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Samus QM, Black BS, Reuland M, Leoutsakos JMS, Pizzi L, Frick KD, Roth DL, Gitlin LN, Lyketsos CG, Johnston D. MIND at Home-Streamlined: Study protocol for a randomized trial of home-based care coordination for persons with dementia and their caregivers. Contemp Clin Trials 2018; 71:103-112. [PMID: 29783091 PMCID: PMC6415306 DOI: 10.1016/j.cct.2018.05.009] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2018] [Revised: 05/08/2018] [Accepted: 05/17/2018] [Indexed: 11/22/2022]
Abstract
BACKGROUND Dementia is associated with high health care costs, premature long-term care (LTC) placement, medical complications, reduced quality of life, and caregiver burden. Most health care providers and systems are not yet organized or equipped to provide comprehensive long-term care management for dementia, although a range of effective symptoms and supportive care approaches exist. The Maximizing Independence at Home-Streamlined (MIND-S) is a promising model of home-based dementia care coordination designed to efficiently improve person-centered outcomes, while reducing care costs. This report describes the rationale and design of an NIA-funded randomized controlled trial to test the impact of MIND-S on time to LTC placement, person with dementia outcomes (unmet needs, behavior, quality of life), family caregiver outcomes (unmet needs, burden), and cost offset at 18 (primary end point) and 24 months, compared to an augmented usual care group. METHODS This is a 24-month, parallel group, randomized trial evaluating MIND-S in a cohort of 304 community-living persons with dementia and their family caregivers in Maryland. MIND-S dyads receive 18 months of care coordination by an interdisciplinary team comprised of trained non-clinical community workers (e.g. Memory Care Coordinators), a registered nurse, and a geriatric psychiatrist. Intervention components include in-home dementia-related needs assessments; individualized care planning; implementation of standardized evidence-based care strategy protocols; and ongoing monitoring and reassessment. Outcomes are assessed by blinded evaluators at baseline, 4.5, 9, 13.5, 18, and 24 months. DISCUSSION Trial results will provide rigorous data to inform innovations in effective system-level approaches to dementia care.
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Affiliation(s)
| | | | | | | | | | - Kevin D Frick
- Carey Business School, Johns Hopkins University, USA
| | - David L Roth
- School of Medicine, Johns Hopkins University, USA
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Samus QM, Davis K, Willink A, Black BS, Reuland M, Leoutsakos J, Roth DL, Wolff J, Gitlin LN, Lyketsos CG, Johnston D. Comprehensive home-based care coordination for vulnerable elders with dementia: Maximizing Independence at Home-Plus-Study protocol. Int J Care Coord 2017; 20:123-134. [PMID: 29607051 PMCID: PMC5870897 DOI: 10.1177/2053434517744071] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
INTRODUCTION Despite availability of effective care strategies for dementia, most health care systems are not yet organized or equipped to provide comprehensive family-centered dementia care management. Maximizing Independence at Home-Plus is a promising new model of dementia care coordination being tested in the U.S. through a Health Care Innovation Award funded by the Centers for Medicare and Medicaid Services that may serve as a model to address these delivery gaps, improve outcomes, and lower costs. This report provides an overview of the Health Care Innovation Award aims, study design, and methodology. METHODS This is a prospective, quasi-experimental intervention study of 342 community-living Medicare-Medicaid dual eligibles and Medicare-only beneficiaries with dementia in Maryland. Primary analyses will assess the impact of Maximizing Independence at Home-Plus on risk of nursing home long-term care placement, hospitalization, and health care expenditures (Medicare, Medicaid) at 12, 18 (primary end point), and 24 months, compared to a propensity-matched comparison group. DISCUSSION The goals of the Maximizing Independence at Home-Plus model are to improve care coordination, ability to remain at home, and life quality for participants and caregivers, while reducing total costs of care for this vulnerable population. This Health Care Innovation Award project will provide timely information on the impact of Maximizing Independence at Home-Plus care coordination model on a variety of outcomes including effects on Medicaid and Medicare expenditures and service utilization. Participant characteristic data, cost savings, and program delivery costs will be analyzed to develop a risk-adjusted payment model to encourage sustainability and facilitate spread.
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Affiliation(s)
| | - Karen Davis
- Johns Hopkins University Bloomberg School of Public Health, USA
| | - Amber Willink
- Johns Hopkins University Bloomberg School of Public Health, USA
| | | | | | | | - David L Roth
- Johns Hopkins University School of Medicine, USA
| | - Jennifer Wolff
- Johns Hopkins University Bloomberg School of Public Health, USA
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Amjad H, Wong SK, Roth DL, Huang J, Willink A, Black BS, Johnston D, Rabins PV, Gitlin LN, Lyketsos CG, Samus QM. Health Services Utilization in Older Adults with Dementia Receiving Care Coordination: The MIND at Home Trial. Health Serv Res 2017; 53:556-579. [PMID: 28083879 DOI: 10.1111/1475-6773.12647] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
OBJECTIVE To investigate effects of a novel dementia care coordination program on health services utilization. DATA SOURCES/STUDY SETTING A total of 303 community-dwelling adults aged ≥70 with a cognitive disorder in Baltimore, Maryland (2008-2011). STUDY DESIGN Single-blind RCT evaluating efficacy of an 18-month care coordination intervention delivered through community-based nonclinical care coordinators, supported by an interdisciplinary clinical team. DATA COLLECTION/EXTRACTION METHODS Study partners reported acute care/inpatient, outpatient, and home- and community-based service utilization at baseline, 9, and 18 months. PRINCIPAL FINDINGS From baseline to 18 months, there were no significant group differences in acute care/inpatient or total outpatient services use, although intervention participants had significantly increased outpatient dementia/mental health visits from 9 to 18 months (p = .04) relative to controls. Home and community-based support service use significantly increased from baseline to 18 months in the intervention compared to control (p = .005). CONCLUSIONS While this dementia care coordination program did not impact acute care/inpatient services utilization, it increased use of dementia-related outpatient medical care and nonmedical supportive community services, a combination that may have helped participants remain at home longer. Future care model modifications that emphasize delirium, falls prevention, and behavior management may be needed to influence inpatient service use.
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Affiliation(s)
- Halima Amjad
- Division of Geriatric Medicine and Gerontology, Johns Hopkins University School of Medicine, Baltimore, MD
| | | | - David L Roth
- Division of Geriatric Medicine and Gerontology, Johns Hopkins University School of Medicine, Baltimore, MD.,Center on Aging and Health, Johns Hopkins University, Baltimore, MD
| | - Jin Huang
- Center on Aging and Health, Johns Hopkins University, Baltimore, MD
| | - Amber Willink
- Department of Health Policy and Management, Johns Hopkins University School of Public Health, Baltimore, MD
| | - Betty S Black
- Division of Geriatric Psychiatry and Neuropsychiatry, Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Deirdre Johnston
- Division of Geriatric Psychiatry and Neuropsychiatry, Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Peter V Rabins
- Division of Geriatric Psychiatry and Neuropsychiatry, Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Laura N Gitlin
- Division of Geriatric Psychiatry and Neuropsychiatry, Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, MD.,Department of Community Public Health Nursing, School of Nursing, The Johns Hopkins University, Baltimore, MD
| | - Constantine G Lyketsos
- Division of Geriatric Psychiatry and Neuropsychiatry, Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Quincy M Samus
- Division of Geriatric Psychiatry and Neuropsychiatry, Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, MD
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Black BS, Taylor HA, Rabins PV, Karlawish J. Study partners perform essential tasks in dementia research and can experience burdens and benefits in this role. Dementia (London) 2016; 17:1471301216648796. [PMID: 27179001 PMCID: PMC5107353 DOI: 10.1177/1471301216648796] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Most studies that enroll individuals with dementia require a study partner for each participant. Study partners-usually family members-perform several key roles: accompanying the participant to visits, providing information about the participant, and assisting with procedures such as taking medication. Little is known, however, about their experiences when performing these roles. Dementia researchers and institutional review boards need to know these experiences because the study partner role is one key factor in a study's success. This prospective qualitative study, using up to three semi-structured interviews with 62 study partners involved in a range of dementia studies, documented their subjective experiences. Content analysis demonstrates that study partners perform a range of tasks-often within the context of being a caregiver-that enable cognitively impaired individuals to participate in dementia research. These tasks present study partners with unique burdens and benefits, some of which dementia researchers and institutional review boards can address.
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Affiliation(s)
- Betty S Black
- Johns Hopkins University School of Medicine, Baltimore, MD, USA; Johns Hopkins Berman Institute of Bioethics, Baltimore, MD, USA; Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, USA
| | - Holly A Taylor
- Johns Hopkins Berman Institute of Bioethics, Baltimore, MD, USA; Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, USA
| | - Peter V Rabins
- Johns Hopkins University School of Medicine, Baltimore, MD, USA; Johns Hopkins Berman Institute of Bioethics, Baltimore, MD, USA; Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, USA
| | - Jason Karlawish
- University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
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Samus QM, Amjad H, Johnston D, Black BS, Bartels SJ, Lyketsos CG. A Multipronged, Adaptive Approach for the Recruitment of Diverse Community-Residing Elders with Memory Impairment: The MIND at Home Experience. Am J Geriatr Psychiatry 2015; 23:698-708. [PMID: 25771267 PMCID: PMC5226267 DOI: 10.1016/j.jagp.2015.01.005] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2014] [Revised: 01/21/2015] [Accepted: 01/27/2015] [Indexed: 10/24/2022]
Abstract
OBJECTIVE To provide a critical review of a multipronged recruitment approach used to identify, recruit, and enroll a diverse community-based sample of persons with memory disorders into an 18-month randomized, controlled dementia care coordination trial. METHODS Descriptive analysis of a recruitment approach comprised five strategies: community liaison ("gatekeepers") method, letters sent from trusted community organizations, display and distribution of study materials in the community, research registries, and general community outreach and engagement activities. Participants were 55 community organizations and 63 staff of community organizations in Baltimore, Maryland. Participant referral sources, eligibility, enrollment status, demographics, and loss to follow-up were tracked in a relational access database. RESULTS In total, 1,275 referrals were received and 303 socioeconomically, cognitively, and racially diverse community-dwelling persons with cognitive disorders were enrolled. Most referrals came from letters sent from community organizations directly to clients on the study's behalf (39%) and referrals from community liaison organizations (29%). African American/black enrollees were most likely to come from community liaison organizations. CONCLUSION A multipronged, adaptive approach led to the successful recruitment of diverse community-residing elders with memory impairment for an intervention trial. Key factors for success included using a range of evidence-supported outreach strategies, forming key strategic community partnerships, seeking regular stakeholder input through all research phases, and obtaining "buy-in" from community stakeholders by aligning study objectives with perceived unmet community needs.
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Affiliation(s)
- Quincy M Samus
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins Bayview, School of Medicine, The Johns Hopkins University, Baltimore, MD.
| | - Halima Amjad
- Department of Gerontology and Geriatric Medicine, Johns Hopkins Bayview, School of Medicine, The Johns Hopkins University, Baltimore, MD
| | - Deirdre Johnston
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins Bayview, School of Medicine, The Johns Hopkins University, Baltimore, MD
| | - Betty S Black
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins Bayview, School of Medicine, The Johns Hopkins University, Baltimore, MD
| | - Stephen J Bartels
- Dartmouth Centers for Health and Aging, Community & Family Medicine, The Dartmouth Medical School, Lebanon, NH
| | - Constantine G Lyketsos
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins Bayview, School of Medicine, The Johns Hopkins University, Baltimore, MD
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Tanner JA, Black BS, Johnston D, Hess E, Leoutsakos JM, Gitlin LN, Rabins PV, Lyketsos C, Samus QM. A randomized controlled trial of a community-based dementia care coordination intervention: effects of MIND at Home on caregiver outcomes. Am J Geriatr Psychiatry 2015; 23:391-402. [PMID: 25260557 PMCID: PMC4355038 DOI: 10.1016/j.jagp.2014.08.002] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2014] [Revised: 07/23/2014] [Accepted: 08/06/2014] [Indexed: 10/24/2022]
Abstract
OBJECTIVE To assess whether MIND at Home, a community-based, multicomponent, care coordination intervention, reduces unmet caregiving needs and burden in informal caregivers of persons with memory disorders. METHODS An 18-month randomized controlled trial of 289 community-living care recipient (CR)-caregiver (informal caregivers, i.e., unpaid individuals who regularly assisted the CR) dyads from 28 postal code areas of Baltimore, Maryland was conducted. All dyads and the CR's primary care physician received the written needs assessment results and intervention recommendations. Intervention dyads then received an 18-month care coordination intervention delivered by nonclinical community workers to address unmet care needs through individualized care planning, referral and linkage to dementia services, provision of caregiver dementia education and skill-building strategies, and care progress monitoring by an interdisciplinary team. Primary outcome was total percent of unmet caregiver needs at 18 months. Secondary outcomes included objective and subjective caregiver burden measures, quality of life (QOL), and depression. RESULTS Total percent of unmet caregiver needs declined in both groups from baseline to 18 months, with no statistically significant between-group difference. No significant group differences occurred in most caregiver burden measures, depression, or QOL. There was a potentially clinically relevant reduction in self-reported number of hours caregivers spent with the CR for MIND participants compared with control subjects. CONCLUSION No statistically significant impacts on caregiver outcomes were found after multiple comparison adjustments. However, MIND at Home appeared to have had a modest and clinically meaningful impact on informal caregiver time spent with CRs.
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Affiliation(s)
| | - Betty S Black
- Department of Psychiatry and Behavioral Sciences, School of Medicine, The Johns Hopkins University, Baltimore, MD
| | - Deirdre Johnston
- Department of Psychiatry and Behavioral Sciences, School of Medicine, The Johns Hopkins University, Baltimore, MD
| | - Edward Hess
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins Bayview, School of Medicine, The Johns Hopkins University, Baltimore, MD
| | - Jeannie-Marie Leoutsakos
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins Bayview, School of Medicine, The Johns Hopkins University, Baltimore, MD
| | - Laura N Gitlin
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins Bayview, School of Medicine, The Johns Hopkins University, Baltimore, MD, Department of Community Public Health Nursing, School of Nursing, The Johns Hopkins University, Baltimore, MD
| | - Peter V Rabins
- Department of Psychiatry and Behavioral Sciences, School of Medicine, The Johns Hopkins University, Baltimore, MD
| | - Constantine Lyketsos
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins Bayview, School of Medicine, The Johns Hopkins University, Baltimore, MD
| | - Quincy M Samus
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins Bayview, The Johns Hopkins University, Baltimore, MD.
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Black BS, Johnston D, Rabins PV, Morrison A, Lyketsos C, Samus QM. Unmet needs of community-residing persons with dementia and their informal caregivers: findings from the maximizing independence at home study. J Am Geriatr Soc 2014; 61:2087-2095. [PMID: 24479141 DOI: 10.1111/jgs.12549] [Citation(s) in RCA: 199] [Impact Index Per Article: 19.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
OBJECTIVES To determine the prevalence and correlates of unmet needs in a sample of community-residing persons with dementia (PWD) and their informal caregivers. DESIGN Analysis of cross-sectional, baseline participant characteristics before randomization in a care coordination intervention trial. SETTING Baltimore, Maryland. PARTICIPANTS Community-residing PWD (n=254) and their informal caregivers (n=246). MEASUREMENTS In-home assessments of dementia-related needs based on the Johns Hopkins Dementia Care Needs Assessment. Bivariate and multivariate regression analyses were conducted to identify demographic, socioeconomic, clinical, functional, and quality-of-life correlates of unmet needs. RESULTS The mean number of unmet needs was 7.7±4.8 in PWD and 4.6±2.3 in caregivers, with almost all PWD (99%) and caregivers (97%) having one or more unmet needs. Unmet needs in PWD were significantly greater in those with higher cognitive function. Ninety percent of PWD had unmet safety needs, more than half had unmet needs for meaningful activities, and almost one-third had not received a prior evaluation or diagnosis. Higher unmet needs in PWD was significantly associated with nonwhite race, lower income, less impairment in activities of daily living, and more symptoms of depression. For caregivers, more than 85% had unmet needs for resource referrals and caregiver education. Higher unmet caregiver needs was significantly associated with nonwhite race, less education, and more symptoms of depression. CONCLUSION Many community-residing PWD and their caregivers have unmet dementia-related needs for care, services, and support. Providers should be aware that unmet needs may be higher in minority and low-income community residents, caregivers with lower education, and individuals with early-stage dementia. Identifying and treating symptoms of depression in PWD and caregivers may enable them to address their other unmet needs.
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Affiliation(s)
- Betty S Black
- Department of Psychiatry and Behavioral Sciences, School of Medicine, Johns Hopkins University, Baltimore, Maryland
| | - Deirdre Johnston
- Department of Psychiatry and Behavioral Sciences, School of Medicine, Johns Hopkins University, Baltimore, Maryland
| | - Peter V Rabins
- Department of Psychiatry and Behavioral Sciences, School of Medicine, Johns Hopkins University, Baltimore, Maryland
| | - Ann Morrison
- Morrison and Associates, LLC, Baltimore, Maryland
| | - Constantine Lyketsos
- Department of Psychiatry and Behavioral Sciences, School of Medicine, Johns Hopkins University, Baltimore, Maryland.,Johns Hopkins Bayview Medical Center, Baltimore, Maryland
| | - Quincy M Samus
- Department of Psychiatry and Behavioral Sciences, School of Medicine, Johns Hopkins University, Baltimore, Maryland.,Johns Hopkins Bayview Medical Center, Baltimore, Maryland
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Rastogi P, Khushalani S, Dhawan S, Goga J, Hemanth N, Kosi R, Sharma RK, Black BS, Jayaram G, Rao V. Understanding clinician perception of common presentations in South Asians seeking mental health treatment and determining barriers and facilitators to treatment. Asian J Psychiatr 2014; 7:15-21. [PMID: 24524704 DOI: 10.1016/j.ajp.2013.09.005] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2013] [Revised: 09/13/2013] [Accepted: 09/13/2013] [Indexed: 10/26/2022]
Abstract
BACKGROUND Little is known about the presentation of mental health symptoms among South Asians living in the US. OBJECTIVE To explore mental health symptom presentation in South Asians in the US and to identify facilitators and barriers to treatment. DESIGN Focus group study. PARTICIPANTS Four focus groups were conducted with 7-8 participants in each group. All participants (N = 29) were clinicians who had been involved in the care of South Asian patients with emotional problems and/or mental illness in the US. APPROACH Qualitative content analysis. RESULTS Key themes identified included: generational differences in symptom presentation, stress was the most common symptom for younger South Asians (<40 years of age), while major mental illnesses such as severe depression, psychosis and anxiety disorder were the primary symptoms for older South Asians (>40 years of age). Substance abuse and verbal/physical/sexual abuse were not uncommon but were often not reported spontaneously. Stigma and denial of mental illness were identified as major barriers to treatment. Facilitators for treatment included use of a medical model and conducting systematic but patient-centered evaluations. CONCLUSIONS South Asians living in the US present with a variety of mental health symptoms ranging from stress associated with acculturation to major mental illnesses. Facilitating the evaluation and treatment of South Asians with mental illness requires sensitivity to cultural issues and use of creative solutions to overcome barriers to treatment.
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Affiliation(s)
- Pramit Rastogi
- Maryland/DC Chapter of the IndoAmerican Psychiatric Association, United States; Johns Hopkins University, School of Medicine, United States.
| | - Sunil Khushalani
- Maryland/DC Chapter of the IndoAmerican Psychiatric Association, United States; Sheppard Pratt Hospital, University of Maryland, United States
| | - Swaran Dhawan
- Maryland/DC Chapter of the IndoAmerican Psychiatric Association, United States; Counselors Helping (South) Asian Indians, Inc. (CHAI), United States
| | - Joshana Goga
- Maryland/DC Chapter of the IndoAmerican Psychiatric Association, United States; Sheppard Pratt Hospital, University of Maryland, United States
| | - Naveena Hemanth
- Maryland/DC Chapter of the IndoAmerican Psychiatric Association, United States
| | - Razia Kosi
- Maryland/DC Chapter of the IndoAmerican Psychiatric Association, United States; Counselors Helping (South) Asian Indians, Inc. (CHAI), United States
| | - Rashmi K Sharma
- Northwestern University, Feinberg School of Medicine, United States
| | - Betty S Black
- Johns Hopkins University, School of Medicine, United States
| | - Geetha Jayaram
- Maryland/DC Chapter of the IndoAmerican Psychiatric Association, United States; Johns Hopkins University, School of Medicine, United States
| | - Vani Rao
- Maryland/DC Chapter of the IndoAmerican Psychiatric Association, United States; Johns Hopkins University, School of Medicine, United States
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Black BS, Wechsler M, Fogarty L. Decision making for participation in dementia research. Am J Geriatr Psychiatry 2013; 21:355-63. [PMID: 23498382 PMCID: PMC3381948 DOI: 10.1016/j.jagp.2012.11.009] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2011] [Revised: 08/11/2011] [Accepted: 10/12/2011] [Indexed: 11/29/2022]
Abstract
OBJECTIVES This study examined the decision-making process used by individuals asked to participate in dementia research and their opinions on how future proxy research decisions would or should be made, including participants' preferred ethical standards for decision making. DESIGN Cross-sectional qualitative methods. SETTING University research institutions. PARTICIPANTS Informants were 39 of 46 individuals with cognitive impairment (i.e., subjects) who were asked to join one of six dementia studies and 46 study partners or surrogate decision makers. MEASUREMENTS Semistructured individual interviews were audio recorded and transcribed for content analysis. RESULTS Within dyads, subjects and surrogates often differed in their perspectives on how decisions were made regarding whether to join a study, and no single method was identified as a predominant approach. Although there was only fair agreement within dyads on who ultimately made the decision, subjects and surrogates most often said it was the subject. For future proxy research decisions, subjects and surrogates most often preferred the ethical standard of best interests and least often favored substituted judgment. However, many participants preferred a combination of best interests and substituted judgment or a more complex approach that also considers the interests of others. CONCLUSIONS Individuals with mild to moderate cognitive impairment can and do engage to some extent in the decision-making process for dementia research and can discuss their opinions on how they would want such decisions made for them in the future. These findings support the recommended approach for obtaining proxy consent and subject assent if the individual lacks consent capacity.
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Affiliation(s)
- Betty S. Black
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins School of Medicine,Johns Hopkins Berman Institute of Bioethics
| | - Malory Wechsler
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins School of Medicine
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Tanner JA, Black BS, Johnston D, Hess E, Rabins PV, Lyketsos C, Samus Q. Effectiveness of a Multicomponent Care Coordination Intervention on Dementia Caregivers in the Community - a Randomized Control Trial. The American Journal of Geriatric Psychiatry 2013. [DOI: 10.1016/j.jagp.2012.12.129] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Rabins PV, Schwartz S, Black BS, Corcoran C, Fauth E, Mielke M, Christensen J, Lyketsos C, Tschanz J. Predictors of progression to severe Alzheimer's disease in an incidence sample. Alzheimers Dement 2012; 9:204-7. [PMID: 23123228 DOI: 10.1016/j.jalz.2012.01.003] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2011] [Revised: 12/21/2011] [Accepted: 01/13/2012] [Indexed: 11/16/2022]
Abstract
BACKGROUND Little is known about factors influencing time to severe Alzheimer's disease (AD). METHODS Incident cases of AD in the cache county memory study were identified. Severe AD was defined as mini-mental state examination score of ≤10 or Clinical Dementia Rating Scale score of 3; cases with either mini-mental state examination score of ≥16 or clinical dementia rating <2 were not categorized as severe AD. Kaplan-Meier, log-rank tests, and Cox analyses were used to identify demographic, clinical, and genetic correlates of time to progression to severe AD. RESULTS Sixty-eight of 335 cases of incident AD developed severe dementia. In bivariate analyses, female gender, less than high school education, at least one clinically significant Neuropsychiatric Inventory domain at baseline, and the youngest and oldest ages exhibited shorter time to severe AD. In competing risk analysis, subjects with mild or at least one clinically significant neuropsychiatric inventory domain score, and subjects with worse health were more likely to progress to severe dementia or death. CONCLUSIONS Demographic and clinical variables predict progression to severe AD. Further study should examine whether these relationships are causal or correlational.
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Affiliation(s)
- Peter V Rabins
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins School of Medicine, Baltimore, MD, USA.
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Abstract
Dementia is a leading cause of death in the United States. This article outlines the current understanding of advanced dementia and identifies research priorities for the next decade. Research over the past 25 years has largely focused on describing the experience of patients with advanced dementia. This work has delineated abundant opportunities for improvement, including greater recognition of advanced dementia as a terminal illness, better treatment of distressing symptoms, increased access to hospice and palliative care services, and less use of costly and aggressive treatments that may be of limited clinical benefit. Addressing those opportunities must be the overarching objective for the field in the coming decade. Priority areas include designing and testing interventions that promote high-quality, goal-directed care; health policy research to identify strategies that incentivize cost-effective and evidence-based care; implementation studies of promising interventions and policies; and further development of disease-specific outcome measures. There is great need and opportunity to improve outcomes, contain expenditures, reduce disparities, and better coordinate care for the millions of persons in the United States who have advanced dementia.
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Affiliation(s)
- Susan L Mitchell
- Hebrew SeniorLife, Institute for Aging Research, Boston, Massachusetts 02131, USA
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Abstract
Dementia is a leading cause of death in the United States. This article outlines the current understanding of advanced dementia and identifies research priorities for the next decade. Research over the past 25 years has largely focused on describing the experience of patients with advanced dementia. This work has delineated abundant opportunities for improvement, including greater recognition of advanced dementia as a terminal illness, better treatment of distressing symptoms, increased access to hospice and palliative care services, and less use of costly and aggressive treatments that may be of limited clinical benefit. Addressing those opportunities must be the overarching objective for the field in the coming decade. Priority areas include designing and testing interventions that promote high-quality, goal-directed care; health policy research to identify strategies that incentivize cost-effective and evidence-based care; implementation studies of promising interventions and policies; and further development of disease-specific outcome measures. There is great need and opportunity to improve outcomes, contain expenditures, reduce disparities, and better coordinate care for the millions of persons in the United States who have advanced dementia.
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Affiliation(s)
- Susan L Mitchell
- Hebrew SeniorLife, Institute for Aging Research, Boston, Massachusetts 02131, USA
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Lee HB, Richardson AK, Black BS, Shore AD, Kasper JD, Rabins PV. Race and cognitive decline among community-dwelling elders with mild cognitive impairment: findings from the Memory and Medical Care Study. Aging Ment Health 2012; 16:372-7. [PMID: 21999809 PMCID: PMC3302954 DOI: 10.1080/13607863.2011.609533] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
OBJECTIVE Previous studies have reported conflicting findings on the relationship between race and cognitive decline in elders with dementia. Few studies have examined the role of race in cognitive decline in mild cognitive impairment (MCI). We investigate the relationship between race and cognitive decline in participants with MCI in a community-based, longitudinal study of cognitively impaired elders. METHOD Based on a validated method utilizing a neuropsychiatric battery, 133 subjects [mean age: 78.7 years (SD = 6.5); female: 112 (76.7%); black: 59 (44.4%)] out of 512 participants in the Memory and Medical Care Study were diagnosed with MCI. The main outcome measure was the Telephone Interview for Cognitive Status (TICS) score over three years. Other baseline subject characteristics (demographics, health-related variables, behavioral, and psychiatric symptoms) were included in the analysis. RESULTS Overall, the three-year decline in mean TICS score was significantly higher among African Americans than non-African Americans [3.31 (SD: 7.5) versus 0.96 (SD: 3.0), t-value = 1.96, p-value = 0.05]. General estimating equation analyses revealed that African American race was associated with a faster rate of cognitive decline in all models. CONCLUSION The rate of cognitive decline in MCI appears to be faster in African Americans than non-African Americans in the community. Diagnosis of MCI among African American elders could lead to early interventions to prevent or delay cognitive decline in the future.
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Affiliation(s)
- Hochang B. Lee
- Department of Psychiatry & Behavioral Sciences, School of Medicine, Johns Hopkins University, Baltimore, Maryland,Department of Mental Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland
| | - Amanda K. Richardson
- Department of Health, Society & Behavior, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland
| | - Betty S. Black
- Department of Psychiatry & Behavioral Sciences, School of Medicine, Johns Hopkins University, Baltimore, Maryland,Department of Health, Society & Behavior, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland,Department of Health Policy and Management, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland
| | - Andrew D. Shore
- Department of Health Policy and Management, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland
| | - Judith D. Kasper
- Department of Health Policy and Management, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland
| | - Peter V. Rabins
- Department of Psychiatry & Behavioral Sciences, School of Medicine, Johns Hopkins University, Baltimore, Maryland,Department of Health Policy and Management, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland,Department of Mental Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland
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Black BS, Johnston D, Morrison A, Rabins PV, Lyketsos CG, Samus QM. Quality of life of community-residing persons with dementia based on self-rated and caregiver-rated measures. Qual Life Res 2011; 21:1379-89. [PMID: 22038392 DOI: 10.1007/s11136-011-0044-z] [Citation(s) in RCA: 66] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/07/2011] [Indexed: 11/26/2022]
Abstract
PURPOSE To identify correlates of self-rated and caregiver-rated quality of life (QOL) in community-residing persons with dementia (PWD) for intervention development. METHODS Cross-sectional data of 254 PWD and their caregivers participating in a clinical trial were derived from in-home assessments. Self-rated QOL was measured with the Quality of Life-Alzheimer Disease (QOL-AD) scale, and caregiver-rated QOL was measured using the QOL-AD and Alzheimer Disease-Related Quality of Life (ADRQL) scales. Multivariate modeling identified correlates of the PWD' QOL. RESULTS Self-rated QOL was related significantly to participant race, unmet needs, depression, and total medications. Caregiver-rated QOL-AD scores were significantly associated with participant function, unmet needs, depression, and health problems and with caregiver burden and self-rated health. Significant correlates of ADRQL scores included neuropsychiatric symptom severity, functional and cognitive impairment, and caregiver burden and depression. CONCLUSIONS Correlates of QOL in community-residing PWD depend on who rates the PWD's QOL and which measure is used. Addressing health problems, medication use, and dementia-related unmet needs, reducing functional dependency, and treating neuropsychiatric symptoms in PWD, while reducing caregiver burden and depression, may maximize QOL in those with dementia.
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Affiliation(s)
- Betty S Black
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins School of Medicine, 600 North Wolfe Street, Meyer Building 279, Baltimore, MD 21287, USA.
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Abstract
BACKGROUND Surrogates make all medical decisions for persons with advanced dementia. This study describes the types of medical decisions that surrogates faced prior to the person's death and their perceived difficulty and satisfaction with those decisions. METHODS Seventy-six surrogates of nursing home residents meeting hospice criteria for dementia were followed longitudinally and interviewed following the death of the person with dementia. RESULTS The most common decisions made were related to transfer to hospital, diagnostic testing, and placement of a feeding tube. Surrogates perceived decisions to not treat to be more difficult than decisions to treat. CONCLUSIONS Surrogates frequently are faced with making medical decisions for persons with advanced dementia near the end of life. Clinicians can help surrogates by acknowledging the difficulty of making decisions to not treat.
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Affiliation(s)
- Peter V Rabins
- The Johns Hopkins Hospital, 600 North Wolfe Street, Meyer 279, Baltimore, MD 21287
| | - Kathryn L Hicks
- Johns Hopkins School of Medicine - Psychiatry, Baltimore, Maryland
| | - Betty S Black
- Johns Hopkins School of Medicine, 600 N. Wolfe Street, Meyer 279, Baltimore, MD 21287
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Marquardt G, Johnston D, Black BS, Morrison A, Rosenblatt A, Lyketsos CG, Samus QM. A Descriptive Study of Home Modifications for People with Dementia and Barriers to Implementation. ACTA ACUST UNITED AC 2011; 25:258-273. [PMID: 21904419 DOI: 10.1080/02763893.2011.595612] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
This study describes home environmental features, safety issues, and health-related modifications in a community dwelling sample of 82 elderly people with dementia. Main barriers to the accessibility of the homes were steps, both inside and outside the house. The majority of the caregivers had made home modifications, which pertained mainly to physical limitations. Home modifications to support cognitive deficits were made to a lesser extent. The main barrier to the implementation of home modifications to accommodate the care recipient's memory loss was skepticism about their usefulness. Regarding the removal of physical barriers, financial constraints were most frequently mentioned.
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Affiliation(s)
- Gesine Marquardt
- Dresden University of Technology, Dresden, Germany and the Johns Hopkins University School of Medicine, Baltimore, MD
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Johnston D, Samus QM, Morrison A, Leoutsakos JS, Hicks K, Handel S, Rye R, Robbins B, Rabins PV, Lyketsos CG, Black BS. Identification of community-residing individuals with dementia and their unmet needs for care. Int J Geriatr Psychiatry 2011; 26:292-8. [PMID: 20658473 PMCID: PMC3039061 DOI: 10.1002/gps.2527] [Citation(s) in RCA: 51] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2009] [Accepted: 03/05/2010] [Indexed: 11/10/2022]
Abstract
BACKGROUND Innovative approaches to the widespread delivery of evidence-based dementia care are needed. The aims of this study were to determine whether a telephone screening method could efficiently identify individuals in the community in need of care for dementia and to develop a multidimensional needs assessment tool for identifying the type and frequency of unmet needs related to memory disorders in the home setting. METHODS This was a cross-sectional evaluation of 292 community-residing individuals aged 70 and older in Maryland. Participants were given a brief cognitive telephone screen. A subsample (n=43) received a comprehensive in-home assessment for dementia and dementia-related needs. Cognitive, functional, behavioral, and clinical factors were assessed. The Johns Hopkins Dementia Care Needs Assessment (JHDCNA) was used to identify unmet needs related to dementia. RESULTS Telephone screening for the sample took 350 h, and 27% screened positive for dementia. Virtually all participants with dementia who received an in-home assessment had at least one unmet need, with the most frequent unmet needs being for a dementia workup, general medical care, environmental safety, assistance with ADL impairments, and access to meaningful activities. Caregivers, when present, also had a number of unmet needs, with the most common being caregiver education about dementia, knowledge of community resources, and caregiver mental health care. CONCLUSIONS Effective and efficient means for identifying community-residing individuals with dementia are needed so that dementia care interventions can be provided to address unmet care needs of patients and their caregivers.
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Affiliation(s)
- D Johnston
- Division of Geriatric Psychiatry & Neuropsychiatry, The Johns Hopkins University School of Medicine, 550 North Broadway/Suite 308, Baltimore, Maryland, USA.
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Marquardt G, Johnston D, Black BS, Morrison A, Rosenblatt A, Lyketsos CG, Samus QM. Association of the spatial layout of the home and ADL abilities among older adults with dementia. Am J Alzheimers Dis Other Demen 2011; 26:51-7. [PMID: 21282278 PMCID: PMC3143576 DOI: 10.1177/1533317510387584] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
We investigated the relationship between architectural space syntax measures describing the spatial layout of a home and activities of daily living (ADL) among people with dementia. We visited the homes of 82 participants in a dementia care comparative effectiveness clinical trial and measured the space syntax variables intelligibility and convexity along with several clinical variables, including ADLs. In regression models, we estimated the cross-sectional association between space syntax measures and ADLs. Higher convexity was associated with worse performance of basic but not instrumental ADLs (adjusted β =19.2, P = .02). Intelligibility was not associated with ADLs. These results imply that enclosed rooms with a clearly legible meaning and function might be better memorized and associated with the spatial layout of the home resulting in better basic ADL performance. These results warrant further research on space syntax measures in the home environment of people with dementia, including longitudinal study, which we are pursuing.
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Abstract
OBJECTIVES To examine quality of life (QOL) in nursing home (NH) residents with advanced dementia and identify correlates of QOL near the end of life. DESIGN Cross-sectional data derived from NH records, interviews with residents' surrogate decision-makers, QOL ratings by NH caregivers, and assessment of residents' cognitive function. SETTING Three NHs in Maryland. PARTICIPANTS A cohort of NH residents with dementia (n=119) who were receiving hospice or palliative care or met hospice criteria for dementia and their surrogates. MEASUREMENTS QOL based on the proxy-rated Alzheimer' Disease-Related Quality of Life (ADRQL) scale administered to NH staff and validated against a single-item surrogate-rated measure of QOL, the Severe Impairment Rating Scale, to measure cognitive function and dichotomous indicators of neuropsychiatric symptoms (behavior problems, mood disorders, psychosis, delusions). RESULTS Total ADRQL scores, ranging from 12.4 to 95.1 out of 100, were normally distributed and positively correlated (P<.001) with surrogate-rated QOL. Multiple regression analysis of ADRQL scores showed that residents with higher cognitive function (P<.001, 95% confidence interval (CI)=0.97-1.65) and those receiving pain medication (P=.006, 95% CI=3.30-19.59) had higher QOL, whereas residents with behavior problems (P=.01, 95% CI=-11.60 to -1.30) had lower QOL. CONCLUSION The ADRQL is a valid indicator of QOL in NH residents with advanced dementia. QOL in this population may be improved near the end of life using appropriate assessment and treatment of pain and effective management of behavior problems.
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Affiliation(s)
| | - David M. Blass
- Johns Hopkins Medical Institutions; Baltimore, MD
- Abarbanel Mental Health Center; Bat Yam, Israel
- Johns Hopkins Berman Institute of Bioethics; Baltimore, MD
| | - Peter V. Rabins
- Johns Hopkins Medical Institutions; Baltimore, MD
- Johns Hopkins Berman Institute of Bioethics; Baltimore, MD
| | - Betty S. Black
- Johns Hopkins Medical Institutions; Baltimore, MD
- Johns Hopkins Berman Institute of Bioethics; Baltimore, MD
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Abstract
This analysis uses data from the Care of Nursing Home Residents with Advanced Dementia (CareAD) study to investigate which factors increase the risk of death in patients who are in the advanced stages of dementia. The hypothesis of this analysis was that specific illnesses with known high mortality would be associated with increased risk of death in the population of nursing home residents with advanced dementia, after controlling for demographic variables and disease-stage variables. Baseline data on 123 end-stage dementia nursing home residents were analyzed with a Cox proportional hazards regression. Of the comorbidities studied, pneumonia was the only illness significantly associated with shortened survival. This information can help health care professionals assist surrogate decision makers in making medical decisions regarding the treatment of comorbid medical illness in persons with advanced dementia.
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Rabins PV, Black BS. ETHICAL PERSPECTIVES IN NEUROLOGY. Continuum (Minneap Minn) 2010; 16:224-7. [DOI: 10.1212/01.con.0000368222.40201.2b] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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Abstract
OBJECTIVES Obtaining assent and respecting dissent are widely adopted safeguards when conducting dementia research involving individuals who lack consent capacity, but there is no consensus on how assent and dissent should be defined or what procedures should be used regarding them. Our objective was to provide recommendations on these issues based on the opinions of knowledgeable key informants. DESIGN Cross-sectional qualitative research. SETTING University research institutions. PARTICIPANTS Forty informants, including 1) nationally known experts on dementia and research ethics, 2) dementia researchers, and 3) dementia caregivers and advocates. MEASUREMENTS Semistructured individual and focus group interviews, audio recorded, and transcribed for content analysis. RESULTS Assent and dissent should be defined broadly and based on an assessment of how adults who lack consent capacity can express or indicate their preferences verbally, behaviorally, or emotionally. Assent requires the ability to indicate a meaningful choice and at least a minimal level of understanding. Assent should be required whenever an individual has the ability to assent, and dissent should be binding if it is unequivocal or sustained after an effort to relieve concerns and/or distress. Standards for seeking assent and respecting dissent should not be linked to the risks or potential benefits of a study. Lacking the ability to assent and/or dissent should not automatically preclude research participation. CONCLUSIONS Obtaining assent and respecting dissent from individuals who lack consent capacity for dementia research allows them to participate, to the extent possible, in the consent process. Assent and dissent are important independent ethical constructs.
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Affiliation(s)
- Betty S Black
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins Medical Institutions, Baltimore, MD, USA.
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Black BS, Fogarty LA, Phillips H, Finucane T, Loreck DJ, Baker A, Blass DM, Rabins PV. Surrogate decision makers' understanding of dementia patients' prior wishes for end-of-life care. J Aging Health 2009; 21:627-50. [PMID: 19269928 DOI: 10.1177/0898264309333316] [Citation(s) in RCA: 67] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVE This study examines how surrogate decision makers for dementia patients developed an understanding of patient preferences about end-of-life (EOL) care and patient wishes. METHODS Semistructured interviews were conducted with 34 surrogate decision makers for hospice-eligible nursing home patients with dementia. The data were content analyzed. RESULTS Most surrogates reported that patients had previously completed an advance directive (59%), discussed preferences for EOL care (56%), or done both (38%). Catalysts for and barriers to completing an advance directive or having EOL care discussions included factors that were both intrinsic and extrinsic to the patient. The most commonly reported wish for EOL care was to not be kept alive by "machines" or "extraordinary measures." DISCUSSION Health care providers may be able to assist patients and families by normalizing discussions of dying, encouraging advance care planning, helping them identify goals for EOL care, and providing information to support treatment decisions consistent with patients' wishes.
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Affiliation(s)
- Betty S Black
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, 600 North Wolfe Street, Meyer Building, Room 279, Baltimore, MD 21287, USA.
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Triplett P, Black BS, Phillips H, Richardson Fahrendorf S, Schwartz J, Angelino AF, Anderson D, Rabins PV. Content of advance directives for individuals with advanced dementia. J Aging Health 2008; 20:583-96. [PMID: 18625761 DOI: 10.1177/0898264308317822] [Citation(s) in RCA: 51] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVE To examine how people with end-stage dementia have conveyed their wishes for end-of-life care in advance directives. METHOD The documents of 123 residents of three Maryland nursing homes, all with end-stage dementia, were reviewed. RESULTS More years of education and White race were significantly associated with having an advance directive. With the exceptions of comfort care and pain treatment, advance directives were used primarily to restrict, not request, many forms of care at the end of life. Decisions about care for end-stage conditions such as Alzheimer's dementia are less often addressed in these documents than for terminal conditions and persistent vegetative state. DISCUSSION For advance directives to better reflect a person's wishes, discussions with individuals and families about advance directives should include a range of care issues in the settings of terminal illness, persistent vegetative state or end-stage illness. These documents should be reviewed periodically to make certain that they convey accurately the person's treatment preferences.
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Affiliation(s)
- Patrick Triplett
- Department of Psychiatry, Johns Hopkins University School of Medicine, Johns Hopkins Hospital, Meyer 279, 600 North Wolfe Street, Baltimore, MD 21287, USA.
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Abstract
Neuropsychiatric symptoms (NPS) are common in dementia, although little is known about their prevalence and treatment near the end of life. This study used a retrospective review of the medical records of 123 hospice-eligible nursing home residents with advanced dementia to investigate the prevalence of NPS and NPS-targeted pharmacological and non-pharmacological treatments. The most prevalent NPS were agitation or aggression (50.4%), depression (45.5%), and withdrawal/lethargy (43.1%). Of the 105 (85.4%) residents who exhibited one or more NPS, 90.5% were receiving at least one NPS-targeted treatment, yet 41.9% received no documented nonpharmacological NPS-targeted care. The majority of documented nonpharmacological care focused on safety and explanations or instructions given to residents. Given the high prevalence of comorbidities, associated risks for medication interactions or serious side effects, and potential low-risk benefits of psychobehavioral care, these findings raise concerns about how to best increase the provision and documentation of nonpharmacological care in advanced dementia.
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Affiliation(s)
- Karan S Kverno
- The Johns Hopkins University School of Nursing, Center for Nursing Research and Sponsored Projects, Baltimore, MD 21205, USA.
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27
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Kverno KS, Black BS, Blass DM, Geiger-Brown J, Rabins PV. Neuropsychiatric symptom patterns in hospice-eligible nursing home residents with advanced dementia. J Am Med Dir Assoc 2008; 9:509-15. [PMID: 18755425 PMCID: PMC2570193 DOI: 10.1016/j.jamda.2008.04.008] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2007] [Revised: 04/14/2008] [Accepted: 04/15/2008] [Indexed: 11/30/2022]
Abstract
OBJECTIVE The purpose of this study was to determine whether specific neuropsychiatric symptom patterns could be identified in a cohort of hospice-eligible nursing home residents with advanced dementia. METHODS Surrogate decision makers gave informed consent to enroll 123 residents from 3 nursing homes. All participating residents met criteria for hospice eligibility and were determined by direct examination at the time of study enrollment to have advanced dementia. Retrospective medical record review was used to collect data on residents' demographics, diagnoses, and the presence of any neuropsychiatric symptoms during the 6 months prior to study enrollment. Latent class analysis (LCA) was used to classify residents based on neuropsychiatric symptom patterns. RESULTS Overall, 85% of residents exhibited one or more neuropsychiatric symptoms. LCA revealed that these individuals could be classified into 3 groups: one with low symptom frequencies (36%) considered to be the normative class, one characterized by psychosis and agitation or aggression (23%), and a third characterized by withdrawal or lethargy (41%). CONCLUSIONS These results add to the growing understanding of neuropsychiatric symptom patterns in advanced dementia and have implications for more dimensional classification and treatment approaches.
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Affiliation(s)
- Karan S Kverno
- Johns Hopkins Medical Institutions Department of Psychiatry and Behavioral Sciences, Baltimore, MD, USA.
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Taylor HA, Black BS, Rabins PV. Deciding in the Best Interest of Clients with Dementia: The Experience of Public Guardians. The Journal of Clinical Ethics 2008. [DOI: 10.1086/jce200819203] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
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Blass DM, Black BS, Phillips H, Finucane T, Baker A, Loreck D, Rabins PV. Medication use in nursing home residents with advanced dementia. Int J Geriatr Psychiatry 2008; 23:490-6. [PMID: 17944007 DOI: 10.1002/gps.1921] [Citation(s) in RCA: 59] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
OBJECTIVE To describe medication usage in nursing home residents with advanced dementia, to identify how this usage changed as patients advanced towards death, and to identify correlates of increased medication usage. METHODS Prospective cohort study (CareAD) during which data on medication prescription were extracted from medical records at regular intervals using standardized extraction procedures. RESULTS Patients (n=125) were prescribed a mean of 14.6 medications during the 6 months prior to study enrollment. In a subgroup of patients who died during the study (n=88), as the time of death approached, the total number of medications prescribed did not vary but the types of medications prescribed did change, with an increase in palliative medications such as opiate analgesics and a decrease in other medication classes such as antibiotics, anti-dementia agents, cardiovascular agents, and psychotropic agents, among others. In linear regression analyses, total medication prescription at study entry was associated with study site, antibiotic treatment, presence of cardiovascular disease, and treatment of gastrointestinal or dermatological conditions. CONCLUSIONS Nursing home residents with advanced dementia are prescribed a large number of medications from numerous medication classes and prescribing patterns change over time. Further study is needed to determine the ideal approach to treating chronic medical problems at the end of life in this patient population.
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Affiliation(s)
- David M Blass
- Abarbanel Mental Health Center, affiliate of The Sackler School of Medicine, Tel Aviv, Israel.
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Maust DT, Blass DM, Black BS, Rabins PV. Treatment decisions regarding hospitalization and surgery for nursing home residents with advanced dementia: the CareAD Study. Int Psychogeriatr 2008; 20:406-18. [PMID: 17825116 DOI: 10.1017/s1041610207005807] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND Dementia differs from other terminal illnesses both in its slow progression and the fact that patients and family members often do not perceive it as a cause of death. Furthermore, because decisional incapacity is almost universal in patients with advanced dementia, decisions must be made by surrogates. However, little is known about the factors that influence how surrogates make decisions for persons with late-stage dementia. METHODS The setting was the first wave of a study of patients with advanced dementia in three Maryland nursing homes (The Care of Nursing Home Residents with Advanced Dementia Study). Of 125 consented participants, 123 residents and their surrogates provided adequate information and agreed to interviews and medical record reviews. Bivariate analysis and logistic regression models were used to explore whether variables related to demographics, illness, communication and surrogate background were associated with surrogate decisions to not provide aggressive treatments (i.e. hospitalization or surgery). RESULTS Treatment decisions regarding aggressive medical care had been made by 81% of surrogates over the preceding 6 months. In bivariate analysis the following factors were significantly associated with not providing aggressive care: resident and surrogate of white race, older surrogate age, worse resident medical illness, worse surrogate perception of resident quality of life, presence of a 'do not hospitalize' order (DNH), and more contact with nurses. In the multivariate analysis, resident white race and presence of a DNH were significant predictors of surrogate decisions to not provide aggressive treatments. Treatment decisions were not associated with surrogate relationship or religiosity. CONCLUSIONS Treatment decisions for individuals with advanced dementia are mostly strongly associated with the patient's race and presence of DNH and less so with changeable features of illness or environment.
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Affiliation(s)
- Donovan T Maust
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, U.S.A
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Taylor HA, Black BS, Rabins PV. Deciding in the best interest of clients with dementia: the experience of public guardians. J Clin Ethics 2008; 19:120-126. [PMID: 18767472] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/26/2023]
Abstract
We conducted an in-depth interview study of public guardians in three local jurisdictions in the state of Maryland to explore the decision-making process utilized by court-appointed public guardians making medical and EOL care decisions on behalf of their clients with dementia. Overall, public guardians appeared to make their decisions in the context of relevant ethical principles and relevant case law and state statute, and the basis upon which they made informed decisions was dependent on their training and experience. The stated goal of public guardians is to make decisions that they believe are in the best interest of their clients. In the case of a healthcare decision, their goal is to maximize quality of life; and in the case of an EOL care decision, their goal is to minimize pain and suffering. In general, public guardians gathered information in order to identify previous preferences of their now-incapacitated clients, so that they could develop a preference profile to assist both an initial decision on whether an individual ought to have a court-appointed public guardian, and with healthcare and EOL decisions once an appointment was made. When guardians were unable to develop a preference profile for a particular client, they relied on past decisions in similar situations. Healthcare and EOL decisions were most often triggered by a recommendation by the client's healthcare provider. Once a decision-point was identified, the public guardian considered the risks and benefits of the proposed intervention in light of the client's current condition. At times the guardians reviewed informational resources such as textbooks and the Internet. In addition, most guardians sought advice from a medical consultant who is available to all public guardians in Maryland. Some guardians sought the advice of this medical consultant only when faced with more complex decisions. Guardians challenged physicians' recommendations when they believed the physicians were recommending an intervention that was not in the best interest of the client--that is, they advocated against either overtreatment or undertreatment. Ultimately, guardians took particularly difficult issues to the court and obtained a judge's opinion.
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Affiliation(s)
- Holly A Taylor
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Berman Institute of Bioethics at Johns Hopkins University, Baltimore, Maryland, USA.
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Black BS, Brandt J, Rabins PV, Samus QM, Steele CD, Lyketsos CG, Rosenblatt A. Predictors of providing informed consent or assent for research participation in assisted living residents. Am J Geriatr Psychiatry 2008; 16:83-91. [PMID: 18165463 PMCID: PMC2709744 DOI: 10.1097/jgp.0b013e318157cabd] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES This study's goal was to identify factors associated with providing either informed consent or assent for research in individuals at high risk for cognitive impairment. DESIGN Cross-sectional baseline data were used to identify predictors of consent or assent status. SETTING The study was conducted at 22 assisted living facilities in Maryland. PARTICIPANTS A stratified random sample of 198 assisted living residents participated in the study. MEASUREMENTS Residents' consent or assent status was documented as providing informed consent, written assent, or verbal assent/no objection. Potential predictors included residents' demographic characteristics, measures of physical and mental health status, and neuropsychological test performance. RESULTS Most participants provided written assent (32.8%) or verbal assent/no objection (30.3%) rather than informed consent (36.9%). Although many resident characteristics correlated with consent or assent status based on bivariate analyses, few variables distinguished those who provided written assent from those in the verbal assent/no objection group. On the basis of multiple discriminant analysis, the best predictors of consent or assent status were Mini-Mental State Exam scores, impairments in instrumental activities of daily living, and dementia diagnosis, which together classified correctly 63.6% of residents. CONCLUSIONS The relatively small proportion of participants who could provide informed consent highlights the importance of assessing decisional capacity for research in a high-risk population and identifying an appropriate surrogate decision maker to provide proxy consent if needed. Consensus on how to define assent is lacking, and specific measures of assent capabilities are needed to better characterize the assent capacity continuum.
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Affiliation(s)
- Betty S Black
- Division of Geriatric Psychiatry and Neuropsychiatry, Department of Psychiatry and Behavioral Sciences, The Johns Hopkins School of Medicine, Johns Hopkins Bloomberg School of Public Health, 600 North Wolfe Street, Baltimore, MD 21287, USA.
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Black BS, Kass NE, Fogarty LA, Rabins PV. Informed consent for dementia research: the study enrollment encounter. IRB 2007; 29:7-14. [PMID: 17847621] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/17/2023]
Affiliation(s)
- Betty S Black
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins School of Medicine, Johns Hopkins University, Baltimore, MD, USA
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Abstract
The choice of outcomes in clinical research should be influenced by a linkage between the targeted symptom or disorder and the outcome being measured, the clinical meaningfulness of the outcome, and the ability to measure the outcome accurately. Dementia, defined as a syndrome consisting of disorders that impair two or more distinct cognitive capacities, occur in clear consciousness, and begin in adulthood, presents unique challenges in the choice of appropriate outcomes for treatment trials.
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Affiliation(s)
- Peter V Rabins
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins School of Medicine, and The Johns Hopkins Hospital, Baltimore, MD 21287, USA
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Chan DC, Kasper JD, Black BS, Rabins PV. Clinical diagnosis of dementia, not behavioral and psychologic symptoms, is associated with psychotropic drug use in community-dwelling elders classified as having dementia. J Geriatr Psychiatry Neurol 2007; 20:100-6. [PMID: 17548780 DOI: 10.1177/0891988706298628] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Little is known about the prevalence and correlates of psychotropic drug use in community-dwelling elders with dementia. Baseline data from 285 community-dwelling elders with a research classification of dementia enrolled in the observational Memory and Medical Care Study were analyzed. Of these, 33.3% with a research classification of dementia were clinically diagnosed, 28.8% used at least 1 psychotropic drug, and 61.8% had at least 1 behavioral or psychologic symptom of dementia. Presence of a behavioral or psychologic symptom of dementia was associated with a higher likelihood of a clinical diagnosis of dementia. A clinical diagnosis of dementia, not a behavioral or psychologic symptom of dementia, was associated with psychotropics use. Clinical recognition of dementia appears to be an intermediate step between presence of symptoms of dementia and the prescription of psychotropics. Most community-dwelling elders meeting the research criteria for dementia were not clinically diagnosed, despite contact with a physician (89%) in the previous year.
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Affiliation(s)
- Ding-Chen Chan
- Harvard Geriatric Medicine Fellowship Program, Boston, Massachusetts, USA
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Chan DC, Kasper JD, Black BS, Rabins PV. Clinical diagnosis of dementia, not presence of behavioral and psychological symptoms, is associated with psychotropic use in community-dwelling elders classified as having dementia. J Geriatr Psychiatry Neurol 2007; 20:50-7. [PMID: 17341771 DOI: 10.1177/0891988706297088] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Little is known about the prevalence and correlates of psychotropic use in community-dwelling elders with dementia. Baseline data from 285 community-dwelling elders with a research classification of dementia (based on a neuropsychological battery of 4 tests) and their knowledgeable informants enrolled in the observational Memory and Medical Care Study were analyzed. A total of 33.3% of subjects with a research classification of dementia were clinically diagnosed, 28.8% used at least 1 psychotropic drug, and 61.8% had at least 1 behavioral or psychological symptom of dementia (BPSD). Presence of BPSD was associated with a higher likelihood of a clinical diagnosis of dementia. Multivariate logistic regression showed a clinical diagnosis of dementia, not BPSD, was associated with psychotropic use; clinical recognition of dementia appears to be an intermediate step between presence of BPSD and prescription of psychotropics. In addition, most community-dwelling elders meeting the research criteria for dementia were not clinically diagnosed, despite contact with a physician (89%) in the previous year.
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Affiliation(s)
- Ding-Cheng Chan
- Department of Health Policy and Management, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland, USA.
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Black BS, Finucane T, Baker A, Loreck D, Blass D, Fogarty L, Phillips H, Hovanec L, Steele C, Rabins PV. Health problems and correlates of pain in nursing home residents with advanced dementia. Alzheimer Dis Assoc Disord 2007; 20:283-90. [PMID: 17132974 DOI: 10.1097/01.wad.0000213854.04861.cc] [Citation(s) in RCA: 66] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
This study describes the health problems and comorbid illnesses of nursing home (NH) residents with advanced dementia (n=123) and identifies correlates of staff-identified pain. Study participants were residents of 3 NHs in Maryland, their surrogate decision makers and their physicians. Residents' cognitive function was assessed at study enrollment, and their medical records were reviewed to identify all health problems/illnesses and use of pain medications during the 6 months before their enrollment. The most prevalent health problems were skin problems (95%), nutrition/hydration problems (85%), psychiatric/behavioral problems (85%), gastrointestinal problems (81%), and infections (80%). Sixty-three percent of residents had recognized pain, and 95% of those residents received pain medications. In a multivariate regression analysis, staff-identified pain was associated with aspiration (P=0.008), peripheral vascular disease (P=0.021), musculoskeletal disorders (P=0.032), higher cognitive function (P=0.013), and use of pain medications, including non-opiates (P=0.004) and the combination of opiates and non-opiates (P=0.001). NH residents with advanced dementia experience a complex mixture of multiple chronic and acute comorbidities. These results suggest the need for clinicians in long-term care facilities to be vigilant in assessing and treating pain, particularly as cognitive function declines in those with advanced dementia.
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Affiliation(s)
- Betty S Black
- The Johns Hopkins Medical Institutions Baltimore, MD 21287, USA.
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Lee HB, Kasper JD, Shore AD, Yokley JL, Black BS, Rabins PV. Level of cognitive impairment predicts mortality in high-risk community samples: the memory and medical care study. J Neuropsychiatry Clin Neurosci 2007; 18:543-6. [PMID: 17135381 DOI: 10.1176/jnp.2006.18.4.543] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Over the course of 3 years, the authors investigated the relationship between severity of cognitive impairment and mortality in a community sample of 498 elders at high risk for cognitive impairment. Subjects were classified as having no cognitive disorder, mild cognitive impairment, or dementia, based on a validated battery of four neuropsychological tests. Severity of impairment was based on Mini-Mental State Examination scores. Additional data were obtained from subjects' knowledgeable informants and Medicare records. Kaplan-Meier survival estimates and Cox hazard proportion analysis of the sample revealed that presence of cognitive impairment increases mortality in a fashion that parallels the severity of the impairment.
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Affiliation(s)
- Hochang B Lee
- The Johns Hopkins University School of Medicine, 550 N. Broadway, Suite 308, Baltimore, MD 21205, USA.
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Abstract
The objectives of this study were to identify the characteristics associated with hospice enrollment, to determine whether enrollment in hospice was associated with less pain and psychiatric symptoms, and to assess caregiver satisfaction with care near death in a sample of patients with dementia and mild cognitive impairment (MCI). Participants included decedents with dementia or MCI and other medical illnesses whose deaths were expected (n = 81) during a 3-year prospective, longitudinal, community-based cohort study. A total of 29.6% (n = 24) of participants received hospice care prior to death. Participants in hospice experienced less pain compared to those not in hospice, but this did not reach statistical significance (41.7% vs. 62.5%, P = 0.085). They were 65% more likely to be free of psychiatric symptoms (including restlessness, sleep problems, agitation, nervousness, and aggression toward others) during their final illness prior to death (OR = 0.35; 95% CI 0.13-0.96). In this cohort of people with dementia and MCI who died, several markers of quality of care suggest that hospice care can be beneficial for patients with dementia or MCI.
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Affiliation(s)
- David B Bekelman
- Department of Medicine, Division of General Internal Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland 21287, USA
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Chan DC, Kasper JD, Black BS, Rabins PV. Presence of behavioral and psychological symptoms predicts nursing home placement in community-dwelling elders with cognitive impairment in univariate but not multivariate analysis. J Gerontol A Biol Sci Med Sci 2003; 58:548-54. [PMID: 12807927 DOI: 10.1093/gerona/58.6.m548] [Citation(s) in RCA: 66] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND The role of behavioral and psychological symptoms as an independent risk factor of nursing home placement (NHP) in cognitively impaired elders has been controversial. METHODS A community sample of 449 cognitively impaired elders and their knowledgeable informants (KIs) was followed for 1 year. Subjects were classified as having dementia (n=330) or mild cognitive impairment (MCI) (n=119) using a neuropsychiatric battery of 4 tests. Subject characteristics (behavioral and psychological symptoms, demographic, health related, and health services use) and KI characteristics were entered into the Cox proportional hazard regression analysis. RESULTS The incidence rate of NHP was 8.9%. At baseline, 57.7% of subjects had at least 1 behavioral and psychological symptom. Presence of these symptoms was associated with shorter time to NHP only in a univariate analysis. Other factors significant in the multivariate Cox modeling were being white (hazard ratio [HR] = 2.17), having fair or poor physical health rating (HR= 2.12), having greater numbers of difficulties with activities of daily living (HR = 1.46), and having a physician's diagnosis of dementia (HR = 6.76). An interaction was found between the last 2 variables (HR = 0.59), indicating that among those with a diagnosis of dementia, a greater number of difficulties with activities of daily living delayed time to NHP. KI characteristics were not associated with NHP. CONCLUSIONS Behavioral and psychological symptoms were common, but having these symptoms was not an independent risk factor of NHP. Caregiver characteristics may not play as important a role in determining NHP as subject characteristics. Interventions aimed at improving or maintaining physical or cognitive functioning may have better chances of delaying NHP.
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Affiliation(s)
- Ding-Cheng Chan
- Department of Health Policy and Management, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland, USA.
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Chan DC, Kasper JD, Black BS, Rabins PV. Prevalence and correlates of behavioral and psychiatric symptoms in community-dwelling elders with dementia or mild cognitive impairment: the Memory and Medical Care Study. Int J Geriatr Psychiatry 2003; 18:174-82. [PMID: 12571828 DOI: 10.1002/gps.781] [Citation(s) in RCA: 78] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND Little is known about the prevalence and correlates of behavioral and psychiatric symptoms of dementia in community-dwelling elders with dementia or mild cognitive impairment (MCI). METHODS 512 people with Mini-Mental State Examination (MMSE) scores < 24 or a decline of at least 4 points over two administrations, and their knowledgeable informants (KIs) were enrolled in the MMCS. The classification of subjects as having dementia or MCI was based on a neuropsychological battery of four tests, not a clinical diagnostic evaluation. The sample for this study included 454 subjects (dementia n = 333; MCI n = 121) and their KIs. Demographic and health-related characteristics of subjects and KIs were obtained during KI interviews. Multivariate logistic regression was used in statistical analysis. RESULTS Compared to dementia subjects, those classified as MCI had a lower prevalence (47.1% vs 66.1%) of any symptoms (psychosis, depression, or agitation), and of agitation (24.8% vs 45.1%). Symptoms of psychosis and depression also were less prevalent, even though differences did not reach statistical significance. In the dementia group symptoms were associated with a report of a physician's diagnosis of dementia, greater functional impairment, and a KI who was a child/child-in-law. In those with MCI, symptoms were correlated with being white, greater functional impairment, and a younger, less educated, KI. CONCLUSIONS Psychiatric and behavioral symptoms were common in community-residing elders with cognitive impairment, but their prevalence and correlates differed by study classification as having dementia or MCI. Identifying and treating these symptoms may benefit patients with cognitive impairment and their families. Longitudinal studies on the predictors, changes in prevalence, and effectiveness of treatments for psychopathology of dementia are needed.
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Affiliation(s)
- Ding-Cheng Chan
- Department of Health Policy and Management, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA.
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Robbins B, Rye R, German PS, Tlasek-Wolfson M, Penrod J, Rabins PV, Black BS. The Psychogeriatric Assessment and Treatment in City Housing (PATCH) program for elders with mental illness in public housing: getting through the crack in the door. Arch Psychiatr Nurs 2000; 14:163-72. [PMID: 10969636 DOI: 10.1053/apnu.2000.8653] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Psychogeriatric Assessment and Treatment in City Housing (PATCH) is an outreach program targeting elderly public housing residents who need mental health care. The PATCH model relies on educating housing personnel to serve as case finders, providing in-home psychiatric evaluation and treatment, and addressing medical and social comorbidities through case management by psychiatric nurses. An examination of PATCH interventions suggests that the program's success is due to its emphasis on: (1) educating patients, housing personnel, and caregivers about patients' illnesses and need for treatment and support; and (2) coordinating care among housing staff members, patients' caregivers and their primary medical providers.
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Affiliation(s)
- B Robbins
- Johns Hopkins Bayview Medical Center, Baltimore, MD, USA
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Rabins PV, Black BS, Roca R, German P, McGuire M, Robbins B, Rye R, Brant L. Effectiveness of a nurse-based outreach program for identifying and treating psychiatric illness in the elderly. JAMA 2000; 283:2802-9. [PMID: 10838648 DOI: 10.1001/jama.283.21.2802] [Citation(s) in RCA: 62] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
CONTEXT Elderly persons with psychiatric disorders are less likely than younger adults to be diagnosed as having a mental disorder and receive needed mental health treatment. Lack of access to care is 1 possible cause of this disparity. OBJECTIVE To determine whether a nurse-based mobile outreach program to seriously mentally ill elderly persons is more effective than usual care in diminishing levels of depression, psychiatric symptoms, and undesirable moves (eg, nursing home placement, eviction, board and care placement). DESIGN Prospective randomized trial conducted between March 1993 and April 1996 to assess the effectiveness of the Psychogeriatric Assessment and Treatment in City Housing (PATCH) program. SETTING Six urban public housing sites for elderly persons in Baltimore, Md. PARTICIPANTS A total of 945 (83%) of 1195 residents in the 6 sites underwent screening for psychiatric illness. Among those screened, 342 screened positive and 603 screened negative. All screen-positive subjects aged 60 years and older (n=310) and a 10% random sample of screen-negative subjects aged 60 years and older (n=61) were selected for a structured psychiatric interview. Eleven subjects moved or died; 245 (82%) of those who screened positive and 53 (88%) of those who screened negative were evaluated to determine who had a psychiatric disorder. Data were weighted to estimate the prevalence of psychiatric disorders at the 6 sites. INTERVENTION Among the 6 sites, residents in 3 buildings were randomized to receive the PATCH model intervention, which included educating building staff to be case finders, performing assessment in residents' apartments, and providing care when indicated; and residents in the remaining 3 buildings were randomized to receive usual care (comparison group). MAIN OUTCOME MEASURES Number of undesirable moves and scores on the Montgomery-Asberg Depression Rating Scale (MADRS), a measure of depressive symptoms, and the Brief Psychiatric Rating Scale (BPRS), a measure of psychiatric symptoms and behavioral disorder, in intervention vs comparison sites. RESULTS Based on weighted data, at 26 months of follow-up, psychiatric cases at the intervention sites had significantly lower (F(1)=31.18; P<.001) MADRS scores (9.1 vs 15.2) and significantly lower (F(1)=17.35; P<.001) BPRS scores (27.4 vs 33.9) than those at the nontreatment comparison sites. There was no significant difference between the groups in undesirable moves (relative risk, 0.97; 95% confidence interval, 0. 44-2.17). CONCLUSIONS These results indicate that the PATCH intervention was more effective than usual care in reducing psychiatric symptoms in persons with psychiatric disorders and those with elevated levels of psychiatric symptoms. JAMA. 2000;283:2802-2809
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Affiliation(s)
- P V Rabins
- Meyer 279, Johns Hopkins Hospital, 600 N Wolfe St, Baltimore, MD 21287-7279.
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Abstract
This study examines risk factors for nursing home placement among elderly residents of public housing. Data on residents of six urban public housing developments for elderly persons (weighted n = 881) were analyzed by using logistic regression procedures to determine the predictors of nursing home placement during a 28-month period. Four baseline indicators of need were identified: greater impairment in instrumental activities of daily living, cognitive disorder, high scores on the General Health Questionnaire, and psychotic disorder. Thus, functional status and mental morbidity are major contributors to nursing home placement in this setting.
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Affiliation(s)
- B S Black
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University, Baltimore, MD 21287-7279, USA.
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Abstract
Epidemiologic survey data were used to examine relationships between alcohol use and abuse and the physical and mental health status of elderly public housing residents (weighted n = 865) and to determine the influence that drinking behavior had on mortality. Residents with a current alcohol disorder (4%) were more likely to rate their physical health as fair/poor but had fewer major medical illnesses, functional impairments, and other current psychiatric disorders. Individuals with a current or past alcohol disorder (22%) were more likely than others to die (odds ratio [OR] = 7.5) during the 28-month follow-up period. In multivariate analyses, women with a past alcohol disorder were more likely than lifetime abstainers to die (OR = 21.9). Drinking behavior was not predictive of death in men. The high prevalence of alcohol disorder and its strong influence on mortality in this predominantly African-American female population demonstrate the need for programs designed to prevent and treat alcoholism in public housing developments for the elderly.
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Affiliation(s)
- B S Black
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.
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Black BS, Rabins PV, German P, Roca R, McGuire M, Brant LJ. Use of formal and informal sources of mental health care among older African-American public-housing residents. Psychol Med 1998; 28:519-530. [PMID: 9626709 DOI: 10.1017/s0033291798006631] [Citation(s) in RCA: 23] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Elderly residents of public housing have high rates of psychiatric disorders, but most of those in need of care do not use any mental health service. This study examines the use of formal and alternative informal sources of mental health care in a sample of elderly African-American public-housing residents. METHOD Data from an epidemiological survey of six Baltimore public-housing developments for the elderly (weighted N = 818) were analysed to examine the utilization of mental health services by older African-American residents. Logistic regression analyses were used to determine correlates of using formal and informal sources by those needing mental health care. RESULTS Thirty-five per cent of subjects needed mental health care. Less than half (47%) of those in need received any mental health care in the previous 6 months. Residents in need were more likely to use formal (38.5%) than informal sources (18.6%) for care. The strongest correlates of using formal providers were substance use disorder (OR = 15.62), Medicare insurance (OR = 10.31) and psychological distress (OR = 10.27). The strongest correlates of using informal sources were perceiving little or no support from religious/spiritual beliefs (OR = 21.65), cognitive disorder (OR = 19.71) and having a confidant (OR = 15.07). CONCLUSIONS Contrary to elderly African-Americans in general, those in public housing rely more on formal than informal sources for mental health problems. Nevertheless, both sources fail to fill the gap between need and met need. Interventions to increase identification, referral and treatment of elderly public-housing residents in need should target general medical providers and clergy and include assertive outreach by mental health specialists.
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Affiliation(s)
- B S Black
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, MD 21287-7279, USA
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Abstract
Epidemiologic survey data from elderly residents of six public housing developments were used to determine the prevalence of need and unmet need for mental health care. Thirty-seven percent of this predominantly African American sample needed mental health services, and 58% of those who needed care had unmet needs. Logistic regression analyses showed that males, older residents, those with no Medicare insurance, and those with more Activities of Daily Living (ADL) impairments were at greater risk of both needing mental health care and receiving no mental health care services. Findings suggest the need for targeted interventions that would increase service utilization and potentially reduce the likelihood of eviction or placement in more restrictive settings.
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Affiliation(s)
- B S Black
- Johns Hopkins Hospital, Department of Psychiatry and Behavioral Sciences, Baltimore, MD 21287-7279, USA
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Black BS, Gher ME, Sandifer JB, Fucini SE, Richardson AC. Comparative study of collagen and expanded polytetrafluoroethylene membranes in the treatment of human class II furcation defects. J Periodontol 1994; 65:598-604. [PMID: 8083792 DOI: 10.1902/jop.1994.65.6.598] [Citation(s) in RCA: 56] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
The purpose of this study was to compare the changes in clinical attachment when either a non-resorbable ePTFE membrane or an absorbable collagen membrane was used as a barrier during surgical treatment of class II molar furcation defects. Thirteen patients, mean age 43.2 years, with two comparable class II molar defects were treated using a split mouth design. Pre-surgical standardized probings were made using an automated probe at a constant force of 25 grams. Four to 6 weeks after initial therapy, the furcations were surgically debrided, the membranes placed to occlude separate furcation defects in each patient, and the sites closed. The ePTFE membrane was removed 6 weeks after placement. Six months postsurgery, the clinical measurements were repeated. Student t test was used to compare the results. There were no significant differences in the mean initial measurements between the treatment groups. The mean decrease in vertical probing depth was 1.40 +/- 1.68 mm for the collagen treated sites and 1.07 +/- 0.81 mm for the ePTFE treated sites. The decrease in horizontal probing depth was 1.49 +/- 1.97 mm for the collagen treated sites and 0.79 +/- 2.16 mm for the ePTFE treated sites. No significant differences were found between any of the clinical parameters measured. Based on the results of this short-term clinical study, the absorbable collagen membrane was statistically equivalent to the non-resorbable ePTFE membrane in the clinical resolution of class II furcation defects.
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Affiliation(s)
- B S Black
- Periodontics Department, Naval Dental School, National Naval Dental Center, Bethesda, MD
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Fucini SE, Quintero G, Gher ME, Black BS, Richardson AC. Small versus large particles of demineralized freeze-dried bone allografts in human intrabony periodontal defects. J Periodontol 1993; 64:844-7. [PMID: 8229619 DOI: 10.1902/jop.1993.64.9.844] [Citation(s) in RCA: 37] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
Various particle sizes of demineralized freeze-dried bone allograft (DFDBA) are currently used to treat patients with periodontal osseous defects. However, the effect of particle size on the healing of human intrabony periodontal defects is unknown since there have been no direct clinical comparisons. The purpose of this study was to compare the bony defect resolution obtained using two different particle size ranges of DFDBA. Cortical bone from a single donor was processed and ground to final particle sizes of 250 mu to 500 mu or 850 mu to 1,000 mu using an analytic mill. Paired interproximal intrabony periodontal defects in 11 patients were grafted with DFDBA. Soft and hard tissue measurements were made using an electronic constant-force probe at the initial and reentry surgeries. Treated sites in 10 patients were reevaluated by reentry approximately 6 months postoperatively. Mean bony defect fill was 1.66 mm for the large particle group and 1.32 mm for the small particle group. There was no statistically significant difference in bony fill between defects grafted with the different particle sizes of DFDBA when used in humans.
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Affiliation(s)
- S E Fucini
- Periodontics Department, Naval Dental School, National Naval Dental Center, Bethesda, MD
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