Solitary living in Alzheimer's disease over 3 years: association between cognitive and functional impairment and community-based services

Living Alone With Mild-to-Moderate Dementia Over a Two-Year Period: Longitudinal Findings From the IDEAL Cohort

OBJECTIVES

To compare the experiences of people with dementia living alone or with others and how these may change over two years.

DESIGN

We analysed longitudinal data from three assessment waves, one year apart, in the British IDEAL cohort.

SETTING

Participants with mild-to-moderate dementia were recruited through National Health Service providers, where possible with a family caregiver, and interviewed at home.

PARTICIPANTS

The current analyses include 281 people with dementia living alone and 1,244 living with others at baseline; follow-up data were available for 200 and 965 respectively at time 2 and 144 and 696 respectively at time 3. For those living alone, 140 nonresident caregivers contributed at baseline, 102 at time 2 and 81 at time 3. For those living with others, 1,127 family caregivers contributed at baseline, 876 at time 2 and 670 at time 3.

MEASUREMENTS

Assessments covered: cognitive and functional ability; self-reported perceptions of health, mood, social engagement, quality of life, satisfaction with life and well-being; use of in-home and community care; and transitions into residential care.

RESULTS

People living alone tended to have better cognitive and functional ability and were more frequent users of in-home care. However, they experienced poorer physical, social, and psychological health and reduced quality of life, satisfaction with life, and well-being. These differences persisted over time and rates of transition into residential care were higher.

CONCLUSIONS

To facilitate continuing in place for people with dementia living alone, a dual focus on supporting functional ability and addressing psychosocial needs is essential in the context of an enabling policy framework.

Associations between personality and psychological characteristics and cognitive outcomes among older adults

Prior research has shown that some personality traits are associated with cognitive outcomes and may confirm risk or protection against cognitive decline. The present study expands on previous work to examine the association between a more comprehensive set of psychological characteristics and cognitive performance in a diverse cohort of older adults. We also examine whether controlling for brain atrophy influences the association between psychological characteristics and cognitive function. A total of 157 older adults completed a battery of psychological questionnaires (Openness to Experience, Conscientiousness, Agreeableness, Neuroticism, Extraversion, positive affect, negative affect-sadness, negative affect-anger, sense of purpose, loneliness, grit, and self-efficacy). Cognitive outcomes were measured across multiple domains: episodic memory, semantic memory, executive function, and spatial ability. Baseline brain (MRI) variables included gray matter, hippocampus, and total white matter hyperintensity volume. Parallel process, multilevel models yielded intercept (individual cognitive domain scores) and linear slope (global cognitive change) random effects for the cognitive outcomes. Positive affect (β = 0.013, SE = 0.005, p = .004) and Openness (β = 0.018, SE = 0.007, p = .009) were associated with less cognitive change, independent of baseline brain variables and covariates. Greater sadness predicted more cognitive decline when controlling for covariates, but not brain atrophy. A variety of psychological characteristics were associated with the cross-sectional measures of cognition. This study highlights the important impact of positive and negative affect on reducing or enhancing the risk of longitudinal cognitive decline. Such findings are especially important, given the available efficacious interventions that can improve affect. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Hospital admissions and emergency department visits for people with dementia

BACKGROUND

Previous studies have suggested that people with dementia (PwD) are more likely to be admitted to hospital, have prolonged hospital stay, or visit an emergency department (ED), compared to people without dementia.

AIM

This study assessed the rates of hospital admissions and ED visits in PwD and investigated the causes and factors predicting this healthcare use. Further, this study assessed survival following hospital admissions and ED visits.

DESIGN

This was a retrospective study with data from 26 875 PwD and 23 961 controls.

METHODS

Data from national datasets were extracted for demographic characteristics, transitions to care homes, hospital and ED use and were linked through the Honest Broker Service. PwD were identified through dementia medication and through causes for hospital admissions and death.

RESULTS

Dementia was associated with increased risk of hospital admissions and ED visits, and with lower odds of hospital readmission. Significant predictors for hospital admissions and readmissions in PwD were transitioning to a care home, living in urban areas and being widowed, while female gender and living in less deprived areas reduced the odds of admissions. Older age and living in less deprived areas were associated with lower odds of an ED visit for PwD. In contrast to predictions, mortality rates were lower for PwD following a hospital admission or ED visit.

CONCLUSIONS

These findings result in a better understanding of hospital and ED use for PwD. Surprisingly, survival for PwD was prolonged following hospital admissions and ED visits and thus, policies and services enabling these visits are necessary, especially for people who live alone or in rural areas; however, increased primary care and other methods, such as eHealth, could provide equally effective care in order to avoid distress and costs for hospital admissions and ED visits.

Predictors of Variation in the Cognitive Function Trajectories among Older Adults Living Alone: A Growth Mixture Modeling Approach

BACKGROUND

Considering the global aging population, this study investigates changes in cognitive function and predictive factors among older adults living alone.

METHODS

Using data collected from the Korean Longitudinal Study of Aging (KLoSA), the study examines 1217 participants to identify distinct cognitive change patterns and the variables affecting them.

RESULTS

Two primary cognitive function change types emerged: "High-Level Declining Type" and "Low-Level Stable Type." Although the former initially displayed normal cognitive function, it gradually declined over a period of 14 years until it reached mild cognitive impairment (MCI) levels by the year 2020. While the latter group had lower cognitive function from the beginning and remained stable throughout the study. Older age, female gender, rural residence, lower education, lower income, unemployment, and higher levels of depression were linked to a higher likelihood of belonging to the "Low-Level Stable Type".

CONCLUSIONS

The findings of these studies emphasize the need for proactive interventions and regular cognitive assessments for older individuals living alone, as cognitive impairment can develop even in individuals whose cognitive abilities are initially good. Also, tailored interventions should target specific demographic and socioeconomic groups to mitigate cognitive decline effectively.

Prescribing pattern of anti-psychotic medications in patients with dementia in Oman: a retrospective observational study

Background

Aggression, agitation, psychosis, and sleep disturbances are common behavioral symptoms of people with dementia and they can be distressing for both individuals and their carers. Due to their potential side effects, antipsychotic medications are recommended only for severe behavioral and psychological symptoms of dementia (BPSD). This study explores the prevalence, patterns, and associated factors with antipsychotic drug use among patients with dementia attending geriatric psychiatry services at Sultan Qaboos University Hospital (SQUH). Using a retrospective cross-sectional design, this study examines antipsychotic use among elderly patients aged 60 years or older with dementia who attended geriatric psychiatry services from January 2020 to December 2021. The following information was solicited: socio-demographic factors, type and severity of dementia, presence of co-morbid medical or mental illness, the psychotropic medications prescribed, the anti-psychotic medication use, duration of use, and the indication of use were solicited as well. A multivariate logistic regression analysis was conducted.

Results

The total prevalence of anti-psychotic use among elderly patients with dementia was 56.6%, and among them, 59% were prescribed anti-psychotics for more than 2 years. Being female, having non-Alzheimer’s dementia, experiencing severe stages of dementia, and having other medical or mental co-morbid conditions were independent predictors of antipsychotic drug use (odds ratio [OR] =1.85, confidence interval [CI] =1.04–3.30; OR=2.77, C.I. 1.52–5.04; OR=4.47, C.I. 2.18–9.18; and OR=2.54, C.I. 1.11–5.78, respectively).

Conclusions

Antipsychotic medication use is prevalent among elderly patients with dementia in Oman. The results from this study will help the policymakers and psychiatrists in Oman to plan for the use of non-pharmacological strategies as the first line of management for BPSD.

Can leisure and entertainment lifestyle promote health among older people living alone in China?-A simultaneous equation approach

Objectives

With the surging number of older people living alone, their lifestyles and health status have aroused increasing concern. This study aims to investigate whether a leisure and entertainment lifestyle (LEL) can improve the multidimensional health among older people living alone and try to identify the latent mechanisms among them.

Method

For this purpose, we extracted data from the Chinese General Social Survey (CGSS) and established a simultaneous equations model, comprising ordinary least square regression (OLS), two-stage least squares (2SLS), and the mediating effect model.

Results

Older people living alone in China reported relatively better mental health status (3.64 ± 1.07), followed by physical health (3.41 ± 1.26) and social health (2.75 ± 1.18). In the OLS model, LEL significantly improved the social health of older people living alone (β = 0.054, P < 0.01), followed by physical health (β = 0.042, P < 0.01) and mental health (β = 0.027, P < 0.01). After endogenous tests from 2SLS model and robustness tests, we found that more active LEL was associated with higher levels of physical health and mental health. However, LEL had no significant effect on the improvement of the social health of the older people living alone. Using the mediation analysis, exercise efficacy partially mediated the relationship of LEL with physical health and mental health, and the ratios were 19.75 and 24.85%, respectively. Similarly, positive life attitudes partially mediated the relationship between LEL and physical health, and LEL and mental health, with ratios of 10.65 and 26.83%, respectively.

Conclusion

Our findings suggested that LEL is significantly associated with better physical and mental health for older people living alone in China, and the association is mediated by exercise efficacy and positive attitudes toward life. Promoting more leisure and recreational activities, upgrading exercise efficacy, and encouraging positive life attitudes are necessary health promotion measures in active aging policies for the wellbeing of older people living alone.

The Living Alone with Cognitive Impairment Project's Policy Advisory Group on Long-Term Services and Supports: Setting a Research Equity Agenda

(1) Background: A United States national policy advisory group (PAG) was convened to identify barriers and facilitators to expand formal long-term services and support (LTSS) for people living alone with cognitive impairment (PLACI), with a focus on equitable access among diverse older adults. The PAG's insights will inform the research activities of the Living Alone with Cognitive Impairment Project, which is aimed at ensuring the equitable treatment of PLACI. (2) Methods: The PAG identified barriers and facilitators of providing effective and culturally relevant LTSS to PLACI via one-on-one meetings with researchers, followed by professionally facilitated discussions among themselves. (3) Results: The PAG identified three factors that were relevant to providing effective and culturally relevant LTSS to PLACI: (i) better characterization of PLACI, (ii) leveraging the diagnosis of cognitive impairment, and (iii) expanding and enhancing services. For each factor, the PAG identified barriers and facilitators, as well as directions for future research. (4) Conclusions: The barriers and facilitators the PAG identified inform an equity research agenda that will help inform policy change.

Chronic wounds in persons living with dementia: An integrative review

BACKGROUND

Persons living with dementia (PLWD) are at risk for chronic wounds; however, they are rarely included in research.

OBJECTIVES

To inform practice and research directions, the aim of this integrative review was to identify and synthesise previous knowledge about the characteristics of chronic wounds in PLWD, in terms of chronic wound types, prevalence, setting and interventions.

DESIGN

A literature search was conducted for publications in English using PubMed, Web of Science and CINAHL. The minimum information required for inclusion was how many PLWD enrolled in the study had wounds.

METHODS

This integrative review followed the Whittemore and Knafl methodology. Data extraction and synthesis were guided by a directed content analysis, with a coding structure based on an initial review of the literature.

RESULTS

Thirty-six articles met the inclusion criteria. The majority were missing characteristics of PLWD including severity of dementia and race/ethnicity/nationality, and none mentioned skin tone. Most focused on pressure injuries in the nursing home and acute care setting. Few included information on interventions. Only one discussed challenges of wound care for a PLWD exhibiting aggression.

CONCLUSION

There is a gap in the literature regarding PLWD and chronic wounds other than pressure injuries that are common in older adults (e.g. diabetic foot ulcers, venous leg ulcers). Research is warranted among those PLWD who live alone and those who receive wound care from family caregivers to understand experiences. Knowledge can inform the development of future novel interventions for wound healing. Future research is needed regarding chronic wounds in those who exhibit behavioural and psychological symptoms of dementia.

RELEVANCE TO CLINICAL PRACTICE

Nurses that care for chronic wounds in PLWD can contribute their knowledge to include information in guidelines on best care practices and contribute their perspective to research teams for future research.

A statewide elder mistreatment virtual assessment program: Legal, ethical, and practical issues

Telecommunication assisted forensic assessments of capacity and mistreatment by geriatricians with expertise in elder abuse and self-neglect are helping to meet the demand for such forensic services for Adult Protective Services (APS) clients in remote and underserved areas of Texas. The use of synchronous audiovisual assisted interviews instead of in-person interviews with clients to provide capacity assessments has become more important with the arrival of the COVID-19 pandemic. There is growing interest in establishing similar programs in other states using geriatrician faculty from medical schools to serve the clients of their state Adult Protective Services agencies. The arrangement between APS and the geriatricians at McGovern Medical School in Houston, Texas is novel. The structure of the arrangement is important for the success of the program. Legal, ethical, and practical considerations are discussed in this article, including approaches to the Health Insurance Portability and Accountability Act, physician liability, state law, and resource limitations. It is hoped that sharing how one such collaboration has addressed these important issues will suggest approaches for the structuring of similar programs.

Early Start of Anti-Dementia Medication Delays Transition to 24-Hour Care in Alzheimer's Disease Patients: A Finnish Nationwide Cohort Study

BACKGROUND

Dementia is one of the strongest predictors of admission to a 24-hour care facility among older people, and 24-hour care is the major cost of Alzheimer's disease (AD).

OBJECTIVE

The aim of this study was to evaluate the association of early start of anti-dementia medication and other predisposing factors with 2-year risk of transition to 24-hour care in the nationwide cohort of Finnish AD patients.

METHODS

This was a retrospective, non-interventional study based on individual-level data from Finnish national health and social care registers. The incident cohort included 7,454 AD patients (ICD-10, G30) comprised of two subgroups: those living unassisted at home (n = 5,002), and those receiving professional home care (n = 2,452). The primary outcome was admission to a 24-hour care facility. Exploratory variables were early versus late anti-dementia medication start, sociodemographic variables, care intensity level, and comorbidities.

RESULTS

Early anti-dementia medication reduced the risk of admission to 24-hour care both in patients living unassisted at home, with a hazard ratio (HR) of 0.58 (p < 0.001), and those receiving professional home care (HR, 0.84; p = 0.039). Being unmarried (HR, 1.69; p < 0.001), having an informal caregiver (HR, 1.69; p = 0.003), or having a diagnosis of additional neurological disorder (HR, 1.68; p = 0.006) or hip fracture (HR, 1.61; p = 0.004) were associated with higher risk of admission to 24-hour care in patients living unassisted at home.

CONCLUSION

To support living at home, early start of anti-dementia medication should be a high priority in newly diagnosed AD patients.

"I can do that on my own!" On the relevance of subjective factors to the use of formal support, from the perspective of people with dementia

Our aim was to reach a better insight of the disposition of people living alone with dementia toward the use of care and support services. In biographical narrative interviews, women and men with dementia communicated to us their opinions, needs, and subjectively perceived level of resources regarding their everyday life and care. Both individual and gender-specific differences concerning the use of formal support become evident in their narrations. We offer indications for a future healthcare practice that is specific to dementia. To fully exploit the potential of participatory research, study designs specific to dementia should be developed further.

Use of Services by People Living Alone With Cognitive Impairment: A Systematic Review

BACKGROUND AND OBJECTIVES

Formal supports and social services are essential to people living alone with cognitive impairment (PLACI) because they are at risk of negative health outcomes and lack cohabitants who may support them with cognitively demanding tasks. To further our understanding of this critical and worldwide issue, we conducted a systematic review to understand whether, and how, PLACI access and use essential formal supports and services.

RESEARCH DESIGN AND METHODS

We searched 6 databases (PubMed, Embase, PsycINFO, CINAHL, Web of Science, and Sociological Abstracts) to identify quantitative and mixed-method literature on formal service use among PLACI. The initial search was conducted in 2018 and updated in 2020.

RESULTS

We identified 32 studies published between 1992 and 2019, representing 13 countries, that met our criteria: 16 reported on health services and 26 on social services. Most studies compared PLACI with people with cognitive impairment living with others. Health service use was lower or similar among PLACI, as opposed to counterparts living with others. Most studies reported a higher use of social services (e.g., home services) among PLACI than those living with others. Overall use of essential home service among PLACI was higher in Europe than in the United States, a country where large portions of PLACI were reported receiving no formal services.

DISCUSSION AND IMPLICATIONS

We identified wide variability among countries and major gaps in service use. Results for use of health services were mixed, although our findings suggest that PLACI may have fewer physician visits than counterparts living with others. Our findings suggest that varying policies and budgets for these services among countries may have affected our findings. We encourage researchers to evaluate and compare the influence of social policies in the well-being of PLACI. We also encourage policy makers to prioritize the needs of PLACI in national dementia strategies.

Living alone for people on dementia medication: related use of drugs

Approximately one-third of people with dementia in the United Kingdom live alone. People living alone with dementia may receive different treatment for dementia and may have different comorbidities compared to people who live with a caregiver. This study explored differences in medication and demographic characteristics between people living alone with dementia and those living with a caregiver in Northern Ireland. People with dementia were identified through the first date that a dementia management medication was prescribed between 2010 and 2016. In total, 25,418 people were prescribed a dementia management medication. Data for whether people with dementia lived alone was extracted through the National Health Application and Infrastructure Services and from national datasets through the Honest Broker Service. Approximately 35% (n= 8,828) of people with dementia in Northern Ireland lived alone. People with dementia who lived alone were younger (mean= 75 years, SD= 8.50) compared to people who lived with a caregiver (mean= 77 years, SD= 7.82). Binary logistic regression highlighted that people who lived alone were more likely to be treated with donepezil medication for dementia and less likely to receive antidepressants. These findings indicate that living alone did not affect treatment for dementia and comorbidity medication in people on dementia medication.

[Influencing factors for nursing home admission in case of pre-existing need of care - a systematic review]

INTRODUCTION

Knowledge about predictors of nursing home placement is highly relevant. If they are known, targeted interventions such as counselling can help prevent or delay relocation to a nursing home. Above all, preventive and structural measures can target influenceable predictors. The aim of the review was to map predictors of nursing home admission and thus the permanent stay in inpatient long-term care for the target group of people with a pre-existing need for care.

METHODS

A systematic literature search in the databases The Cochrane Library, PubMed, CINAHL, GeroLit and CareLit® was conducted in September 2017. Longitudinal studies with quantitative analyses were included. The methodological quality was assessed using the Newcastle-Ottawa Scale.

RESULTS

45 cohort studies were included. 21 studies examined study populations with need for care, in 24 studies the care status was unclear. A variety of predictors of nursing home admission with at least one-and-a-half times higher risk for both study populations could be identified, including higher age, dementia, underweight, higher age of caregiver, psychiatric symptoms, smoking status, ethnicity, challenging behaviour in people with dementia, higher number of hospitalizations and lower level of life satisfaction.

DISCUSSION

All the predictors identified are relevant to people in need of care. No predictors for the study population with need of care could be identified that are particularly important in contrast to persons with an unclear care status. However, the quality of studies among people with care and support needs is limited compared to studies targeting people with unclear care status.

CONCLUSIONS

Many factors seem to predict the admission to a nursing facility. For the first time, these factors are listed in this systematic review for the target group of people in need of care. Interventions or preventive measures based on known influenceable predictors can help prevent or delay nursing home admission.

Determinants Of Antipsychotic Drugs Prescription Among Community-Living Older Adults With Dementia: A Population-Based Study Using Health Information Systems In The Lazio Region, Italy

Introduction

Despite recommendations from associations of geriatric and psychiatry societies and warnings from drug agencies, antipsychotic (AP) drugs are frequently used to control behavioral and psychological symptoms of dementia. APs are associated with a range of potential adverse events, including increased risk of cerebrovascular events and mortality. Evidence suggests limited efficacy of APs for aggression and psychosis. Our objectives were to investigate patterns and predictors for prescription of APs among older adults with dementia residing in a large region of central Italy, and to identify patient characteristics related to typical or atypical APs prescribing.

Methods

This is a retrospective population-based cohort study using data from regional health information systems (HIS). We included dementia patients aged ≥65 years residing in the Lazio region. The exposure was defined as new use vs non-use of APs. Dementia patients with incident use of APs during 2015 were followed-up from the date of first prescription to the earliest among discontinuation of use, death, or end of study (December 31, 2016).

Results

We enrolled 24,735 dementia patients, 1727 (6.7%) new users and 23,008 non-users of APs. Forty-four percent of AP users were treated for more than 3 months, and among these about 60% received APs continuously for at least 12 months. Individuals using antidepressant or anti-dementia drugs had higher odds of being prescribed with APs (OR: 1.67 and OR: 1.86, respectively). Patients exposed to polypharmacy were less likely to receive APs (OR: 0.82). Cardiovascular risk factors and comorbidities were not associated with APs use. Low socio-economic position was associated with lower odds of atypical AP prescribing (OR: 0.57).

Conclusion

The study showed that a not negligible proportion of patients had a period of AP use longer than recommended by guidelines. We identified socio-demographic and clinical factors associated with first use of APs, providing insight into prescribing practices in a community setting and useful information to address areas of potential inappropriateness.

Sex and gender differences in polypharmacy in persons with dementia: A scoping review

Purpose:

To date, research studies in most disciplines have not made sex-based analysis a priority despite increasing evidence of its importance. We now understand that both sex and gender impact medication prescribing, use, and effect. This is particularly true for older adults with dementia who have alterations in drug metabolism, drug response, and the permeability of the blood–brain barrier. To better understand the influence of sex and gender on drug use in older adults with dementia, we conducted a scoping review.

Methods:

This scoping review systematically searched the Medline, Embase, Web of Science, CINAHL, and ProQuest databases to find published reports on polypharmacy in populations of older adults with dementia that included a sex- or gender-based analysis.

Results:

A total of 12 published reports were identified. Findings were cohort studies and case-control trials that commented on sex-related differences in medication use as a secondary analysis to the studies’ primary objective. These studies showed that community-dwelling women received more potentially inappropriate medications and more psychotropic medications, while nursing home dwelling men received more potentially inappropriate medications, cholinesterase inhibitors, and antipsychotics. None of the identified studies explicitly examined gender-related differences in medication use.

Conclusion:

This scoping review supports that there is inadequate understanding of both sex and gender differences in drug use in older men and women with dementia. To tailor medication-specific interventions to improve drug therapy for older adults with dementia, it is important that future work includes sex- or gender-based analysis of drug use.

The Precarity of Older Adults Living Alone With Cognitive Impairment

PURPOSE OF THE STUDY

To examine the lived experience of older adults living alone with cognitive impairment to better understand their needs and concerns. Based on our previous work suggesting that older adults living alone often experience a sense of precarity, we were interested in exploring this construct in older adults living alone with a diagnosis of cognitive impairment. The notion of precarity points to the uncertainty deriving from coping with cumulative pressures while trying to preserve a sense of independence.

DESIGN AND METHODS

This is a qualitative study of 12 adults aged 65 and older living alone with cognitive impairment. Six participants had a diagnosis of Alzheimer's disease; 6 had a diagnosis of mild cognitive impairment. Participants' lived experiences were elicited through 40 ethnographic interviews and participant observation in their homes. Using a qualitative content analysis approach, interview transcripts and fieldnotes were analyzed to identify codes and themes.

RESULTS

Qualitative analysis of transcripts revealed three themes. Theme 1 described the distress stemming from the uncertainty of having cognitive impairment that has an unpredictable course. Theme 2 drew attention to the tendency of participants to feel responsible for managing their cognitive impairment. Theme 3 described the pressures stemming from the lack of appropriate services to support independent living for persons with cognitive impairment.

IMPLICATIONS

These 3 themes all pointed to facets of precarity. Findings also suggest the dearth of programs to support older adults living alone with cognitive impairment and the need to develop novel programs and interventions.

Influences on the access to and use of formal community care by people with dementia and their informal caregivers: a scoping review

BACKGROUND

The literature describes the obstacles to sufficient care faced by people with dementia and their informal caregivers. Although factors influencing access and utilisation are frequently studied, the body of knowledge lacks an overview of aspects related to influence. The frequently used Behavioural Model of Health Care Use (BM) could be used to structure and explain these aspects. An adaptation of the BM emphasises psychosocial influences and appears to enrich the understanding of the use of long-term care for dementia.

METHODS

We conducted a scoping review with the aim of providing an overview of the aspects influencing the access to and utilisation of formal community care in dementia. Our search covered the PubMed, CINAHL, Social Science Citation Index and PsychInfo databases, as well as grey literature. Two researchers assessed the full texts for eligibility. A data extraction form was developed and tested. We analysed the main topics investigated by the studies and mapped and described the investigated psychosocial aspects according to the BM after narratively summarising the findings. We used the Mixed Method Appraisal Tool (MMAT) to critically appraise the included studies.

RESULTS

A total of 94 studies were included: n = 55 with quantitative designs, 35 with qualitative designs and four with mixed methods. The studies investigated different services, mainly focusing on health care services. One third of the studies provided information regarding the severity of dementia. The most frequently investigated main topics were ethnicity and attitudes towards services. Psychosocial aspects were frequently investigated, although few studies considered the perspectives of people with dementia. Approximately half of the studies reported a theoretical framework. The adapted BM facilitated the structuring and description of psychosocial aspects. However, this instrument did not address topics beyond the scope of psychosocial aspects, such as sociodemographic characteristics.

CONCLUSIONS

The access to and utilisation of formal community care for dementia can only be partly explained by individual influencing aspects. Therefore, a theoretical framework would likely help to describe this complex subject. Our findings indicate that the psychosocial categories of the adapted BM enriched the original BM, and that people with dementia should more often be included in healthcare service research to ensure a better understanding of the barriers to accessing formal community care.

The Effects and Meanings of Receiving a Diagnosis of Mild Cognitive Impairment or Alzheimer's Disease When One Lives Alone

BACKGROUND

One third of older adults with cognitive impairment live alone and are at high risk for poor health outcomes. Little is known about how older adults who live alone experience the process of receiving a diagnosis of mild cognitive impairment (MCI) or Alzheimer's disease (AD).

OBJECTIVE

The aim of this study was to understand the effects and meanings of receiving a diagnosis of MCI or AD on the lived experience of older adults living alone.

METHODS

This is a qualitative study of adults age 65 and over living alone with cognitive impairment. Participants' lived experiences were elicited through ethnographic interviews and participant observation in their homes. Using a qualitative content analysis approach, interview transcripts and fieldnotes were analyzed to identify codes and themes.

RESULTS

Twenty-nine older adults and 6 members of their social circles completed 114 ethnographic interviews. Core themes included: relief, distress, ambiguous recollections, and not knowing what to do. Participants sometimes felt uplifted and relieved by the diagnostic process. Some participants did not mention having received a diagnosis or had only partial recollections about it. Participants reported that, as time passed, they did not know what to do with regard to the treatment of their condition. Sometimes they also did not know how to prepare for a likely worsening of their condition, which they would experience while living alone.

CONCLUSION

Findings suggest the need for more tailored care and follow-up as soon as MCI or AD is diagnosed in persons living alone.

Home care services for older clients with and without cognitive impairment in Sweden

Little is known about the types of home care services granted to older clients in Sweden. The objectives of this study were to: (a) identify and describe the range of granted home care services and service hours; (b) compare services granted for clients with and without documented cognitive impairment; and (c) examine associations between the range of granted home care services and factors related to cognitive impairment and demographical characteristics. The study design was descriptive and cross-sectional. The data, included records of granted home care services for clients age 65+ with (n = 43) and without (n = 88) cognitive impairment documented by the local municipality assessors, collected from one agency in Sweden during a 2-month period in 2015. Data analyses resulted in an overview of the range of home care services divided into two categories: personal care and service. In the personal care category, the median was 3 for types of services (range 0-12), and shower (n = 69; 52.7%) was the most common service. In the service category, the median was 5 for types of services (range 0-10), and cleaning the household (n = 103; 78.6%) was the most common service. The median for service hours was 27 hr per month (range 2.5-127.5). Logistic regression models revealed that cognitive impairment was associated with a higher number of services in the personal care category and a higher number of hours per month. Living alone was associated with a higher number of services in the service category. In conclusion, a wide range of home care services were provided for clients who have complex needs in daily life. Home care services were granted to clients with cognitive impairment and to a greater extent with clients who were living alone.

‘Overjoyed that I can go outside’: Using walking interviews to learn about the lived experience and meaning of neighbourhood for people living with dementia

This study explores the relationships between people living with dementia and their neighbourhood as they venture out from home on a regular and often routine basis. Here, we report findings from the Swedish field site of an international 5-year project: Neighbourhoods: our people, our places. The aims of this study were to investigate the lived experience of the neighbourhood for people with dementia and through this to better understand the meaning that neighbourhood held for the participants. In this study, we focus on the walking interviews which were conducted with 14 community-dwelling people with dementia (11 men and 3 women) and were analysed using an interpretative phenomenological method. Four themes were revealed from these interviews: life narratives embedded within neighbourhood; the support of selfhood and wellbeing through movement; the neighbourhood as an immediate social context; and restorative connections to nature. These themes were distilled into the ‘essence’ of what neighbourhood meant for the people we interviewed: A walkable area of subjective significance and social opportunity in which to move freely and feel rejuvenated. We have found that the neighbourhood for community-dwelling people with dementia holds a sense of attachment and offers the potential for freedom of movement. Our research indicates that a dementia diagnosis doesn’t necessarily reduce this freedom of movement. The implications for practice and policy are considered: future research should explore and pay closer attention to the diverse living conditions of people living with dementia, and not least the particular challenges faced by people living alone with dementia.

Advancing Research on Care Needs and Supportive Approaches for Persons With Dementia: Recommendations and Rationale

The first National Research Summit on Care, Services, and Supports for Persons with Dementia and Their Caregivers was held on October 16-17, 2017, at the National Institutes of Health. In this paper, participants from the Summit Session on Research on Care Needs and Supportive Approaches for Persons with Dementia summarize the state of the science, identify gaps in knowledge, and offer recommendations to improve science and practice in long-term care. Recommendations cover 4 areas focused on persons living with dementia: (1) symptoms (behavioral and psychological symptoms of dementia, function, cognition, and sleep); (2) dementia care settings (physical and social environments, home, and residential care); (3) living with dementia (living well with dementia, living alone with dementia, and living with dementia and intellectual and developmental disabilities); and (4) technology as a cross-cutting theme. The participants identify 10 of the most pressing research issues based on the findings from their collective papers. Final Summit recommendations included those presented by session participants and will be used to advise federal agencies and other organizations that fund research.

Living Alone with Alzheimer's Disease: Data from SveDem, the Swedish Dementia Registry

Background: Many people with Alzheimer’s disease (AD) live alone in their own homes. There is a lack of knowledge about whether these individuals receive the same quality of diagnostics and treatment for AD as patients who are cohabiting.

Objectives: To investigate the diagnostic work-up and treatment of community-dwelling AD patients who live alone.

Methods: We performed a cross-sectional cohort study based on data from the Swedish Dementia Registry (SveDem). We studied patients diagnosed with AD between 2007 and 2015 (n = 26,163). Information about drugs and comorbidities was acquired from the Swedish Prescribed Drug Register and the Swedish Patient Register.

Results: 11,878 (46%) patients lived alone, primarily older women. After adjusting for confounders, living alone was inversely associated with receiving computed tomography (OR 0.90; 95% CI 0.82–0.99), magnetic resonance imaging (OR 0.91; 95% CI 0.83–0.99), and lumbar puncture (OR 0.86; 95% CI 0.80–0.92). Living alone was also negatively associated with the use of cholinesterase inhibitors (OR 0.81; 95% CI 0.76; 0.87), memantine (OR 0.77; 95% CI 0.72; 0.83), and cardiovascular medication (OR 0.92; 0.86; 0.99). On the other hand, living alone was positively associated with the use of antidepressants (OR 1.15; 95% CI 1.08; 1.22), antipsychotics (OR 1.41; 95% CI 1.25; 1.58), and hypnotics and sedatives (OR 1.09; 95% CI 1.02; 1.17).

Conclusions: Solitary living AD patients do not receive the same extent of care as those who are cohabiting.

On Living Alone with Alzheimer's Disease

A sociologist's encounters with a retired executive living alone with Alzheimer's disease reveal gaps in the U.S. healthcare system. These gaps emerge during eight ethnographic interviews and participant observation between 2014 and 2017 with Ms. Judith Banks, 79. Ms. Banks' perspective offers an inside-view of the challenges of living alone with cognitive impairment. Receiving a diagnosis of Alzheimer's disease was "brutal" for her and the support to continue living in the community almost non-existent. Gaps in the U.S. healthcare system further emerge from the contrast between Ms. Banks' case study and the examination of the Danish system of care for non-institutionalized persons with dementia. Given that one third of people with dementia live alone in the U.S. and that they are likely to experience poorer health outcomes than counterparts living with others, it is critical to ensure that they receive appropriate health services upon diagnosis of cognitive impairment.

Views of Caregivers on the Ethics of Assistive Technology Used for Home Surveillance of People Living with Dementia

This paper examines the ethics of using assistive technology such as video surveillance in the homes of people living with dementia. Ideation and concept elaboration around the introduction of a camera-based surveillance service in the homes of people with dementia, typically living alone, is explored. The paper reviews relevant literature on surveillance of people living with dementia, and summarises the findings from ideation and concept elaboration workshops, designed to capture the views of those involved in the care of people living with dementia at home. The research question relates to the ethical considerations of using assistive technologies that include video surveillance in the homes of people living with dementia, and the implications for a person living with dementia whenever video surveillance is used in their home and access to the camera is given to the person’s family. The review of related work indicated that such video surveillance may result in loss of autonomy or freedom for the person with dementia. The workshops reflected the findings from the related work, and revealed useful information to inform the service design, in particular in fine-tuning the service to find the best relationship between privacy and usefulness. Those who took part in the workshops supported the concept of the use of camera in the homes of people living with dementia, with some significant caveats around privacy. The research carried out in this work is small in scale but points towards an acceptance by many caregivers of people living with dementia of surveillance technologies. This paper indicates that those who care for people living with dementia at home are willing to make use of camera technology and therefore the value of this work is to help shed light on the direction for future research.

Mild versus moderate stages of Alzheimer's disease: three-year outcomes in a routine clinical setting of cholinesterase inhibitor therapy

Background

There is an increasing interest in cognitive and functional outcomes in the respective stages of Alzheimer’s disease (AD) and in novel therapies particularly for the milder phases of AD. Our aim was to describe and compare various aspects of disease progression in patients with mild versus moderate AD in routine clinical practice of cholinesterase inhibitor (ChEI) therapy.

Methods

This 3-year, prospective, observational, multicentre study included 1021 participants. Of these, 734 had mild AD (Mini-Mental State Examination (MMSE) score, 20–26) and 287 had moderate AD (MMSE score, 10–19) at the start of ChEI treatment. At baseline and every 6 months, patients were assessed using cognitive, global, instrumental and basic activities of daily living (ADL) scales. Potential predictors of deterioration in moderate AD were analysed using mixed-effects models.

Results

The change from baseline between participants with mild and moderate stages of AD after 3 years of ChEI therapy differed significantly on the Alzheimer’s Disease Assessment Scale-cognitive subscale (ADAS-cog) and basic ADL, but not using the MMSE and instrumental ADL scales. Protective independent factors for better cognitive long-term outcome in the group with moderate AD were older age, higher instrumental ADL ability, no antipsychotics, usage of non-steroidal anti-inflammatory drugs/acetylsalicylic acid, living with family member, lower education and a higher mean dose of ChEI. Apolipoprotein E genotype did not influence the rates of disease progression or the longitudinal outcomes. Prediction models were provided for moderate AD.

Conclusions

More sensitive cognitive measures, such as the ADAS-cog scale, are required to detect a possibly faster deterioration among the participants with moderate AD. This study highlighted the clinical importance of instrumental ADL evaluations in patients at a mild stage of AD, and the importance of optimizing the ChEI dose even for individuals with moderate AD. Solitary living was a risk factor for faster cognitive decline, and probably expanded the need for formal care in the group with moderate AD. The patients with more advanced AD and presumably more pronounced neuroinflammation might have additional cognitive benefits from longer-term treatment with anti-inflammatory drugs.

Early Cognitively Based Functional Limitations Predict Loss of Independence in Instrumental Activities of Daily Living in Older Adults

Older adults with early forms of neurodegenerative disease are at risk for functional disability, which is often defined by the loss of independence in instrumental activities of daily living (IADLs). The current study investigated the influence of mild changes in everyday functional abilities (referred to as functional limitations) on risk for development of incident functional disability. A total of 407 participants, who were considered cognitively normal or diagnosed with mild cognitive impairment (MCI) at baseline, were followed longitudinally over an average 4.1 years (range=0.8-9.2 years). Informant-based ratings from the Everyday Cognition (ECog; Farias et al., 2008) and the Instrumental Activities of Daily Living (Lawton & Brody, 1969) scales assessed the degree of functional limitations and incident IADL disability, respectively. Cox proportional hazards models revealed that more severe functional limitations (as measured by the Total ECog score) at baseline were associated with approximately a four-fold increased risk of developing IADL disability a few years later. Among the ECog domains, functional limitations in Everyday Planning, Everyday Memory, and Everyday Visuospatial domains were associated with the greatest risk of incident functional disability. These results remained robust even after controlling for participants' neuropsychological functioning on tests of executive functions and episodic memory. Current findings indicate that early functional limitations have prognostic value in identifying older adults at risk for developing functional disability. Findings highlight the importance of developing interventions to support everyday abilities related to memory, executive function, and visuospatial skills in an effort to delay loss of independence in IADLs.