Integrating care for older adults with cognitive impairment

An Integrated Patient-Centred Medical Home (PCMH) Care Model Reduces Prospective Healthcare Utilisation for Community-Dwelling Older Adults with Complex Needs: A Matched Observational Study in Singapore

The global ageing population is associated with increased health service use. The PCMH care model integrates primary care and home-based care management to deliver comprehensive and personalised healthcare to community-dwelling older adults with bio-psycho-social needs. We examined if an integrated PCMH reduced healthcare utilisation burden of older persons in Singapore. We compared the healthcare utilisation between the intervention group and coarsened exact matched controls for a follow-up of 15 months. Baseline matching covariates included socio-demographics, health status, and past healthcare use. We accounted for COVID-19 social distancing effects on health-seeking behaviour. The intervention group consisted of 165 older adults with complex needs. We analysed national administrative healthcare utilisation data from 2017 to 2020. We applied multivariable zero-inflated regression modelling and presented findings stratified by high (CCI ≥ 5) and low disease burden (CCI < 5). Compared to controls, there were significant reductions in emergency department (β = -0.85; 95%CI = -1.55 to -0.14) and primary care visits (β = -1.70; 95%CI = -2.17 to -1.22) and a decrease in specialist outpatient visits (β = -0.29; 95%CI = -0.64 to 0.07) in the 3-month period immediately after one-year enrolment. The number of acute hospitalisations remained stable. Compared to controls, the intervention group with high and low comorbidity burden had significant decreases in primary care use, while only those with lower comorbidity burden had significant reductions in utilisation of other service types. An integrated PCMH appears beneficial in reducing healthcare utilisation for older persons with complex needs after 1 year in the programme. Future research can explore longer-term utilisation and scalability of the care model.

Medicare-funded home-based clinical care for community-dwelling persons with dementia: An essential healthcare delivery mechanism

BACKGROUND

Over the past decade, medical care has shifted from institutions into home settings-particularly among persons with dementia. Yet it is unknown how home-based clinical services currently support persons with dementia, and what factors shape access.

METHODS

Using the National Health and Aging Trends Study linked to Medicare claims 2012-2017, we identified 6664 community-dwelling adults age ≥ 70 years enrolled in fee-for-service Medicare. Annual assessment of dementia status was determined via self-report, cognitive interview, and/or proxy assessment. Receipt of four types of home-based clinical care (home-based medical care (HBMC) (i.e., nurse practitioner, physician, or physician assistant visits), skilled home health care (SHHC), podiatry visits, and other types of home-based clinical services (e.g., behavioral health)) was assessed annually. We compared age-adjusted rates of home-based clinical care by dementia status and determined sociodemographic, health, and environmental characteristics associated with utilization of home-based clinical care among persons with dementia.

RESULTS

Nearly half (44.4%) of persons with dementia received any home-based clinical care annually compared to only 14.4% of those without dementia. Persons with dementia received substantially more of each type of home-based clinical care than those without dementia including a 5-fold increased use of HBMC (95% CI = 3.8-6.2) and double the use of SHHC (95% CI = 2.0-2.5). In adjusted models, Hispanic/Latino persons with dementia were less likely to receive HBMC (OR = 0.32; 95% CI = 0.11-0.93). Use of HBMC, podiatry, and other home-based clinical care was significantly more likely among those living in residential care facilities, in the Northeast and in metropolitan areas.

CONCLUSION

Although almost half of community-dwelling persons with dementia receive home-based clinical care, there is significant variation in utilization based on race/ethnicity and environmental context. Increased understanding as to how these factors impact utilization is necessary to reduce potential inequities in healthcare delivery among the dementia population.

Characteristics associated with neuropsychiatric symptoms in persons living with dementia and caregiver distress and diminished well-being

BACKGROUND

The population of persons living with dementia (PLWDs) is increasing, although mainstream dementia care quality is suboptimal.

PURPOSE

To identify characteristics associated with: (1) PLWDs' neuropsychiatric symptoms and quality of life; and (2) distress from neuropsychiatric symptoms and well-being among their family caregivers (N = 49).

METHODOLOGY

Cross-sectional single-group examination of PLWD and caregivers when they enrolled into a nurse-led dementia-centered primary care clinic. Pearson correlations were run between characteristics of PLWD and caregiver and variables representing PLWD's neuropsychiatric symptoms and quality of life and their caregivers' well-being. Statistically significant correlations were reported via Cohen d statistics.

RESULTS

Caregivers' characteristics associated with higher distress from neuropsychiatric symptoms and diminished well-being included Black race, female gender, younger age, caring for a parent with dementia, and being employed. Characteristics of PLWD associated with caregivers' higher distress and diminished well-being included longer time since dementia onset, higher Charlson Comorbidity Index, and non-Alzheimer dementia. Caregivers' characteristics associated with higher neuropsychiatric symptom burden included Black race, female gender, younger age, caring for parent PLWD, and being employed. Characteristics of PLWDs associated with higher neuropsychiatric symptom burden included non-Alzheimer dementia, longer time since dementia onset, more comorbidities, and higher Charlson Comorbidity Index. Finally, a longer time since dementia onset was associated with PLWDs' lower quality of life.

CONCLUSIONS

Black race, caring for caring for a parent with dementia, younger age, and being employed were characteristics linked to PLWDs' higher neuropsychiatric symptom burden and caregivers' diminished well-being.

IMPLICATIONS

Clinicians must assess and intervene with unpaid caregivers who may not appear obviously distressed.

Dementia Care Across a Tertiary Care Health System: What Exists Now and What Needs to Change

OBJECTIVES

This study explored the process of care for persons living with dementia (PLWDs) in various care settings across a tertiary care system and considers challenges and opportunities for change.

DESIGN

Aimed at quality improvement, qualitative interviews were conducted with key stakeholders in dementia care across geriatric outpatient clinics, medical and psychiatric emergency departments, and the main hospital in 2016.

SETTING AND PARTICIPANTS

Forty-nine interactive interviews were conducted with a purposive and snowball sampling of health care professionals (physicians, nurses, social workers, administrators) and families in a large, academic health care system.

MEASURES

Qualitative interview guides were developed by the study team to assess the process of care for PLWDs and strengths and challenges to delivering that care.

RESULTS

Key themes emerging from the interviews in each care setting are presented. The outpatient setting offers expertise, a multidisciplinary clinic, and research opportunities, but needs to respond to long waitlists, space limitations, and lack of consensus about who owns dementia care. The emergency department offers a low nurse/patient ratio and expertise in acute medical problems, but experiences competing demands and staff turnover; additionally, dementia does not appear on medical records, which can impede care. The hospital offers consultative services and resources, yet the physical space is confined and chaotic; sitters and antipsychotics can be overused, and placement outside of the hospital for PLWDs can be a challenge.

CONCLUSIONS AND IMPLICATIONS

Five key recommendations are provided to help health systems proactively prepare for the coming boom of PLWD and their caregivers, including outpatient education, a dementia care management program to link services, Internet-based training for providers, and repurposing sitters as Elder Life specialists.

Development and Feasibility of SymTrak, aMulti-domain Tool for Monitoring Symptoms of Older Adults in Primary Care

BACKGROUND

A clinically practical, brief, user-friendly, multi-domain self-report and caregiver-report tool is needed for tracking actionable symptoms in primary care for elderly patients with multiple chronic conditions (MCCs).

OBJECTIVE

Develop and assess usability, administration time, and internal reliability of SymTrak.

DESIGN AND PARTICIPANTS

Phase I: legacy instruments, content validity, analyses of existing data, focus groups (physicians, nurses, patients, informal caregivers), and Think Aloud interviews (patients, caregivers) were used to develop SymTrak. Phase II (pilot feasibility study): 81 (27 patient-caregiver dyads, 27 patients without an identified caregiver) participants were self-administered SymTrak in clinic.

MAIN MEASURES

SymTrak and demographic questions.

KEY RESULTS

Consistent themes emerged from phase I focus groups. Ambiguous wording was corrected with Think Aloud feedback. In phase II, patients and caregivers preferred circling words instead of numbers for item response options. SymTrak self-administration completion time in clinic was brief; mean was 2.4, 3.0, and 3.3 min for the finalized circlingwords version, respectively, for caregivers, dyadic patients, and patients without a caregiver; and the maximum was 6.2 min for any participant. Usability questionnaire ratings were high. Cronbach's alpha for the SymTrak 23-item total score was 0.86, 0.79, and 0.81 for caregivers, dyadic patients, and patients without a caregiver, respectively.

CONCLUSIONS

SymTrak demonstrates content validity, positive qualitative findings, high perceived usability, brief self-administered completion time, and good internal reliability.

Benefits of Occupational Therapy in Dementia Patients: Findings from a Real-World Observational Study

BACKGROUND

There is a growing interest in developing non-pharmacological approaches in dementia. Clinical efficacy of occupational therapy (OT) under routine care conditions has not been investigated yet.

OBJECTIVE

To analyze the short-term effects of OT in patients with dementia; and to identify factors related to greater benefit.

METHODS

Patients referred to OT were evaluated before starting a 3-month intervention and at 3 and 6 months later. Measures included: Mini-Mental State Examination (MMSE), Disability Assessment in Dementia (DAD), Neuropsychiatric Inventory (NPI) Questionnaire, patients' quality of life (EQ 5D-VAS), caregivers' burden (Zarit scale), and amount of informal care. Linear mixed models were used to analyze trajectories of outcomes. Logistic regressions with stepwise descending selection were used to study factors associated with benefits.

RESULTS

421 dementia patients benefited from OT (mean MMSE = 17.3). Patients remained cognitively stable over time. Functional performances also remained stable at 3 months and significantly decreased at 6 months (crude reduction of 2.8 points, p < 0.01). Behavioral troubles were significantly reduced over the intervention period and remained stable after (p < 0.01). Patients' quality of life increased over the 3-month intervention (p = 0.16) and significantly decreased thereafter. Caregivers' burden and informal care significantly decreased over the 3-month intervention and remained stable thereafter. Patients who benefited from OT with regard to function were less educated and had higher cognitive level.

CONCLUSION

OT may be an effective intervention to maintain cognition and functionality and to reduce psychiatric symptoms in dementia patients. Mild stages of dementia could gain more benefits from OT with regard to functional decline.

Evaluation of an integrated primary care-led dementia shared care program in Singapore: An effectiveness and cost-effectiveness study

AIM

With an aging Singapore population, there is an increasing demand for dementia care. The present study aimed to evaluate the effectiveness and cost-effectiveness of the Primary Care Dementia Clinic (PCDC) in comparison with the Memory Clinic (MC; hospital-based) and other polyclinics.

METHODS

A quasi-experimental design was implemented. Effectiveness of PCDC was assessed through caregiver satisfaction, quality of life (caregiver-rated) and adverse events rates. Quality-of-Life measures using the EuroQol 5 Dimension Questionnaire (EQ-5D) at baseline, 6 months and 12 months was assessed. Costs were calculated from a societal perspective. The incremental cost-effectiveness of the PCDC was compared with MC and other polyclinics.

RESULTS

The present study showed that quality of life and the rate of adverse events at 12 months were similar between the three groups. Caregiver satisfaction at 12 months was higher in the PCDC group when compared with other polyclinics. There were no observed differences in societal cost between the three groups. At 6-month follow up, direct medical costs for PCDC were significantly lower that of other polyclinics. At 12-month follow up, PCDC patients had higher Quality Adjusted Life Years (QALYs) compared with the MC group.

CONCLUSION

PCDC provided effective care, similar to care at MC and better than care at other polyclinics. Caregiver satisfaction was higher for the PCDC group, and PCDC patients had lower direct medical costs at 6-month follow up. Given these findings, adopting a PCDC model in other polyclinics in Singapore can be beneficial for optimal right siting of patients. Geriatr Gerontol Int 2018; 18: 479-486.

Home is where the future is: The BrightFocus Foundation consensus panel on dementia care

INTRODUCTION

A national consensus panel was convened to develop recommendations on future directions for home-based dementia care (HBDC).

METHODS

The panel summarized advantages and challenges of shifting to HBDC as the nexus of care and developed consensus-based recommendations.

RESULTS

The panel developed five core recommendations: (1) HBDC should be considered the nexus of new dementia models, from diagnosis to end of life in dementia; (2) new payment models are needed to support HBDC and reward integration of care; (3) a diverse new workforce that spans the care continuum should be prepared urgently; (4) new technologies to promote communication, monitoring/safety, and symptoms management must be tested, integrated, and deployed; and (5) targeted dissemination efforts for HBDC must be employed.

DISCUSSION

HBDC represents a promising paradigm shift to improve care for those living with dementia and their family caregivers: these recommendations provide a framework to chart a course forward for HBDC.

Which medical and social decision topics are important after early diagnosis of Alzheimer's Disease from the perspectives of people with Alzheimer's Disease, spouses and professionals?

BACKGROUND

The relevance of early decision making will rise with increasing availability of early detection of Alzheimer's disease (AD) using brain imaging or biomarkers.

RESULTS

Five people with mild AD, six relatives and 13 healthcare professionals with experience in the management of AD were interviewed in a qualitative study regarding medical and social decision topics that emerge after early diagnosis of Alzheimer's disease. Medical treatment, assistance in everyday life and legal issues emerged as the main decision topics after an early diagnosis of AD. People with AD mostly got in contact with the health and social care system through the initiative of their spouses. They were usually aware of their illness and most received antidementia drugs and/or behavioural interventions. Following diagnosis people with AD received support by their spouses. Healthcare professionals were aware of the risk of excessive demand on relatives due to supporting their family member with AD. In the opinion of healthcare professionals legal issues should be arranged in time before patients lose their decisional capacity. In addition, people with AD and spouses reported various coping strategies, in particular "carry on as normal" after diagnosis but mostly are reluctant to actively plan for future stages of the disease.

CONCLUSIONS

Due to the common desire to "carry on as usual" after a diagnosis of AD, many people with AD and spouses may miss the opportunity to discuss and decide on important medical and social topics. A structured approach e.g. a decision aid might support people with AD and spouses in their decision making process and thereby preserve persons' with AD autonomy before they lose the capacity in decision-making.

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

OBJECTIVE

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

METHOD

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

RESULTS

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

CONCLUSION

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

The effects of an integrated care intervention for the frail elderly on informal caregivers: a quasi-experimental study

BACKGROUND

This study explored the effects of an integrated care model aimed at the frail elderly on the perceived health, objective burden, subjective burden and quality of life of informal caregivers.

METHODS

A quasi-experimental design with before/after measurement (with questionnaires) and a control group was used. The analysis encompassed within and between groups analyses and regression analyses with baseline measurements, control variables (gender, age, co-residence with care receiver, income, education, having a life partner, employment and the duration of caregiving) and the intervention as independent variables.

RESULTS

The intervention significantly contributed to the reduction of subjective burden and significantly contributed to the increased likelihood that informal caregivers assumed household tasks. No effects were observed on perceived, health, time investment and quality of life.

CONCLUSIONS

This study implies that integrated care models aimed at the frail elderly can benefit informal caregivers and that such interventions can be implemented without demanding additional time investments from informal caregivers. Recommendations for future interventions and research are provided.

TRIAL REGISTRATION

Current Controlled Trials http://ISRCTN05748494. Registration date: 14/03/2013.

A multidimensional home-based care coordination intervention for elders with memory disorders: the maximizing independence at home (MIND) pilot randomized trial

OBJECTIVES

To assess whether a dementia care coordination intervention delays time to transition from home and reduces unmet needs in elders with memory disorders.

DESIGN

18-month randomized controlled trial of 303 community-living elders.

SETTING

28 postal code areas of Baltimore, MD.

PARTICIPANTS

Age 70+ years, with a cognitive disorder, community-living, English-speaking, and having a study partner available.

INTERVENTION

18-month care coordination intervention to systematically identify and address dementia-related care needs through individualized care planning; referral and linkage to services; provision of dementia education and skill-building strategies; and care monitoring by an interdisciplinary team.

MEASUREMENTS

Primary outcomes were time to transfer from home and total percent of unmet care needs at 18 months.

RESULTS

Intervention participants had a significant delay in time to all-cause transition from home and the adjusted hazard of leaving the home was decreased by 37% (Hazard ratio: 0.63, 95% Confidence Interval: 0.42-0.94) compared with control participants. Although there was no significant group difference in reduction of total percent of unmet needs from baseline to 18 months, the intervention group had significant reductions in the proportion of unmet needs in safety and legal/advance care domains relative to controls. Intervention participants had a significant improvement in self-reported quality of life (QOL) relative to control participants. No group differences were found in proxy-rated QOL, neuropsychiatric symptoms, or depression.

CONCLUSIONS

A home-based dementia care coordination intervention delivered by non-clinical community workers trained and overseen by geriatric clinicians led to delays in transition from home, reduced unmet needs, and improved self-reported QOL.

Predictive factors for the objective burden of informal care in people with dementia: a systematic review

BACKGROUND

Informal care plays a substantial role in the provision of total care in dementia. Several reviews have been published on the predictive factors of subjective burden; however, such a review lacks information on objective burden, which refers to the amount and/or costs of informal care.

OBJECTIVES

The objectives of this study were to (1) give an overview of the predictive factors that are associated with the objective burden of informal care; (2) discuss whether these factors are similar to the predictive factors of subjective burden; and (3) examine whether they are modifiable.

DESIGN

The literature in a number of international databases was systematically searched. Methodological quality and level of certainty were assessed.

RESULTS

Ten studies were identified as relevant for the purpose of this review, describing a total of 39 predictive factors. Three factors (behavioral problems and impairments regarding daily functioning and cognition) were considered to be predictors of objective burden. Three factors were not related; 12 were potential predictors; and the results of the remaining 22 factors were inconclusive.

CONCLUSIONS

Many factors were found to be (potential) predictors of objective burden, reflecting its complex nature. Objective and subjective burdens are 2 different relevant aspects of informal care. Interventions aimed at countering behavioral problems and impairments regarding daily functioning could reduce objective burden.

A review of barriers and enablers to diagnosis and management of persons with dementia in primary care

Background

With the rise in the prevalence of dementia disorders and the growing critical impact of dementia on health-care resources, the provision of dementia care has increasingly come under scrutiny, with primary care physicians (PCP) being at the centre of such attention.

Purpose

To critically examine barriers and enablers to timely diagnosis and optimal management of community living persons with dementia (PWD) in primary care.

Methods

An interpretive scoping review was used to synthesize and analyze an extensive body of heterogeneous Western literature published over the past decade.

Results

The current primary care systems in many Western countries, including Canada, face many challenges in providing responsive, comprehensive, safe, and cost-effective dementia care. This paper has identified a multitude of highly inter-related obstacles to optimal primary dementia care, including challenges related to: a) the complex biomedical, psychosocial, and ethical nature of the condition; b) the gaps in knowledge, skills, attitudes, and resources of PWD/caregivers and their primary care providers; and c) the broader systemic and structural barriers negatively affecting the context of dementia care.

Conclusions

Further progress will require a coordinated campaign and significantly increased levels of commitment and effort, which should be ideally orchestrated by national dementia strategies focusing on the barriers and enablers identified in this paper.

Undiagnosed illness and neuropsychiatric behaviors in community residing older adults with dementia

The aim of this retrospective analysis was to examine prevalence of undiagnosed acute illness and characteristics including neuropsychiatric symptoms associated with illness in community residing older adults with Alzheimer disease or related disorders. Subjects included 265 community residing older adults with dementia who participated in 1 of 2 interventions being tested in randomized clinical trials. Measures included a brief nursing assessment and laboratory evaluations including complete blood count, blood chemistry (Chem 7), and thyroid function tests of serum samples and culture and sensitivity tests of urine samples. Undiagnosed illness was identified according to currently published criteria. Neuropsychiatric behaviors were assessed using 21 behaviors derived from standard measures. Thirty-six percent (N=96) of patients had clinical findings indicative of undetected illness. Conditions most prevalent were bacteriuria (15%), followed by hyperglycemia (6%) and anemia (5%). The behavior most often demonstrated among those with detected illness was resisting or refusing care (66% vs. 47% for those without detected illness). Individuals with detected illness had significantly lower functional status scores [3.8 vs. 4.4, t(275)=7.01, P=0.01], lower cognitive status scores [10.5 vs. 14.4, t(275)=12.1, P<0.01], and were more likely to be prescribed psychotropic medications for behavior (41% vs. 26%, χ=3.67, P<0.05) than those without illness. Findings suggest that challenges of diagnosing acute illness with atypical presentation must be addressed to promote quality of care and the specialized needs for this vulnerable population.

[Perception, attitudes and needs of Primary Care professionals as regards the patient with dementia]

OBJECTIVE

To find out the perception, attitudes and needs expressed by primary care professionals in the Girona (Spain) health area as regards the diagnosis and monitoring of patients with cognitive disorders.

DESIGN

Cross sectional study conducted in 26 primary healthcare areas (ABS) in Girona.

SETTING

Primary healthcare areas (ABS) in Girona.

PARTICIPANTS

Physicians and primary nursing care (PNC). MAIN MEASURAMENTS: Self-administered questionnaire by the professionals in the centres. In the context of regular meetings of the teams.

RESULTS

A total 218 practitioners from 19 ABS (73% of total) responded to the questionnaire (108 physicians and 110 primary nursing care-PNC-). Almost all (98.6%) of participants thought they needed training in dementia, but 49.1% of physicians and 74.5% of PNC mentioned never having any specific training or not in the last 5 years. A total of 88.7% of doctors do not make a diagnosis of dementia on a regular basis, and only in 25.5% of cases do they make one in the mild stages of dementia. The main barriers reported by physicians in the diagnosis of dementia were the lack of confidence in diagnosis (32.6%) and lack of consultation time (31.4%). The great majority (87%) of physicians mentioned difficulties in monitoring and control of these patients.

CONCLUSIONS

This study provides useful information for those involved in the care of dementia. It identifies priority training issues, and barriers and difficulties in the diagnosis, treatment and monitoring of these patients in the field of primary care.

Care plans for people with Alzheimer's disease

Intuitively a good idea, but hard to prove they are effective in practice