Advance Care Planning in Community-Dwelling Patients With Dementia

CONTEXT

Little is known about advance care planning (ACP) among community-dwelling patients with dementia.

OBJECTIVES

To describe aspects of ACP among patients with dementia and examine the association between ACP and health care proxy (HCP) acceptance of patients' illness.

METHODS

Cross-sectional observational survey of 62 HCPs of patients with dementia (N = 14 mild, N = 48 moderate/severe), from seven outpatient geriatric and memory disorder clinics in Boston. Aspects of ACP included HCP's report of patients' preferences for level of future care, communication with HCP and physician regarding care preferences, and proxy preparedness for shared decision making. The association between ACP and HCP acceptance with patients' illness was examined using the Peace, Equanimity, and Acceptance subscale of the Cancer Experience Scale.

RESULTS

Eleven percent of proxies believed that the patient would want life-prolonging treatment, 31% a time-limited trial of curative treatment, and 47% comfort-focused care. Thirty-one percent reported that the patient had communicated with their physician regarding preferences for care, and 77% had communicated with the HCP. Forty-four percent of HCPs wanted more discussion with the patient regarding care preferences. The HCP having discussed care preferences with the patient was associated with greater acceptance of the patient's illness (P = 0.004).

CONCLUSION

Our findings support need for greater ACP discussions between patients and proxies. Discussions regarding goals of care are likely to benefit patients through delivery of care congruent with their wishes and HCPs in terms of greater acceptance of patients' illness.

Advance Directives among Nursing Home Residents with Mild, Moderate, and Advanced Dementia

OBJECTIVE

To describe prevalence and content of AD documentation among NH residents by dementia stage.

BACKGROUND

The prevalence of advance directives (ADs) among nursing home (NH) residents with mild, moderate, and advanced dementia remains unclear.

METHODS

Population-based, cross-sectional study of all licensed NHs in five U.S. states. Subjects included all long-stay (>90 day) NH residents with dementia, aged ≥65 years, and a Cognitive Performance Scale (CPS) score ≥1 from the 2007 to 2008 Minimum Data Set 2.0 (n = 180,621). Dementia severity was classified as follows: mild (CPS 1-2), moderate (CPS 3-4), and advanced (CPS 5-6).

MEASUREMENTS

ADs were defined as the presence of a living will, do-not-resuscitate order, do-not-hospitalize order, medication restriction, or feeding restriction).

RESULTS

Overall, 59% of residents had any AD and 17% had a living will. Prevalence of any AD increased by dementia severity: mild (51.2%), moderate (58.2%), and advanced (61.5%) (p < 0.001). In adjusted analysis, resident characteristics associated with any AD documentation included older age, female gender, being white, and having more severe dementia. Having a living will was associated with higher education (≥high school graduate vs. some high school or less) and being married.

DISCUSSION

While dementia severity was associated with greater likelihood of having documented any AD, almost 4 in 10 residents with dementia lacked any AD. Effective outreach may focus efforts on subgroups with lower odds of any AD or living wills, including non-white, less educated, and unmarried NH residents. A greater understanding of how such factors impact care planning will help to address barriers to patient-centered care for this population.

Preventing Burdensome Transitions of Nursing Home Residents with Advanced Dementia: It's More than Advance Directives

BACKGROUND

Although a palliative approach to care is recommended for people with advanced dementia, many nursing home (NH) residents with dementia experience burdensome interventions such as hospital transfers at the end of life.

OBJECTIVE

The goal of this study was to examine how decisions to transfer NH residents with advanced dementia are made, from the perspective of NH nurses and physicians.

METHODS

A qualitative, descriptive method was used. Purposive sampling was used to recruit 20 healthcare providers from 9 NHs. Data collection included semistructured, open-ended interviews.

RESULTS

Decision making regarding hospital transfer comprised two phases. Phase one, laying the groundwork, was influenced by the ability of the providers to effectively establish trust, foreshadow, and illuminate hazards of hospitalization. Phase two, responding to an acute event, began at the start of an acute event and ended when a decision was made to either treat the resident in the NH or transfer to the hospital. Responding to the acute event was influenced by the ability to care for residents in the NH, the providers' comfort with end-of-life conversations, and surrogates' preferences.

CONCLUSIONS

Advance care planning before an acute event is only the first step in a process of decision making. Attention to and support for decision making is needed at the time of each acute event to ensure that goals of care are maintained.

Interventions Associated With the Management of Suspected Infections in Advanced Dementia

CONTEXT

Nursing home (NH) residents with advanced dementia are commonly suspected of having infections. Most episodes are treated with antimicrobials, although evidence supporting bacterial infections is often lacking. The extent to which other interventions are used in managing suspected infections is unknown.

OBJECTIVES

To describe interventions used to manage suspected infections in advanced dementia and identify factors associated with greater intervention use.

METHODS

Residents with advanced dementia who experienced suspected infections in 35 Boston NHs were followed for 12 months. Data describing interventions used in managing each episode were ascertained, including blood draws, chest radiographs, procurement of urine samples, and hospital transfers. Resident and episode characteristics associated with greater intervention use were identified using mixed model regression.

RESULTS

A total of 240 residents experienced 496 suspected infections involving the following interventions: any, n = 360 (72.6%); hospital transfer, n = 51 (10.3%); blood draw, n = 215 (43.3%); chest radiograph, n = 120 (24.2%); and urine sample, n = 222 (44.8%). Factors associated with greater intervention use included black race (adjusted odds ratio [AOR] 3.19; 95% CI, 1.37-7.44); no do not hospitalize order (AOR, 1.83; 95% CI, 1.16-2.90); not on hospice (AOR, 5.41; 95% CI, 2.14-13.70); and suspected source being respiratory (AOR, 10.67; 95% CI, 4.99-22.80), urine (AOR, 15.79; 95% CI, 7.41-33.66) or fever of unknown source (AOR, 20.26; 95% CI, 8.42-48.73) vs. skin/soft tissue.

CONCLUSION

NH residents with advanced dementia frequently experience potentially burdensome interventions when suspected of having an infection. Advance directives to limit such interventions may be appropriate for residents whose goal of care is comfort.

Development and psychometric properties of the family distress in advanced dementia scale

OBJECTIVE

The majority of scales to measure family member distress in dementia are designed for community settings and do not capture the unique burdens of the nursing home (NH) environment. We report the psychometric properties of a new Family Distress in Advanced Dementia Scale for use in the NH setting.

DESIGN, SETTING, PARTICIPANTS

Cross-sectional questionnaire of 130 family member health care proxies of NH residents with advanced dementia in 31 Boston-area NHs.

METHODS

Thirty-one initial items were evaluated, measuring the frequency over the past 3 months of sources of distress. Exploratory factor analysis identified domains of distress; Cronbach's alpha was computed for each domain. Associations between the domains and other measures were evaluated using Pearson correlation coefficients, including measures of depression (PHQ-9), satisfaction with care (Satisfaction with Care at the End-of-Life in Dementia [SWC-EOLD]), and caregiver burden (Zarit Burden Interview short version).

RESULTS

Factor analysis suggested 3 domains: emotional distress (9 items), dementia preparedness (5 items), and NH relations (7 items). Cronbach's alpha coefficients were 0.82, 0.75, and 0.83 respectively. The PHQ-9 correlated most strongly with the emotional distress factor (r = 0.34), the SWC-EOWD correlated most strongly with the NH relations factor (r = 0.35), as did the Zarit Burden Scale (r = 0.50).

CONCLUSIONS

The Family Distress in Advanced Dementia Scale encompasses 3 domains of distress. This scale represents a much needed tool to assess distress among family members of NH residents with advanced dementia and provides a metric to evaluate interventions in the population.

Healthcare Proxy Awareness of Suspected Infections in Nursing Home Residents with Advanced Dementia

OBJECTIVES

To determine healthcare proxy involvement in decision-making regarding infections in individuals with advanced dementia.

DESIGN

Prospective cohort study.

SETTING

Thirty-five Boston-area nursing homes (NHs).

PARTICIPANTS

NH residents with advanced dementia and their proxies (N = 362).

MEASUREMENTS

Charts were abstracted monthly (up to 12 months) for documentation of suspected infections and provider-proxy discussions for each episode. Proxies were interviewed within 8 weeks of the infection to determine their awareness and decision-making involvement. Factors associated with proxy awareness and discussion documentation were identified.

RESULTS

There were 496 suspected infections; proxies were reached for interview for 395 (80%). Proxy-provider discussions were documented for 207 (52%) episodes, yet proxies were aware of only 156 (39%). Proxies participated in decision-making for 89 (57%) episodes of which they were aware. Proxy awareness was associated with antimicrobial use (adjusted odds ratio (AOR) = 3.43, 95% confidence interval (CI) = 1.94-6.05), hospital transfer (AOR = 3.00, 95% CI = 1.19-7.53), infection within 30 days of death (AOR = 3.32, 95% CI = 1.54-7.18), and fewer days between infection and study interview (AOR = 2.71, 95% CI = 1.63-4.51). Discussion documentation was associated with the resident residing in a dementia special care unit (AOR = 1.71, 95% CI = 1.04-2.80), the resident not on hospice (AOR = 3.25, 95% CI = 1.31-8.02), more provider visits (AOR = 1.71, 95% CI = 1.07-2.75), proxy visits of more than 7 h/wk (AOR = 1.93, 95% CI = 1.02-3.67), and episode within 30 days of death (AOR = 3.99, 95% CI = 1.98-8.02).

CONCLUSION

Proxies are unaware of and do not participate in decision-making for most suspected infections that NH residents with advanced dementia experience. Proxy awareness of episodes and documentation of provider-proxy discussions are not congruent.

Infection management and multidrug-resistant organisms in nursing home residents with advanced dementia

IMPORTANCE

Infection management in advanced dementia has important implications for (1) providing high-quality care to patients near the end of life and (2) minimizing the public health threat posed by the emergence of multidrug-resistant organisms (MDROs).

DESIGN, SETTING, AND PARTICIPANTS

Prospective cohort study of 362 residents with advanced dementia and their health care proxies in 35 Boston area nursing homes for up to 12 months.

MAIN OUTCOMES AND MEASURES

Data were collected to characterize suspected infections, use of antimicrobial agents (antimicrobials), clinician counseling of proxies about antimicrobials, proxy preference for the goals of care, and colonization with MDROs (methicillin-resistant Staphylococcus aureus, vancomycin-resistant enterococci, and multidrug-resistant gram-negative bacteria). Main outcomes were (1) proportion of suspected infections treated with antimicrobials that met minimum clinical criteria to initiate antimicrobial treatment based on consensus guidelines and (2) cumulative incidence of MDRO acquisition among noncolonized residents at baseline.

RESULTS

The cohort experienced 496 suspected infections; 72.4% were treated with antimicrobials, most commonly quinolones (39.8%) and third- or fourth-generation cephalosporins (20.6%). At baseline, 94.8% of proxies stated that comfort was the primary goal of care, and 37.8% received counseling from clinicians about antimicrobial use. Minimum clinical criteria supporting antimicrobial treatment initiation were present for 44.0% of treated episodes and were more likely when proxies were counseled about antimicrobial use (adjusted odds ratio, 1.42; 95% CI, 1.08-1.86) and when the infection source was not the urinary tract (referent). Among noncolonized residents at baseline, the cumulative incidence of MDRO acquisition at 1 year was 48%. Acquisition was associated with exposure (>1 day) to quinolones (adjusted hazard ratio [AHR], 1.89; 95% CI, 1.28-2.81) and third- or fourth-generation cephalosporins (AHR, 1.57; 95% CI, 1.04-2.40).

CONCLUSIONS AND RELEVANCE

Antimicrobials are prescribed for most suspected infections in advanced dementia but often in the absence of minimum clinical criteria to support their use. Colonization with MDROs is extensive in nursing homes and is associated with exposure to quinolones and third- and fourth-generation cephalosporins. A more judicious approach to infection management may reduce unnecessary treatment in these frail patients, who most often have comfort as their primary goal of care, and the public health threat of MDRO emergence.

Depressive symptoms among dementia caregivers: role of mediating factors

OBJECTIVE

To compare depressive symptoms between caregivers to persons with dementia and other illnesses and determine whether caregiver role captivity and care recipient disruptive behaviors mediate this association.

METHODS

Prospective cohort study of older women in four U.S. communities followed from 1999 to 2009. Home-based interviews were used in 345 caregiving participants from the Caregiver-Study of Osteoporotic Fractures. Caregiver status was based on self-report of performing one or more instrumental or basic activities of daily living for a care recipient. Depressive symptoms were measured using the 20-item Center for Epidemiologic Studies Depression Scale. Scores of 16 or greater represented high depressive symptoms. Caregiver role captivity and care recipient problematic behaviors were measured using validated instruments.

RESULTS

Approximately one third of the caregivers cared for a person with dementia. High depressive symptoms were more common among dementia caregivers (22.8% versus 11.2%, p <0.001) (unadjusted odds ratio: 2.12; 95% confidence interval [CI]: 1.20-3.74). This association was completely mediated by caregiver role captivity and care recipient problematic behaviors. In adjusted results, high depressive symptoms were associated with middle and highest tertiles of role captivity (adjusted odds ratios [AOR]: 5.01; 95% CI: 2.31-11.05 and AOR: 9.41; 95% CI: 3.95-22.40 for the middle and highest tertiles, respectively) and care recipient problematic behaviors (AOR: 2.52; 95% CI: 1.02-6.19 and AOR: 5.26; 95% CI: 2.00-13.8 for the middle and highest tertiles, respectively).

CONCLUSION

Older caregivers to persons with dementia are at increased risk of high depressive symptoms. Targeting problematic behaviors among dementia patients and addressing aspects of dementia care that result in role captivity may ameliorate caregiver depression.

What is family-centered care for nursing home residents with advanced dementia?

To understand family members' perspectives on person- and family-centered end-of-life care provided to nursing home (NH) residents with advanced dementia, we conducted a qualitative follow-up interview with 16 respondents who had participated in an earlier prospective study, Choices, Attitudes, and Strategies for Care of Advance Dementia at End of Life (CASCADE). Family members of NH residents (N = 16) with advanced dementia participated in semistructured qualitative interviews that inquired about overall NH experience, communication, surrogate decision making, emotional reaction, and recommendations for improvement. Analysis identified 5 areas considered important by family members: (1) providing basic care; (2) ensuring safety and security; (3) creating a sense of belonging and attachment; (4) fostering self-esteem and self-efficacy; and (5) coming to terms with the experience. These themes can provide a framework for creating and testing strategies to meet the goal of person- and family-centered care.

Preliminary data from an advanced dementia consult service: integrating research, education, and clinical expertise

Hospitalized individuals with advanced dementia often receive care that is of limited clinical benefit and inconsistent with preferences. An advanced dementia consultation service was designed, and a pre and post pilot study was conducted in a Boston hospital to evaluate it. Geriatricians and a palliative care nurse practitioner conducted consultations, which consisted of structured consultation, counseling and provision of an information booklet to the family, and postdischarge follow-up with the family and primary care providers. Individuals aged 65 and older with advanced dementia who were admitted were identified, and consultations were solicited using pop-ups programmed into the computerized provider order entry (POE) system. In the initial 3-month period, 24 subjects received usual care. In the subsequent 3-month period, consultations were provided to five subjects for whom they were requested. Data were obtained from the electronic medical record and proxy interviews (admission, 1 month after discharge). Mean age of the combined sample (N = 29) was 85.4, 58.6% were from nursing homes, and 86.2% of their proxies stated that comfort was the goal of care. Nonetheless, their hospitalizations were characterized by high rates of intravenous antibiotics (86.2%), more than five venipunctures (44.8%), and radiological examinations (96.6%). Acknowledging the small sample size, there were trends toward better outcomes in the intervention group, including greater proxy knowledge of the disease, better communication between proxies and providers, more advance care planning, lower rehospitalization rates, and fewer feeding tube insertions after discharge. Targeted consultation for advanced dementia is feasible and may promote greater engagement of proxies and goal-directed care after discharge.

Skilled nursing facility admissions of nursing home residents with advanced dementia

OBJECTIVES

To describe the extent to which hospitalized nursing home (NH) residents with advanced dementia were admitted to a skilled nursing facility (SNF) after a qualifying hospitalization and to identify resident and nursing home characteristics associated with a greater likelihood of SNF admissions.

DESIGN

Cohort study using data from the Minimum Data Set, Medicare claims, and the On-line Survey Certification of Automated Records.

SETTING

United States, 2000-2006.

PARTICIPANTS

Nursing home residents with advanced dementia aged 65 and older with a 3-day hospitalization (N = 4,177).

MEASUREMENTS

The likelihood of SNF admission after hospitalization was calculated. Resident and nursing home factors associated with SNF admission were identified using hierarchical multivariable logistic regression.

RESULTS

Sixty-one percent of residents with advanced dementia were admitted to a SNF after their hospitalization. Percutaneous endoscopic gastrostomy (PEG) tube placement during hospitalization was strongly associated with SNF admission (adjusted odds ratio (AOR) = 2.31, 95% confidence interval (CI) = 1.85-2.88), as was better functional status (AOR = 1.21, 95% CI = 1.05-1.38). The presence of diabetes mellitus was associated with lower likelihood of SNF admission (AOR = 0.85, 95% CI = 0.73-0.99). Facility features significantly associated with SNF admission included more than 100 beds (AOR = 1.25, 95% CI = 1.07-1.46), being part of a chain (AOR = 1.31, 95% CI = 1.14-1.50), urban location (AOR = 1.21, 95% CI = 1.03-1.41), and for-profit status (AOR = 1.28, 95% CI = 1.09-1.51).

CONCLUSION

The majority of nursing home residents with advanced dementia are admitted to SNFs after a qualifying hospitalization. SNF admission is strongly associated with PEG tube insertion during hospitalization and with nursing home factors. Efforts to optimize appropriate use of SNF services in individuals with advanced dementia should focus on these factors.

Encouraging trends in acute myocardial infarction survival in the oldest old

BACKGROUND

There are limited data informing the optimal treatment strategy for acute myocardial infarction in the oldest old (aged ≥85 years). The study aim was to examine whether decade-long increases in guideline-based cardiac medication use mediate declines in post-discharge mortality among oldest old patients hospitalized with acute myocardial infarction.

METHODS

The study sample included 1137 patients aged ≥85 years hospitalized in 6 biennial periods between 1997 and 2007 for acute myocardial infarction at all 11 greater Worcester, Massachusetts, medical centers. We examined trends in 90-day survival after hospital discharge and guideline-based medication use (aspirin, angiotensin-converting enzyme inhibitors/angiotensin receptor blockers, beta-blockers, lipid-lowering agents) for acute myocardial infarction during hospitalization and at discharge. Sequential multivariable Cox regression models examined the relationship among guideline-based medication use, study year, and 90-day post-discharge survival rates.

RESULTS

Patients hospitalized between 2003 and 2007 experienced higher 90-day survival rates than those hospitalized between 1997 and 2001 (69.1% vs 59.8%, P < .05). Between 1997 and 2007, the average number of guideline-based medications prescribed at discharge increased significantly (1.8 to 2.9, P < .001). The unadjusted hazard ratio for 90-day post-discharge mortality in 2003-2007 compared with 1997-2001 was 0.73 (95% confidence interval, 0.60-0.89); after adjustment for patient characteristics and guideline-based cardiac medication use, this relationship was no longer significant (hazard ratio, 1.26; 95% confidence interval, 1.00-1.58).

CONCLUSIONS

Between 1997 and 2007, 90-day survival improved among a population-based sample of patients aged ≥85 years hospitalized for acute myocardial infarction. This encouraging trend was explained by increased use of guideline-based medications.

The study of pathogen resistance and antimicrobial use in dementia: study design and methodology

Advanced dementia is characterized by the onset of infections and antimicrobial use is extensive. The extent to which this antimicrobial use is appropriate and contributes to the emergence of antimicrobial resistant bacteria is not known. The object of this report is to present the methodology established in the Study of Pathogen Resistance and Exposure to Antimicrobials in Dementia (SPREAD), and describe how challenges specific to this research were met. SPREAD is an ongoing, federally funded, 5-year prospective cohort study initiated in September 2009. Subjects include nursing home residents with advanced dementia and their proxies recruited from 31 Boston-area facilities. The recruitment and data collection protocols are described. Characteristics of participant facilities are presented and compared to those nationwide. To date, 295 resident/proxy dyads have been recruited. Baseline and selected follow-up data demonstrate successful recruitment of subjects and repeated collection of complex data documenting infections, decision-making for these infections, and antimicrobial bacteria resistance among the residents. SPREAD integrates methods in dementia, palliative care and infectious diseases research. Its successful implementation further establishes the feasibility of conducting rigorous, multi-site NH research in advanced dementia, and the described methodology serves as a detailed reference for subsequent publications emanating from the study.

Hospital transfers of nursing home residents with advanced dementia

OBJECTIVES

To describe diagnoses and factors associated with hospital transfer in nursing home (NH) residents with advanced dementia.

DESIGN

Prospective cohort study.

SETTING

Twenty-two Boston, Massachusetts-area NHs.

PARTICIPANTS

Three hundred twenty-three NH residents with advanced dementia.

MEASUREMENTS

Data were collected quarterly for up to 18 months. Data regarding transfers were collected with regard to hospitalization or emergency department (ED) visit, diagnosis, and duration of inpatient admission. Information on the occurrence of any acute medical event (pneumonia, febrile episode, or other acute illness) in the prior 90 days was obtained quarterly. Logistic regression conducted at the level of the acute medical event identified characteristics associated with hospital transfer.

RESULTS

The entire cohort experienced 74 hospitalizations and 60 ED visits. Suspected infections were the most common reason for hospitalization (44, 59%), most frequently attributable to a respiratory source (30, 41%). Feeding tube-related complications accounted for 47% of ED visits. In adjusted analysis conducted on acute medical events, younger resident age, event type (pneumonia or other event vs febrile episode), chronic obstructive pulmonary disease, and the lack of a do-not-hospitalize (DNH) order (adjusted odds ratio = 5.22, 95% confidence interval = 2.31-11.79) were associated with hospital transfer.

CONCLUSION

The majority of hospitalizations of NH residents with advanced dementia were due to infections and thus were potentially avoidable, because infections are often treatable in the NH. Feeding tube-related complications accounted for almost half of all ED visits, representing a common but underrecognized burden of this intervention. Advance care planning in the form of a DNH order was the only identified modifiable factor associated with avoiding hospitalization.

Mental health and exposure to patient distress among families of nursing home residents with advanced dementia

CONTEXT

The effect of suffering among patients with advanced dementia on their family members' mental health has not been investigated.

OBJECTIVES

To describe family members' exposure to distressing symptoms among nursing home (NH) residents with advanced dementia and associations between such exposure and family members' mental health.

METHODS

Data were obtained from an 18-month prospective cohort study of NH residents with advanced dementia and their family member health care proxies (HCPs). Exposure to resident symptoms and associated fear and helplessness was measured quarterly using the Stressful Caregiving Adult Reactions to Experiences of Dying (SCARED) scale (range 0-120). HCP mental health was assessed quarterly using the Composite International Diagnostic Interview Short Form (CIDI-SF) (depression), K6 (psychological distress, range 0-24), and SF-12(®) mental health subscale.

RESULTS

Seven hundred seventy-nine SCARED scale assessments were completed by 225 HCPs. The most frequent distressing symptoms were the following: feeling the resident had had enough (33.2%), choking (21.1%), and pain (18.9%). The symptoms eliciting the greatest fear were thinking the resident was dead and seeing them choke. A sense of helplessness was highest when the resident was observed to be in pain or choking. Family members with SCARED scores >0 were more likely to meet criteria for depression on the CIDI-SF (adjusted odds ratio [AOR] 2.59, 95% confidence interval [CI] 1.14, 5.85), have a K6 score >0 (AOR 2.31, 95% CI 1.55, 3.43), and have lower SF-12 scores (adjusted parameter estimate -1.51, 95% CI -2.56, -0.47).

CONCLUSION

Family member exposure to distressing symptoms experienced by their loved ones with advanced dementia is not uncommon and is associated with worse mental health.

Negotiating depression treatment with older adults: primary care providers' perspectives

BACKGROUND

Primary care occupies a strategic position in the evaluation and treatment of depression in late life, yet many older patients do not initiate or adhere to treatments available in primary care.

AIM

To explore how primary care providers describe the process of discussing depression care with older adults.

METHOD

 Semi-structured interviews conducted with 15 providers involved with intervention studies of depression management for older adults. We used the constant comparative method to identify themes related to negotiating the treatment of depression with older adults.

RESULTS

Providers felt that older patients often attribute depression to non-medical causes. They talked about the challenges and described the need to 'convince' them of the medical model of depression.

CONCLUSION

How primary care physicians surmise patients' views of depression may influence the discussion of depression in practice. As medication is most often provided for depression treatment, some may feel compelled to convince their patients of biomedical explanations while others may avoid treating depression altogether.

Cholinesterase inhibitor and memantine use in newly admitted nursing home residents with dementia

OBJECTIVES

To quantify the use of cholinesterase inhibitors (ChEIs) and memantine in nursing home (NH) residents with dementia upon NH admission and 3 months later and to examine factors associated with reduction in therapy.

DESIGN

Retrospective cohort study.

SETTING

Nationwide sample of U.S. NHs.

PARTICIPANTS

Three thousand five hundred six NH residents with dementia newly admitted in 2006.

MEASUREMENTS

Data from pharmacy dispensing records were used to determine ChEI and memantine medication use upon NH admission and at 3-month follow-up. The Minimum Data Set was used to determine resident- and facility-level characteristics. Severity of dementia was defined using the Cognitive Performance Scale (CPS).

RESULTS

Overall, 40.1% (n=1,407) of newly admitted NH residents with dementia received ChEIs and memantine on NH admission. Use of ChEIs and memantine on admission was significantly greater in residents with mild to moderately severe dementia (41.2%) than in those with advanced dementia (33.3%, P=.001). After 3 months, ChEI and memantine use decreased by about half in both groups (48.6% with mild to moderately severe dementia vs 57.0% with advanced dementia, P<.05). NH residents with advanced dementia were significantly more likely reduce their use of ChEIs and memantine than those with mild to moderately severe dementia (odds ratio=1.44, 95% confidence interval=1.03-2.01, P=.04).

CONCLUSION

Many NH residents with advanced dementia receive ChEIs and memantine upon NH admission, and approximately half of these decrease their medication use over the ensuing months. Further study is required to optimize use of ChEIs and memantine in NH populations and to determine the effects of withdrawing therapy on resident outcomes.

Hospice use and outcomes in nursing home residents with advanced dementia

OBJECTIVES

To identify characteristics of nursing home (NH) residents with advanced dementia and their healthcare proxies (HCPs) associated with hospice referral and to examine the association between hospice use and the treatment of pain and dyspnea and unmet needs during the last 7 days of life.

DESIGN

Prospective cohort study.

SETTING

Twenty-two Boston-area NHs.

PARTICIPANTS

Three hundred twenty-three NH residents with advanced dementia and their HCPs.

MEASUREMENTS

Data were collected at baseline and quarterly for up to 18 months. Hospice referral, frequency of pain and dyspnea, and treatment of these symptoms was ascertained. HCPs reported unmet needs during the last 7 days of the residents' lives for communication, information, emotional support, and help with personal care.

RESULTS

Twenty-two percent of residents were referred to hospice. After multivariable adjustment, factors associated with hospice referral were nonwhite race, eating problems, HCP's perception that the resident's had less than 6 months to live, and better HCP mental health. Residents in hospice were more likely to receive scheduled opioids for pain (adjusted odds ratio (AOR)=3.16; 95% confidence interval (95% CI)=1.57-6.36) and oxygen, morphine, scopolamine, or hyoscyamine for dyspnea (AOR=3.28, 95% CI=1.37-7.86). HCPs of residents in hospice reported fewer unmet needs in all domains during the last 7 days of the residents' life.

CONCLUSION

A minority of NH residents with advanced dementia received hospice care. Hospice recipients were more likely to received scheduled opioids for pain and symptomatic treatment for dyspnea and had fewer unmet needs at the end of life.

Survival and comfort after treatment of pneumonia in advanced dementia

BACKGROUND

Pneumonia is common among patients with advanced dementia, especially toward the end of life. Whether antimicrobial treatment improves survival or comfort is not well understood. The objective of this study was to examine the effect of antimicrobial treatment for suspected pneumonia on survival and comfort in patients with advanced dementia.

METHODS

From 2003 to 2009, data were prospectively collected from 323 nursing home residents with advanced dementia in 22 facilities in the area of Boston, Massachusetts. Each resident was followed up for as long as 18 months or until death. All suspected pneumonia episodes were ascertained, and antimicrobial treatment for each episode was categorized as none, oral only, intramuscular only, or intravenous (or hospitalization). Multivariable methods were used to adjust for differences among episodes in each treatment group. The main outcome measures were survival and comfort (scored according to the Symptom Management at End-of-Life in Dementia scale) after suspected pneumonia episodes.

RESULTS

Residents experienced 225 suspected pneumonia episodes, which were treated with antimicrobial agents as follows: none, 8.9%; oral only, 55.1%, intramuscular, 15.6%, and intravenous (or hospitalization), 20.4%. After multivariable adjustment, all antimicrobial treatments improved survival after pneumonia compared with no treatment: oral (adjusted hazard ratio [AHR], 0.20; 95% confidence interval [CI], 0.10-0.37), intramuscular (AHR, 0.26; 95% CI, 0.12-0.57), and intravenous (or hospitalization) (AHR, 0.20; 95% CI, 0.09-0.42). After multivariable adjustment, residents receiving any form of antimicrobial treatment for pneumonia had lower scores on the Symptom Management at End-of-Life in Dementia scale (worse comfort) compared with untreated residents.

CONCLUSION

Antimicrobial treatment of suspected pneumonia episodes is associated with prolonged survival but not with improved comfort in nursing home residents with advanced dementia.

Racial and ethnic differences in hospice use among patients with heart failure

BACKGROUND

Heart failure is the leading noncancer diagnosis for patients in hospice care and the leading cause of hospitalization among Medicare beneficiaries. Racial and ethnic differences in hospice patients are well documented for patients with cancer but poorly described for those with heart failure.

METHODS

On the basis of a national sample of 98 258 Medicare beneficiaries 66 years and older on January 1, 2001, with a diagnosis of heart failure who had at least 1 physician or hospital encounter and who were not enrolled in hospice care between January 1 and December 31, 2000, we determined the effect of race and ethnicity on hospice entry for patients with heart failure in 2001 after adjusting for sociodemographic, clinical, and geographic factors.

RESULTS

In unadjusted analysis, blacks (odds ratio [OR], 0.52) and Hispanics (0.43) used hospice care for heart failure less than whites. Racial and ethnic differences in patients who received hospice care for heart failure persisted after adjusting for markers of income, urbanicity, severity of illness, local density of hospice use, and medical comorbidity (adjusted OR for blacks, 0.59; 95% confidence interval, 0.47-0.73; and adjusted OR for Hispanics, 0.49; 95% confidence interval, 0.37-0.66; compared with whites). Advanced age, greater comorbidity, emergency department visits, hospitalizations, and greater local density of hospice use were also associated with hospice use.

CONCLUSIONS

In a national sample of Medicare beneficiaries with heart failure, blacks and Hispanics used hospice care for heart failure less than whites after adjustment for individual and market factors. To understand the mechanisms underlying these findings, further examination of patient preferences and physician referral behavior is needed.

The clinical course of advanced dementia

BACKGROUND

Dementia is a leading cause of death in the United States but is underrecognized as a terminal illness. The clinical course of nursing home residents with advanced dementia has not been well described.

METHODS

We followed 323 nursing home residents with advanced dementia and their health care proxies for 18 months in 22 nursing homes. Data were collected to characterize the residents' survival, clinical complications, symptoms, and treatments and to determine the proxies' understanding of the residents' prognosis and the clinical complications expected in patients with advanced dementia.

RESULTS

Over a period of 18 months, 54.8% of the residents died. The probability of pneumonia was 41.1%; a febrile episode, 52.6%; and an eating problem, 85.8%. After adjustment for age, sex, and disease duration, the 6-month mortality rate for residents who had pneumonia was 46.7%; a febrile episode, 44.5%; and an eating problem, 38.6%. Distressing symptoms, including dyspnea (46.0%) and pain (39.1%), were common. In the last 3 months of life, 40.7% of residents underwent at least one burdensome intervention (hospitalization, emergency room visit, parenteral therapy, or tube feeding). Residents whose proxies had an understanding of the poor prognosis and clinical complications expected in advanced dementia were much less likely to have burdensome interventions in the last 3 months of life than were residents whose proxies did not have this understanding (adjusted odds ratio, 0.12; 95% confidence interval, 0.04 to 0.37).

CONCLUSIONS

Pneumonia, febrile episodes, and eating problems are frequent complications in patients with advanced dementia, and these complications are associated with high 6-month mortality rates. Distressing symptoms and burdensome interventions are also common among such patients. Patients with health care proxies who have an understanding of the prognosis and clinical course are likely to receive less aggressive care near the end of life.

Concerns about end-of-life care and support for euthanasia

Popular support for euthanasia is known to vary according to sociodemographic characteristics. However, little is known about whether support is associated with concerns regarding the emotional, physical, and economic burdens of end-of-life care. This study used data from the 1998 General Social Survey, a national survey of community-dwelling adults. The outcome variable assessed the respondents' support for a doctor's right to end life in the setting of terminal illness. Independent variables assessed the following concerns: 1) concern about the emotional burden of end-of-life decision making for family members; 2) worry about the economic burden of terminal illness; 3) concern about pain at the end of life; 4) worry that lack of money or insurance will result in second-class end-of-life care; and 5) belief that their religious community will be helpful at the end of life. Multivariable logistic regression estimated the independent effect of these concerns on support for euthanasia, adjusting for sociodemographic characteristics. Of 786 respondents, 70.6% approved of euthanasia in the setting of terminal illness. In adjusted analyses, respondents with concerns about the emotional toll of decision making on family members, economic burden, and poor health care because of lack of insurance were significantly more likely to support euthanasia. Respondents with faith in the helpfulness of their religious community were less likely to support euthanasia. In conclusion, emotional and economic concerns about end-of-life care were associated with support for the right to euthanasia. Future work can evaluate whether alleviating these concerns may reduce the perceived desire for euthanasia by patients near the end of life.

Personality traits of centenarians' offspring

OBJECTIVES

To determine whether the offspring of centenarians have personality characteristics that are distinct from the general population.

DESIGN

Case-control.

SETTING

Nationwide U.S. sample.

PARTICIPANTS

Unrelated offspring of centenarians (n=246, mean age 75) were compared with published norms.

MEASUREMENTS

Using the NEO-Five-Factor Inventory (NEO-FFI) questionnaire, measures of the personality traits neuroticism, extraversion, openness, agreeableness, and conscientiousness were obtained. T-scores and percentiles were calculated according to sex and used to interpret the results.

RESULTS

Male and female offspring of centenarians scored in the low range of published norms for neuroticism and in the high range for extraversion. The women also scored comparatively high in agreeableness. Otherwise, both sexes scored within normal range for conscientiousness and openness, and the men scored within normal range for agreeableness.

CONCLUSION

Specific personality traits may be important to the relative successful aging demonstrated by the offspring of centenarians. Similarities across four of the five domains between male and female offspring is noteworthy and may relate to their successful aging. Measures of personality are an important phenotype to include in studies that assess genetic and environmental influences of longevity and successful aging.

The overlap syndrome of depression and delirium in older hospitalized patients

OBJECTIVES

To measure the prevalence, predictors, and posthospitalization outcomes associated with the overlap syndrome of coexisting depression and incident delirium in older hospitalized patients.

DESIGN

Secondary analysis of prospective cohort data from the control group of the Delirium Prevention Trial.

SETTING

General medical service of an academic medical center. Follow-up interviews at 1 month and 1 year post-hospital discharge.

PARTICIPANTS

Four hundred fifty-nine patients aged 70 and older who were not delirious at hospital admission.

MEASUREMENTS

Depressive symptoms assessed at hospital admission using the 15-item Geriatric Depression Scale (cutoff score of 6 used to define depression), daily assessments of incident delirium from admission to discharge using the Confusion Assessment Method, activities of daily living at admission and 1 month postdischarge, and new nursing home placement and mortality determined at 1 year.

RESULTS

Of 459 participants, 23 (5.0%) had the overlap syndrome, 39 (8.5%) delirium alone, 121 (26.3%) depression alone, and 276 (60.1%) neither condition. In adjusted analysis, patients with the overlap syndrome had higher odds of new nursing home placement or death at 1 year (adjusted odds ratio (AOR)=5.38, 95% confidence interval (CI)=1.57-18.38) and 1-month functional decline (AOR=3.30, 95% CI=1.14-9.56) than patients with neither condition.

CONCLUSION

The overlap syndrome of depression and delirium is associated with significant risk of functional decline, institutionalization, and death. Efforts to identify, prevent, and treat this condition may reduce the risk of adverse outcomes in older hospitalized patients.

Healthcare proxies of nursing home residents with advanced dementia: decisions they confront and their satisfaction with decision-making

OBJECTIVES

To describe the medical decisions confronting healthcare proxies (HCPs) of nursing home (NH) residents with advanced dementia and to identify factors associated with greater decision-making satisfaction.

DESIGN

Prospective cohort study.

SETTING

Twenty-two Boston-area NHs.

PARTICIPANTS

Three hundred twenty-three NH residents with advanced dementia and their HCPs.

MEASUREMENTS

Decisions made by HCPs over 18 months were ascertained quarterly. After making a decision, HCPs completed the Decision Satisfaction Inventory (DSI) (range 0-100). Independent variables included HCP and resident sociodemographic characteristics, health status, and advance care planning. Multivariable linear regression identified factors associated with higher DSI scores (greater satisfaction).

RESULTS

Of 323 HCPs, 123 (38.1%) recalled making at least one medical decision; 232 decisions were made, concerning feeding problems (27.2%), infections (20.7%), pain (12.9%), dyspnea (8.2%), behavior problems (6.9%), hospitalizations (3.9%), cancer (3.0%), and other complications (17.2%). Mean DSI score +/- standard deviation was 78.4 +/- 19.5, indicating high overall satisfaction. NH provider involvement in shared decision-making was the area of least satisfaction. In adjusted analysis, greater decision-making satisfaction was associated with the resident living on a special care dementia unit (P=.002), greater resident comfort (P=.004), and the HCP not being the resident's child (P=.02).

CONCLUSION

HCPs of NH patients with advanced dementia can most commonly expect to encounter medical decisions relating to feeding problems, infections, and pain. Inadequate support from NH providers is the greatest source of HCP dissatisfaction with decision-making. Greater resident comfort and care in a special care dementia unit are potentially modifiable factors associated with greater decision-making satisfaction.

Beneath the surface: discovering the unvoiced concerns of older adults with type 2 diabetes mellitus

Emerging clinical guidelines recommend shared decision making to individualize drug regimens for older adults with Type 2 diabetes mellitus. While the current health education campaign for diabetes in the United States recommends physician-initiated medication-related discussions about adherence and side effects, little emphasis is placed on soliciting patient concerns. This study's aim was to explore the concerns of older adults with diabetes about the complexity of their drug regimens and to determine whether they discussed medication-related concerns with their physician. Twenty-two patients with Type 2 diabetes age 65 years and older who used five or more medications were selected from an urban academic geriatric medicine practice in the United States. In-depth semi-structured interviews were conducted to uncover participants' perceptions of multiple medication use and related discussions with providers. The predominant theme that emerged was the variability in medication-related topics that patients perceived they could discuss with their physician. While most participants described physician-initiated discussions about adherence and side effects, many did not bring up concerns about medication cost or their desire to reduce medication burden. In order to encourage greater patient involvement in medication decision making for diabetes treatment, educational messages promoting patient-physician dialogue need to take more account of patient concerns.

Stigma and the acceptability of depression treatments among african americans and whites

BACKGROUND

Stigma is associated with depression treatment, however, whether stigma differs between depression treatment modalities is not known, nor have racial differences in depression treatment stigma been fully explored.

OBJECTIVE

To measure stigma for four depression treatments and estimate its association with treatment acceptability for African Americans and whites.

DESIGN

Cross-sectional, anonymous mailed survey.

PARTICIPANTS

Four hundred and ninety African-American and white primary care patients.

MEASUREMENTS

The acceptability of four depression treatments (prescription medication, mental health counseling, herbal remedy, and spiritual counseling) was assessed using a vignette. Treatment-specific stigma was evaluated by asking whether participants would: (1) feel ashamed; (2) feel comfortable telling friends and family; (3) feel okay if people in their community knew; and (4) not want people at work to know about each depression treatment. Sociodemographics, depression history, and current depressive symptoms were measured.

RESULTS

Treatment-specific stigma was lower for herbal remedy than prescription medication or mental health counseling (p < .01). Whites had higher stigma than African Americans for all treatment modalities. In adjusted analyses, stigma relating to self [AOR 0.43 (0.20-0.95)] and friends and family [AOR 0.42 (0.21-0.88)] was associated with lower acceptability of mental health counseling. Stigma did not account for the lower acceptability of prescription medication among African Americans.

CONCLUSIONS

Treatment associated stigma significantly affects the acceptability of mental health counseling but not prescription medication. Efforts to improve depression treatment utilization might benefit from addressing concerns about stigma of mental health counseling.

Ethnicity and preferences for depression treatment

OBJECTIVE

The objective of this work was to describe ethnic differences in attitudes toward depression, depression treatment, stigma and preferences for depression treatment (counseling vs. medication).

METHOD

This study used a cross-sectional Internet survey measuring treatment preference, stigma and attitudes toward depression. Depressive symptoms were measured with the Center for Epidemiological Studies Depression (CES-D) scale. Multivariable regression models adjusting for treatment attitudes and demographics estimated the independent effect of ethnicity on treatment preference.

RESULTS

A total of 78,753 persons with significant depressive symptoms (CES-D>22), including 3596 African Americans, 2794 Asians/Pacific Islanders and 3203 Hispanics, participated. Compared to whites, African Americans, Asians/Pacific Islanders and Hispanics were more likely to prefer counseling to medications [odds ratio (OR)=2.6, 95% confidence interval (95% CI)=2.4-2.8; OR=2.5, 95% CI=2.2-2.7; and OR=1.8, 95% CI=1.7-2.0, respectively]. Ethnic minorities were less likely to believe that medications were effective and that depression was biologically based, but were more likely to believe that antidepressants were addictive and that counseling and prayer were effective in treating depression. Attitudes and beliefs somewhat attenuated the association between ethnicity and treatment preference in adjusted analyses.

CONCLUSION

Racial and ethnic minorities prefer counseling for depression treatment more than whites. Beliefs about the effects of antidepressants, prayer and counseling partially mediate preferences for depression treatment.

Older patients' aversion to antidepressants. A qualitative study

BACKGROUND

Depression is common among older patients yet is often inadequately treated. Patient beliefs about antidepressants are known to affect treatment initiation and adherence, but are often not expressed in clinical settings.

OBJECTIVE

To explore attitudes toward antidepressants in a sample of depressed, community-dwelling elders who were offered treatment. DESIGN. Cross-sectional, qualitative study utilizing semi-structured interviews.

PARTICIPANTS

Primary care patients age 60 years and over with depression, from academic and community primary care practices of the University of Pennsylvania Health System and the Philadelphia Department of Veterans Affairs. Patients participated in either the Prevention of Suicide in Primary Care Elderly: Collaborative Trial or the Primary Care Research in Substance Abuse and Mental Health for the Elderly Trial. Sixty-eight patients were interviewed and responses from 42 participants with negative attitudes toward medication for depression were analyzed.

MEASUREMENTS

Interviews were audiotaped, transcribed, and entered into a qualitative software program for coding and analysis. A multidisciplinary team of investigators coded the transcripts and identified key features of narratives expressing aversion to antidepressants.

RESULTS

Four themes characterized resistance to antidepressants: (1) fear of dependence; (2) resistance to viewing depressive symptoms as a medical illness; (3) concern that antidepressants will prevent natural sadness; (4) prior negative experiences with medications for depression.

CONCLUSIONS

Many elders resisted the use of antidepressants. Patients expressed concerns that seem to reflect their concept of depression as well as their specific concerns regarding antidepressants. These findings may enhance patient-provider communication about depression treatment in elders.

Factors associated with undertreatment of medical student depression

The authors measured factors associated with under-treatment of medical students' depression. They administered a cross-sectional Beck Depression Inventory and sociodemographic questionnaire to students at 1 medical school, defining their outcome measure as the use of counseling services or antidepressant medication. Of an estimated 450 available student participants in the study, 322 (71.6%) completed the questionnaire. Forty-nine students (15.2%) were classified as depressed and 10 (20.4%) reported experiencing suicidal ideation during medical school, but only 13 (26.5%) of the depressed students reported treatment. The researchers observed no difference in treatment by year in school, completion of psychiatric requirement, race, or depression severity. Treatment for depression was significantly associated with older age and personal and family histories of depression. Despite the availability of effective medications and confidential mental health services, medical students with depression are undertreated. The authors' findings support the need for targeted messages to help medical students recognize their depression and refer themselves for appropriate treatment.

Depressed medical students' use of mental health services and barriers to use

PURPOSE

Depression is an underrecognized yet common and treatable disorder among medical students. Little is known about the rate of mental health service use by depressed medical students. This study sought to determine the level of mental health service use by depressed medical students and their reported barriers to use.

METHOD

In the spring of 1994, a one-time survey of 194 first- and second-year medical students was conducted in the School of Medicine at the University of California, San Francisco. Outcome measures were self-reported use of counseling services, barriers to use, suicidal ideation, and depressive symptoms as measured by the 13-item Beck Depression Inventory (BDI).

RESULTS

Twenty-four percent (n = 46) of the medical students were depressed by BDI criteria. Of the depressed students, only 22% (n = 10) were using mental health counseling services. The most frequently cited barriers to using these services were lack of time (48%), lack of confidentiality (37%), stigma associated with using mental health services (30%), cost (28%), fear of documentation on academic record (24%), and fear of unwanted intervention (26%).

CONCLUSION

These data demonstrate that depression among medical students may be undertreated. Medical schools can assist depressed students by addressing issues such as the stigma of using mental health services, confidentiality, and documentation. Early treatment of impaired future caregivers may have far-reaching implications for the individual students, their colleagues, and their future patients.