Quality of Care and Outcomes Among a Diverse Group of Long-Term Care Residents With Alzheimer's Disease and Related Dementias

Inequalities in the Quality and Safety of Post-Diagnostic Primary Care for People With Dementia: A Scoping Review

INTRODUCTION

International guidelines make recommendations for the delivery of safe, high-quality primary care for people with dementia including prescribing, personalised care planning and regular holistic reviews. It is unclear how the quality and safety of this healthcare varies with socio-economic factors.

OBJECTIVE

This scoping review aimed to understand the depth and breadth of existing evidence exploring socio-economic variation in the quality and safety of primary care for people with dementia.

METHODS

Prescribing and care planning indicators of high-quality, safe primary care were defined from guidance. Composite and proxy markers of socio-economic status (SES) were defined. EMBASE, MEDLINE, PsychInfo, The Cochrane Database of Systematic Reviews, worldcat.org and clinicaltrial.gov databases were searched. Studies in English, on human participants from 2006 onwards were eligible. Narrative synthesis was conducted. Studies explored how one or more selected indicators (anti-dementia medication and anti-psychotic prescribing, potentially inappropriate prescribing (PIP), medication review, dementia review or care planning) varied with a recognised marker of SES in people with dementia.

RESULTS

Searches identified 1980 studies after removing duplicates. 385 full texts were reviewed, with 53 eligible for inclusion (51 quantitative, 2 reviews). Most identified studies explored prescribing processes (50 quantitative, 2 reviews), with 2 exploring annual review. There was evidence of substantial disparity in quality and safety indicators in studies exploring prescribing; 20/29 (69%) of studies exploring anti-dementia medication prescribing found those with markers of lower SES were significantly less likely to receive these. 16/28 studies exploring PIP/Anti-psychotics found significant disparities in safe prescribing for those with markers of lower SES. Neither study exploring annual reviews found any significant differences across SES.

CONCLUSION

We found evidence of disparity in the quality and safety of post-diagnostic primary care for people with dementia based on SES, particularly for a range of prescribing indicators. Further work exploring inequalities in care planning and reviews for people with dementia is needed to understand existing inequalities in the quality and safety of primary care for people with dementia.

Differences in Medication Use by Gender and Race in Hospitalized Persons Living with Dementia

The purpose of this study was to describe differences in treatment of White versus Black older adults, males versus females, and those living at home, assisted living, or nursing home communities with regard to the use of psychotropic, pain, and cardiovascular medications. Baseline data from the first 352 participants in the study, implementation of Function-Focused Care for Acute Care Using the Evidence Integration Triangle, were used. Data included age, gender, race, comorbidities, admission diagnosis, and living location prior to hospitalization, the Saint Louis University Mental Status exam, the modified Charlson Comorbidity Index, the Pain Assessment in Advanced Dementia scale, the Confusion Assessment Method, and medications prescribed. Generalized linear mixed model analyses were done, controlling for race or gender (depending on which comparison analysis was being done), age, cognitive status, hospital, delirium, and comorbidities. Medication use was significantly higher for White older adults, compared to Black older adults, for antidepressants, anxiolytics, non-opioid pain medications, and opioids and lower for antihypertensives. Females received more anxiolytics than their male counterparts. There were differences in medication use by living location with regard to non-opioid pain medication, antipsychotics, statins, and anticoagulants. The findings provide some current information about differences in medication use across groups of individuals and can help guide future research and hypothesis testing for approaches to minimizing these differences in treatment.

Racial Differences in Nursing Home Quality of Life Among Residents Living With Alzheimer's Disease and Related Dementias

ObjectivesAmong nursing home (NH) residents with Alzheimer's disease (AD) and AD-related dementias (AD/ADRD), racial/ethnic disparities in quality of care exist. However, little is known about quality of life (QoL). This study examines racial/ethnic differences in self-reported QoL among NH residents with AD/ADRD. Methods: Validated, in-person QoL surveys from 12,562 long-stay NH residents with AD/ADRD in Minnesota (2012-2015) were linked to Minimum Data Set assessments and facility characteristics. Hierarchical linear models assessed disparities in resident-reported mean QoL score (range, 0-100 points), adjusting for case-mix and facility factors. Results: Compared to White residents, racially/ethnically minoritized residents reported significantly lower total mean QoL scores (75.53 points vs. 80.34 points, p < .001). After adjustment for resident- and facility-level characteristics, significant racial/ethnic differences remained, with large disparities in food enjoyment, attention from staff, and engagement domains. Discussion: Policy changes and practice guidelines are needed to address racial/ethnic disparities in QoL of NH residents with AD/ADRD.

Physician Antipsychotic Overprescribing Letters and Cognitive, Behavioral, and Physical Health Outcomes Among People With Dementia: A Secondary Analysis of a Randomized Clinical Trial

Importance

Antipsychotics, such as quetiapine, are frequently prescribed to people with dementia to address behavioral symptoms but can also cause harm in this population.

Objective

To determine whether warning letters to high prescribers of quetiapine can successfully reduce its use among patients with dementia and to investigate the impacts on patients' health outcomes.

Design, Setting, and Participants

This is a secondary analysis of a randomized clinical trial of overprescribing letters that began in April 2015 and included the highest-volume primary care physician (PCP) prescribers of quetiapine in original Medicare. Outcomes of patients with dementia were analyzed in repeated 90-day cross-sections through December 2018. Analyses were conducted from September 2021 to February 2024.

Interventions

PCPs were randomized to a placebo letter or 3 overprescribing warning letters stating that their prescribing of quetiapine was high and under review by Medicare.

Main Outcomes and Measures

The primary outcome of this analysis was patients' total quetiapine use in days per 90-day period (the original trial primary outcome was total quetiapine prescribing by study PCPs). Prespecified secondary outcomes included measures of cognitive function and behavioral symptoms from nursing home assessments, indicators of depression from screening questionnaires in assessments and diagnoses in claims, metabolic diagnoses derived from assessments and claims, indicators of use of the hospital and other health care services, and death. Outcomes were analyzed separately for patients living in nursing homes and in the community.

Results

Of the 5055 study PCPs, 2528 were randomized to the placebo letter, and 2527 were randomized to the 3 warning letters. A total of 84 881 patients with dementia living in nursing homes and 261 288 community-dwelling patients with dementia were attributed to these PCPs. There were 92 874 baseline patients (mean [SD] age, 81.5 [10.5] years; 64 242 female [69.2%]). The intervention reduced quetiapine use among both nursing home patients (adjusted difference, -0.7 days; 95% CI, -1.3 to -0.1 days; P = .02) and community-dwelling patients (adjusted difference, -1.5 days; 95% CI, -1.8 to -1.1 days; P < .001). There were no detected adverse effects on cognitive function (cognitive function scale adjusted difference, 0.01; 95% CI, -0.01 to 0.03; P = .19), behavioral symptoms (agitated or reactive behavior adjusted difference, -0.2%; 95% CI -1.2% to 0.8% percentage points; P = .72), depression, metabolic diagnoses, or more severe outcomes, including hospitalization and death.

Conclusions and Relevance

This study found that overprescribing warning letters to PCPs safely reduced quetiapine prescribing to their patients with dementia. This intervention and others like it may be useful for future efforts to promote guideline-concordant care.

Trial Registration

ClinicalTrials.gov Identifier: NCT05172687.

Mapping racial and ethnic healthcare disparities for persons living with dementia: A scoping review

INTRODUCTION

We set out to map evidence of disparities in Alzheimer's disease and Alzheimer's disease related dementias healthcare, including issues of access, quality, and outcomes for racial/ethnic minoritized persons living with dementia (PLWD) and family caregivers.

METHODS

We conducted a scoping review of the literature published from 2000 to 2022 in PubMed, PsycINFO, and CINAHL. The inclusion criteria were: (1) focused on PLWD and/or family caregivers, (2) examined disparities or differences in healthcare, (3) were conducted in the United States, (4) compared two or more racial/ethnic groups, and (5) reported quantitative or qualitative findings.

RESULTS

Key findings include accumulating evidence that minoritized populations are less likely to receive an accurate and timely diagnosis, be prescribed anti-dementia medications, and use hospice care, and more likely to have a higher risk of hospitalization and receive more aggressive life-sustaining treatment at the end-of-life.

DISCUSSION

Future studies need to examine underlying processes and develop interventions to reduce disparities while also being more broadly inclusive of diverse populations.