Continuity of GP care for patients with dementia: impact on prescribing and the health of patients

Background

Higher continuity of GP care (CGPC), that is, consulting the same doctor consistently, can improve doctor–patient relationships and increase quality of care; however, its effects on patients with dementia are mostly unknown.

Aim

To estimate the associations between CGPC and potentially inappropriate prescribing (PIP), and with the incidence of adverse health outcomes (AHOs) in patients with dementia.

Design and setting

A retrospective cohort study with 1 year of follow-up anonymised medical records from 9324 patients with dementia, aged ≥65 years living in England in 2016.

Method

CGPC measures include the Usual Provider of Care (UPC), Bice–Boxerman Continuity of Care (BB), and Sequential Continuity (SECON) indices. Regression models estimated associations with PIPs and survival analysis with incidence of AHOs during the follow-up adjusted for age, sex, deprivation level, 14 comorbidities, and frailty.

Results

The highest quartile (HQ) of UPC (highest continuity) had 34.8% less risk of delirium (odds ratio [OR] 0.65, 95% confidence interval [CI] = 0.51 to 0.84), 57.9% less risk of incontinence (OR 0.42, 95% CI = 0.31 to 0.58), and 9.7% less risk of emergency admissions to hospital (OR 0.90, 95% CI = 0.82 to 0.99) compared with the lowest quartile. Polypharmacy and PIP were identified in 81.6% (n = 7612) and 75.4% (n = 7027) of patients, respectively. The HQ had fewer prescribed medications (HQ: mean 8.5, lowest quartile (LQ): mean 9.7, P<0.01) and had fewer PIPs (HQ: mean 2.1, LQ: mean 2.5, P<0.01), including fewer loop diuretics in patients with incontinence, drugs that can cause constipation, and benzodiazepines with high fall risk. The BB and SECON measures produced similar findings.

Conclusion

Higher CGPC for patients with dementia was associated with safer prescribing and lower rates of major adverse events. Increasing continuity of care for patients with dementia may help improve treatment and outcomes.

Potentially inappropriate prescribing in dementia, multi-morbidity and incidence of adverse health outcomes

IMPORTANCE

treatment of dementia in individuals with comorbidities is complex, leading to potentially inappropriate prescribing (PIP). The impact of PIP in this population is unknown.

OBJECTIVE

to estimate the rate of PIP and its effect on adverse health outcomes (AHO).

DESIGN

retrospective cohort.

SETTING

primary care electronic health records linked to hospital discharge data from England.

SUBJECTS

11,175 individuals with dementia aged over 65 years in 2016 and 43,463 age- and sex-matched controls.

METHODS

Screening Tool of Older Persons' Prescriptions V2 defined PIP. Logistic regression tested associations with comorbidities at baseline, and survival analyses risk of incident AHO, adjusted for age, gender, deprivation and 14 comorbidities.

RESULTS

the dementia group had increased risk of PIP (73% prevalence; odds ratio [OR]: 1.92; confidence interval [CI]: 83-103%; P < 0.01) after adjusting for comorbidities. Most frequent PIP criteria were related to anti-cholinergic drugs and therapeutic duplication. Risk of PIP was higher in patients also diagnosed with coronary-heart disease (odds OR: 2.17; CI: 1.91-2.46; P < 0.01), severe mental illness (OR: 2.09; CI: 1.62-2.70; P < 0.01); and depression (OR: 1.81; CI: 1.62-2.01; P < 0.01). During follow-up (1 year), PIP was associated with increased all-cause mortality (hazard ratio: 1.14; CI: 1.02-1.26; P < 0.02), skin ulcer and pressure sores (hazard ratio: 1.66; CI: 1.12-2.46; P < 0.01), falls (hazard ratio: 1.37; CI: 1.15-1.63; P < 0.01), anaemia (hazard ratio: 1.61; CI: 1.10-2.38; P < 0.02) and osteoporosis (hazard ratio: 1.62; CI: 1.02-2.57; P < 0.04).

CONCLUSION

patients with dementia frequently receive PIPs, and those who do are more likely to experience AHO. These results highlight the need to optimise medication in dementia patients, especially those with comorbidities.

Potentially inappropriate prescribing in dementia: a state-of-the-art review since 2007

OBJECTIVES

Dementia frequently occurs alongside comorbidities. Coexisting conditions are often managed with multiple medications, leading to increased risk of potentially inappropriate medication and adverse drug reactions. We aimed to estimate prevalence of, and identify factors reported to be associated with, potentially inappropriate prescribing (PIP) for older individuals diagnosed with dementia.

DESIGN

We used a state-of-the-art review approach, selecting papers written in English and published from 2007 to January 2018. Publications were retrieved from Scopus and Web of Science databases. Inclusion criteria included a formal diagnosis of dementia, a formal classification of PIP and reported prevalence of PIP as an outcome. Random effects models were used to provide a pooled estimate of prevalence of PIP. The Appraisal tool for Cross-Sectional Studies (AXIS tool) was used to assess bias in the included studies.

RESULTS

The bibliographic search yielded 221 citations, with 12 studies meeting the inclusion criteria. The estimates of PIP prevalence for people living with dementia ranged from 14% to 64%. Prevalence was 31% (95% CI 9 to 52) in the community, and 42% (95% CI 30 to 55) in nursing/care homes. PIP included prescribing likely related to dementia (eg, hypnotics and sedative and cholinesterase inhibitors) and prescribing related to treatment of comorbidities (eg, cardiovascular drugs and non-steroidal anti-inflammatory medication). Higher levels of comorbidity were associated with increased risk of PIP; however, only one study investigated associations with specific comorbidities of dementia.

CONCLUSION

PIP remains a significant issue in healthcare management for people living with dementia. Higher levels of comorbidity are associated with increased prevalence of PIP, but the specific conditions driving this increase remain unknown. Further work is necessary to investigate PIP related to the presence of common comorbidities in patients living with dementia.

Association of diagnostic delay with impairment severity among institutional care facility residents diagnosed with dementia in Ontario, Canada

AIM

To compare the levels of cognitive function at the time of diagnosis among institutional care facility residents with dementia, who were diagnosed either before or after admission to a facility in Ontario, Canada.

METHODS

The study utilized a population-based secondary data analysis approach, using data from the Canadian Institute for Health Information's Continuing Care Reporting System from 2009 to 2011. Cognitive function within 30 days of diagnosis was measured by a seven-point cognitive performance scale (CPS) - 0 (intact) to 6 (very severe impairment).

RESULTS

Data were extracted from 39633 institutional care facility residents who had a diagnosis of dementia on record. The average CPS score was higher for residents whose diagnosis was made after admission to a facility than for residents whose diagnosis was made before admission (3.1 vs 2.9, P=0.009). The proportion of diagnosis at CPS ≥ 4 (moderately severe to very severe impairment) was also higher in the diagnosis after admission group (29.7% vs 24.6%, P=0.001). Multivariable analysis showed that diagnoses made after admission were more likely to be at a severe stage of cognitive decline (CPS ≥ 4) than diagnoses made before admission (adjusted odds ratio 1.49, P=0.001). A similar result was also noted when comparison was made between mild and moderate-to-severe stages of cognitive decline. After admission diagnoses were more likely to be at moderate-to-severe stages of cognitive decline (CPS ≥ 3) than before admission diagnoses (adjusted odds ratio 1.70, P=0.001).

CONCLUSION

Our findings suggest that dementia diagnoses after admission to institutional care facilities are more likely to be made at poorer stages of cognitive function decline.

Prevalence and correlates of potentially undetected dementia among residents of institutional care facilities in Ontario, Canada, 2009-2011

OBJECTIVES

This study aims to determine the prevalence of potentially undetected dementia among institutional care facility residents in Ontario, Canada, and to identify factors associated with undetection.

METHODS

We utilized a population-based secondary data analysis approach, pertaining to data from the Canadian Institute for Health Information's Continuing Care Reporting System, 2009-2011. Potentially undetected dementia was defined as having severely impaired cognitive function and requiring extensive assistance on activity of daily living (ADL) but no records of dementia diagnoses. Cognitive function was measured by the Cognitive Performance Scale (CPS), 0 (intact) to 6 (very severe impairment), and ADL by a hierarchy scale, 0 (independent) to 6 (total dependence).

RESULTS

Of the 242,957 residents who had no records of dementia diagnoses, 11.6% (n = 28,078) had a CPS score ≥4 (severe impairment or higher) and ADL score ≥3 (required extensive assistance or more). Data from 11,614 demented residents with corresponding CPS and ADL scores were used for comparison. Residents without dementia diagnosis were younger (77 vs. 84 years), more likely to have never married (20% vs. 6%), and have longer admission (4 vs. 2.8 years). The most significant factors for no diagnoses were never married (adjusted odds ratio = 2.1, 95% confidence interval [CI] = 1.91-2.29), admitted to hospital-based facilities (adjusted odds ratio = 1.58, 95% CI = 1.48-1.69), presence of schizophrenia (adjusted odds ratio = 1.43, 95% CI = 1.22-1.69), depression (adjusted odds ratio = 1.23, 95% CI = 1.16-1.29), and diabetes mellitus (adjusted odds ratio = 1.32, 95% CI = 1.26-1.40).

CONCLUSIONS

A large number of residents who had poor cognitive function and inadequate ADL ability did not have dementia diagnoses on record. Social and comorbid conditions were contributing factors to potentially undetected dementia.

Simvastatin blocks blood-brain barrier disruptions induced by elevated cholesterol both in vivo and in vitro

Background. Hypercholesterolemia and disruptions of the blood brain barrier (BBB) have been implicated as underlying mechanisms in the pathogenesis of Alzheimer's disease (AD). Simvastatin therapy may be of benefit in treating AD; however, its mechanism has not been yet fully understood. Objective. To explore whether simvastatin could block disruption of BBB induced by cholesterol both in vivo and in vitro. Methods. New Zealand rabbits were fed cholesterol-enriched diet with or without simvastatin. Total cholesterol of serum and brain was measured. BBB dysfunction was evaluated. To further test the results in vivo, rat brain microvascular endothelial cells (RBMECs) were stimulated with cholesterol in the presence/absence of simvastatin in vitro. BBB disruption was evaluated. Results. Simvastatin blocked cholesterol-rich diet induced leakage of Evan's blue dye. Cholesterol content in the serum was affected by simvastatin, but not brain cholesterol. Simvastatin blocked high-cholesterol medium-induced decrease in TEER and increase in transendothelial FITC-labeled BSA Passage in RBMECs. Conclusions. The present study firstly shows that simvastatin improves disturbed BBB function both in vivo and in vitro. Our data provide that simvastatin may be useful for attenuating disturbed BBB mediated by hypercholesterolemia.

Systematic review on the efficacy and safety of herbal medicines for vascular dementia

We present a systematic review of existing research that aims to assess the efficacy and safety of herbal medications (HM), as either monotherapy or adjunct to orthodox medications (OM), mainly comprised of cholinesterase inhibitors, for vascular dementia (VaD). We included 47 studies conducted in mainland China, each testing different HM. Of 43 HM monotherapy studies, 37 reported HM to be significantly better than OM or placebo; six reported similar efficacy between HM and OM. All four HM adjuvant studies reported significant efficacy. No major adverse events for HM were reported. Heterogeneity in diagnostic criteria, interventions and outcome measures hindered comprehensive data analysis. Studies suggested that HM can be a safe and effective treatment for VaD, either alone or in conjunction with OM. However, methodological flaws in the design of the studies limited the extent to which the results could be interpreted. Thirty most commonly used herbal constituents, including Rhizoma Chuanxiong (Chuanxiong in Chinese), Radix Polygoni Multiflori (Heshouwu in Chinese) and Radix Astragali (Huangqi in Chinese). were ranked. Further multi-center trials with large sample sizes, high methodological quality and standardized HM ingredients are necessary for clinical recommendations to be made.

Prevalence and impact of dementia-related functional limitations in the United States, 2001 to 2005

These analyses examined the relationship between dementia and comorbid conditions with respect to degree of functional impairment and emotional impact. Analyses were conducted using National Health Interview Survey (2001 through 2005) data from a subset of individuals aged > or =60 years with activity limitations attributed to dementia, senility, or Alzheimer disease compared with those whose limitations were attributed to other conditions. The mean number of limited activities was 6.84 (95% confidence interval: 6.48-7.20) for persons with dementia-related limitations and 4.87 (95% confidence interval: 4.81-4.93) for those with limitations not dementia related. Both groups reported similar prevalence of diabetes, acute myocardial infarction, heart disease, prostate cancer, breast cancer, angina, and emphysema; respondents with dementia-related functional limitations were more likely to report diabetes, depression or anxiety, and vision problems as being related to functional limitations. Persons with dementia-related functional limitations were also more likely than persons with non-dementia-related functional limitations to report feeling sad, hopeless, worthless, nervous, and that "everything is an effort." Improving or maintaining functional independence in patients with dementia will likely require a multifaceted approach across disease states. Additional research will help define the impact of dementia on the development and progression of functional limitations related to comorbidities.