared to PWoD, community-dwelling PWD had higher rates of pneumonia and hip fracture, but not widowhood. Knowing how often PWD experience these events can aid in anticipatory guidance and care planning for this growing population.

A nurse-led multicentre randomized controlled trial on effectiveness and cost-effectiveness of Chinese iSupport for dementia program: A study protocol

AIMS

To describe a nurse-led multicentre randomized controlled trial protocol developed to evaluate the effectiveness and cost-effectiveness of a Chinese iSupport for Dementia program in Australia and Greater China including mainland China, Taiwan, Hong Kong and Macau.

DESIGN

A multicentre randomized controlled trial following the SPIRIT checklist.

METHODS

Participants in the study will be recruited from Australia and Greater China and will be randomly assigned to the intervention group or the usual care group. Interventions will include self-learning of the iSupport program, virtual peer support and nurse program facilitator support for 6 months. Primary outcome measures will be the 12-Item Short-Form Health Survey. Secondary outcome measures will include: Revised Scale for Caregiving Self-efficacy; Quality of Social Support Scale; Revised Memory and Behaviour Problem Checklist; the Quality of Life in Alzheimer's Disease-Proxy; usages of care services; and cost-effectiveness of the intervention. Outcomes will be measured at baseline, 6 months and 9 months from the baseline. Caregivers' experiences of the peer support will be explored. This project was funded by the National Foundation for Australia-China Relations, Australian Government (Project ID: NFACR216). The total amount is $440,000 Australian dollars (or £ 236,231).

DISCUSSION

Approximately, 20% of people living with dementia in the world live in Australia and Greater China. Older Chinese are usually cared for by family caregivers at home due to the influence of Confucianism. However, free and online psychoeducation programs for this large cohort of caregivers are not available or accessible. The World Health Organization iSupport for Dementia is an evidence-based online psychoeducation program for caregivers. Implementing a culturally adapted Chinese iSupport program will address this gap in supporting caregivers.

IMPACT

This study will provide research evidence on effectiveness and cost-effectiveness of an online psychoeducation program for caregivers. Findings will inform policy and practice development.

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.

Incident Dementia, Glycated Hemoglobin (HbA1c) Levels, and Potentially Preventable Hospitalizations in People Aged 65 and Older With Diabetes

BACKGROUND

This study was aimed to determine whether incident dementia and HbA1c levels are associated with increased rates of potentially preventable hospitalizations (PPHs) in persons with diabetes.

METHOD

A total of 565 adults aged 65+ ever treated for diabetes were enrolled from Adult Changes in Thought study. PPHs were from principal discharge diagnoses and included diabetes PPH (dPPH), respiratory PPH (rPPH), urinovolemic PPH (uPPH), cardiovascular PPH, and other PPH. Poisson generalized estimating equations estimated rate ratios (RRs) and 95% confidence intervals (CIs) for the associations between dementia or HbA1c measures and rate of PPHs.

RESULTS

A total of 562 individuals contributed 3 602 dementia-free years, and 132 individuals contributed 511 dementia follow-up years. One hundred twenty-eight (23%) dementia-free individuals had 210 PPH admissions and a crude rate of 58 per 1 000 person-years, while 55 (42%) individuals with dementia had 93 PPH admissions and a crude rate of 182 per 1 000 person-years. The adjusted RR (95% CI) comparing rates between dementia and dementia-free groups were 2.27 (1.60, 3.21) for overall PPH; 5.90 (2.70, 12.88) for dPPH; 5.17 (2.49, 10.73) for uPPH; and 2.01 (1.06, 3.83) for rPPH. Compared with HbA1c of 7%-8% and adjusted for dementia, the RR (95% CI) for overall PPH was 1.43 (1.00, 2.06) for >8% HbA1c and 1.18 (0.85, 1.65) for <7% HbA1c. The uPPH RR was also increased, comparing >8% and <7% HbA1c levels.

CONCLUSION

Incident dementia is associated with higher rates of PPHs among people with diabetes, especially PPHs due to diabetes, urinary tract infection (UTI), and dehydration. Potential evidence suggested that HbA1c levels of >8% versus lower levels are associated with higher rates of overall PPHs and UTI- and dehydration-related PPHs.

Avoidable Hospitalizations in Persons with Dementia: a Population-Wide Descriptive Study (2000-2015)

Background

Whether avoidable hospitalizations in community-dwelling persons with dementia have decreased during primary care reforms is unknown.

Methods

We described the prevalence and trends in avoidable hospitalizations in population-based repeated yearly cohorts of 192,144 community-dwelling persons with incident dementia (Quebec, 2000-2015) in the context of a province-wide primary care reform, using the provincial health administrative database.

Results

Trends in both types of Ambulatory Care Sensitive Condition (ACSC) hospitalization (general and older population) and 30-day readmission rates remained constant with average rates per 100 person-years: 20.5 (19.9-21.1), 31.7 (31.0-32.4), 20.6 (20.1-21.2), respectively. Rates of delayed hospital discharge (i.e., alternate level of care (ALC) hospitalizations) decreased from 23.8 (21.1-26.9) to 17.9 (16.1-20.1) (relative change -24.6%).

Conclusions

These figures shed light on the importance of the phenomenon, its lack of improvement for most outcomes over the years, and the need to develop evidence-based policies to prevent avoidable hospitalizations in this vulnerable population.

Predictive value of geriatric-quickSOFA in hospitalized older people with sepsis

BACKGROUND

QuickSOFA, a prognostic score proposed for patients with infection, has shown a poor predictive value in the geriatric population, probably because of the inappropriateness of the Glasgow Coma Scale (GCS) in assessing acute alteration of mental status in older patients. Indeed, the GCS might result chronically low in older patient with pre-existing cognitive disorders. The aim of this study was to develop an alternative quickSOFA (geriatric-quickSOFA), using the presence of delirium, assessed according to DSM-5 criteria, instead of GCS assessment, to predict mortality in hospitalized older patients with sepsis.

METHODS

Retrospective observational study in Acute Geriatrics Unit of St. Anna Hospital of Ferrara (Italy). The study enrolled 165 patients hospitalized between 2017 and 2018 with diagnosis of sepsis or septic shock. Demographic, clinical data and 30-day survival were collected for each patient. Based on arterial blood pressure, respiratory rate, and the presence of delirium, geriatric-quickSOFA was calculated at admission. Primary outcome was 30-day mortality.

RESULTS

One hundred sixty-five patients were enrolled with a median age of 88 years; 60.6% were men. High quickSOFA score was not significantly correlated neither with in-hospital nor 30-day mortality. High geriatric-qSOFA score was significantly related to both in-hospital (13.3%vs 51.5%, p = 0.0003) and 30-day mortality (30.0%vs 84.3%, p < 0.00001).

CONCLUSION

Geriatric-quickSOFA is significantly associate with short-term mortality risk in older patients with sepsis. Geriatric quickSOFA seems to represent a more suitable and useful predictive tool than the traditional quickSOFA in the geriatric population.