Cognitive Performance at Time of AD Diagnosis: A Clinically Augmented Register-Based Study

We aimed to evaluate the feasibility of using real-world register data for identifying persons with mild Alzheimer’s disease (AD) and to describe their cognitive performance at the time of diagnosis. Patients diagnosed with AD during 2010–2013 (aged 60–81 years) were identified from the Finnish national health registers and enlarged with a smaller private sector sample (total n = 1,268). Patients with other disorders impacting cognition were excluded. Detailed clinical and cognitive screening data (the Consortium to Establish a Registry for Alzheimer’s Disease neuropsychological battery [CERAD-nb]) were obtained from local health records. Adequate cognitive data were available for 389 patients with mild AD (31%) of the entire AD group. The main reasons for not including patients in analyses of cognitive performance were AD diagnosis at a moderate/severe stage (n = 266, 21%), AD diagnosis given before full register coverage (n = 152, 12%), and missing CERAD-nb data (n = 139, 11%). The cognitive performance of persons with late-onset AD (n = 284), mixed cerebrovascular disease and AD (n = 51), and other AD subtypes (n = 54) was compared with that of a non-demented sample (n = 1980) from the general population. Compared with the other AD groups, patients with late-onset AD performed the worst in word list recognition, while patients with mixed cerebrovascular disease and AD performed the worst in constructional praxis and clock drawing tests. A combination of national registers and local health records can be used to collect data relevant for cognitive screening; today, the process is laborious, but it could be improved in the future with refined search algorithms and electronic data.

Education-Based Cutoffs for Cognitive Screening of Alzheimer's Disease

INTRODUCTION

The educational background and size of the elderly population are undergoing significant changes in Finland during the 2020s. A similar process is likely to occur also in several European countries. For cognitive screening of early Alzheimer's disease (AD), using outdated norms and cutoff scores may negatively affect clinical accuracy. The aim of the present study was to examine the effects of education, age, and gender on the Consortium to Establish a Registry for Alzheimer's Disease neuropsychological battery (CERAD-nb) in a large register-based, clinical sample of patients with mild AD and nondemented at-risk persons from the general population (controls) and to examine whether corrected cutoff scores would increase the accuracy of differentiation between the 2 groups.

METHODS

CERAD-nb scores were obtained from AD patients (n = 389, 58% women, mean age 74.0 years) and from controls (n = 1,980, 52% women, mean age 68.5 years). The differences in CERAD-nb performance were evaluated by univariate GLM. Differentiation between the 2 groups was evaluated using a receiver operating characteristic (ROC) curve, where a larger area under the ROC curve represents better discrimination. Youden's J was calculated for the overall performance and accuracy of each of the measures.

RESULTS

Of the demographic factors, education was the strongest predictor of CERAD-nb performance, explaining more variation than age or gender in both the AD patients and the controls. Education corrected cutoff scores had better diagnostic accuracy in discriminating between the AD patients and controls than existing uncorrected scores. The highest level of discrimination between the 2 groups overall was found for two CERAD-nb total scores.

CONCLUSIONS

Education-corrected cutoff scores were superior to uncorrected scores in differentiating between controls and AD patients especially for the highest level of education and should therefore be used in clinical cognitive screening, also as the proportion of the educated elderly is increasing substantially during the 2020s. Our results also indicate that total scores of the CERAD-nb are better at discriminating AD patients from controls than any single subtest score. A digital tool for calculating the total scores and comparing education-based cutoffs would increase the efficiency and usability of the test.

Training Staff in Long-Term Care Facilities-Effects on Residents' Symptoms, Psychological Well-Being, and Proxy Satisfaction

CONTEXT

Long-term care facility (LTCF) residents have unmet needs in end-of-life and symptom care.

OBJECTIVES

This study examines the effects of an end-of-life care staff training intervention on LTCF residents' pain, symptoms, and psychological well-being and their proxies' satisfaction with care.

METHODS

We report findings from a single-blind, cluster randomized controlled trial featuring 324 residents with end-of-life care needs in 20 LTCF wards in Helsinki. The training intervention included four 4-hour educational workshops on palliative care principles (advance care planning, adverse effects of hospitalizations, symptom management, communication, supporting proxies, challenging situations). Training was provided to all members of staff in small groups. Education was based on constructive learning methods and included participants' own resident cases, role-plays, and small-group discussions. During a 12-month follow-up we assessed residents' symptoms with the Edmonton Symptom Assessment Scale (ESAS), pain with the PAINAD instrument and psychological well-being using a PWB questionnaire. Proxies' satisfaction with care was assessed using the SWC-EOLD.

RESULTS

The change in ESAS symptom scores from baseline to 6 months favored the intervention group compared with the control group. However, the finding was diluted at 12 months. PAINAD, PWB, and SWC-EOLD scores remained unaffected by the intervention. All follow-up analyses were adjusted for age, gender, do-not-resuscitate order, need for help, and clustering.

CONCLUSION

Our rigorous randomized controlled trial on palliative care training intervention demonstrated mild effects on residents' symptoms and no robust effects on psychological well-being or on proxies' satisfaction with care.

Effects of Staff Training on Nursing Home Residents' End-Of-Life Care: A Randomized Controlled Trial

OBJECTIVES

This trial examines the effects of end-of-life training on long-term care facility (LTCF) residents' health-related quality of life (HRQoL) and use and costs of hospital services.

DESIGN

A single-blind, cluster randomized (at facility level) controlled trial (RCT). Our training intervention included 4 small-group 4-hour educational sessions on the principles of palliative and end-of-life care (advance care planning, adverse effects of hospitalizations, symptom management, communication, supporting proxies, challenging situations). Training was provided to all members of staff. Education was based on constructive learning methods and included resident cases, role-plays, and small-group discussions.

SETTING AND PARTICIPANTS

We recruited 324 residents with possible need for end-of-life care due to advanced illness from 20 LTCF wards in Helsinki.

METHODS

Primary outcome measures were HRQoL and hospital inpatient days per person-year during a 2-year follow-up. Secondary outcomes were number of emergency department visits and cost of all hospital services.

RESULTS

HRQoL according to the 15-Dimensional Health-Related Quality-of-Life Instrument declined in both groups, and no difference was present in the changes between the groups (P for group .75, adjusted for age, sex, do-not-resuscitate orders, need for help, and clustering). Neither the number of hospital inpatient days (1.87 vs 0.81 per person-year) nor the number of emergency department visits differed significantly between intervention and control groups (P for group .41). The total hospital costs were similar in the intervention and control groups.

CONCLUSIONS AND IMPLICATIONS

Our rigorous RCT on end-of-life care training intervention demonstrated no effects on residents' HRQoL or their use of hospitals. Unsupported training interventions alone might be insufficient to produce meaningful care quality improvements.

Monetary value of informal caregiving in dementia from a societal perspective

BACKGROUND

Dementia is a condition which results in a high cost of care, a significant proportion of which is the cost associated with informal care. In previous studies, informal caregiving has been challenging to assess due to difficulties in estimating the true time spent on caregiving work and how to value caregivers' time. The aim of this study was to compare the costs of dementia among patients living alone and among those living with a caregiver to show the monetary value of informal caregiving from a societal perspective.

METHODS

Data from our four dementia trials using the same measures were combined, allowing the inclusion of 604 participants. Participants were followed up for 2 years or until death for their use of health and social services. Use of all services was retrieved from medical/social records. We also included the costs of lost productivity of those caregivers who were not retired.

RESULTS

The total mean cost of services and lost productivity was €22,068/person-year (pyrs). Participants living alone had a mean cost of €45,156/pyrs, whereas those living with a spouse had a mean cost of €16,416/pyrs (mean cost ratio 2.99, 95% confidence interval 2.64-3.39). Participants living alone and having <15 Mini-Mental State Examination points had higher costs than people with dementia in institutional care.

CONCLUSIONS

Detailed data of service use and characteristics of people with dementia showed that from a societal perspective, living alone is a very strong determinant of service use in dementia. Informal caregivers do invaluable work for society.

Delirium Café: interactive learning to enhance delirium care

PURPOSE

The aim of Delirium Café was to try a new learning method to increase awareness of delirium and improve delirium care in an acute hospital setting in Helsinki, Finland.

METHOD

World Café-an active learning method, with four facilitators and four stations covering important aspects of delirium recognition and management, was used.

RESULTS

22 junior doctors and 4 members of the senior staff participated in the event on 13th of March 2019, the World Delirium Awareness Day (WDAD). Nobody dropped out during the 1 h training. Feedback on the educational method was positive.

CONCLUSION

Delirium Café seems to be both feasible and applicable as a new interactive-learning method in postgraduate medical teaching.

Relationship of Neuropsychiatric Symptoms with Falls in Alzheimer's Disease - Does Exercise Modify the Risk?

OBJECTIVES

To explore how neuropsychiatric symptoms (NPS) are associated with number of falls and how exercise modifies the risk of falling in community-dwelling people with Alzheimer's disease (AD) and NPS.

DESIGN

Secondary analysis of a randomized controlled trial.

SETTING

Community.

PARTICIPANTS

Community-dwelling individuals with AD (N=210) who completed the Neuropsychiatric Inventory (NPI) (N = 179).

INTERVENTION

Participants were randomized into 3 groups: group-based exercise (4-hour sessions with approximately 1 hour of training) and tailored home-based exercise (1 hour of training) twice a week for 1 year and a control group receiving usual community care. In this secondary analysis, we merged the home-based and group-based exercise groups and compared this group with the control group.

MEASUREMENTS

NPS were measured using the NPI at baseline, and spousal caregivers recorded falls in daily fall diaries during 1 year of follow-up.

RESULTS

The number of falls increased linearly with NPI score in the control group. Fall rates were 1.48 (95% confidence interval (CI)=1.26-1.73) per person-year in the intervention group and 2.87 (95% CI=2.43-3.35) in the control group. Adjusted for age, sex, Mini-Mental State Examination (MMSE) score, and Short Physical Performance Battery (SPPB) score, incidence rate ratio (IRR) was 0.48 (95% Cl=0.39-0.60, p < .001). Main effects for fall rate were significant for group (p < .001) and NPI total (p < .02); the interaction effect was also significant (p = .009) (adjusted for sex, age, MMSE score, SPPB score, and psychotropic medication use).

CONCLUSION

Exercise may decrease the risk of falling in community-dwelling individuals with AD and NPS. Future exercise trials should confirm this finding in participants with significant NPS.

TRIAL REGISTRATION

ACTRN12608000037303. J Am Geriatr Soc 66:2377-2381, 2018.

Health-related quality of life as a predictor of mortality in heterogeneous samples of older adults

BACKGROUND

Health-related quality of life (HRQoL) is associated with survival in older people with multimorbidities and disabilities. However, older people differ in their characteristics, and less is known about whether HRQoL predicts survival in heterogeneous older population samples differing in their functional, cognitive, psychological or social disabilities. The aim of this study was to explore HRQoL in heterogeneous samples of older men and women, and to explore its prognostic significance for mortality.

METHODS

We analysed combined individual patient data from eight heterogeneous study samples all of which were assessed with the same methods. We used 15D, a generic, comprehensive instrument for measuring HRQoL, which provides a single index in addition to a profile. Two-year mortality was retrieved from central registers.

RESULTS

Health-related quality of life measurements with 15D were available for 3153 older adults. The mean HRQoL was highest among older businessmen (0.878) and lowest among nursing home residents (0.601). 15D predicted independently and significantly the 2-year survival in the total sample [hazard ratio (HR)/SD 0.44, 95% CI 0.40-0.48)]. However, 15D did not predict mortality in samples of spousal caregivers, lonely older adults and cardiovascular patients.

CONCLUSIONS

15D captures health and disability factors associated with prognosis whereas in older populations suffering from psychological and social impairments such as caregiver burden or loneliness HRQoL may not reflect their health risks.

Effects of Exercise on Functional Performance and Fall Rate in Subjects with Mild or Advanced Alzheimer's Disease: Secondary Analyses of a Randomized Controlled Study

BACKGROUND

Exercise improves functional performance in subjects with dementia. However, whether the benefits of exercise are evident in all stages of dementia remains uncertain. This study examines how people in different stages of Alzheimer's disease (AD) benefit from exercise intervention in their physical functioning and risk of falling.

METHODS

The present study is a subanalysis of a randomized controlled trial examining the effects of exercise intervention (twice a week for 12 months) in AD patients (n = 194). We studied the effects separately in participants with mild dementia and in participants with advanced dementia.

RESULTS

In subjects with mild dementia, the deterioration in physical functioning was slower in the intervention group than in the controls. Changes in Functional Independence Measure at 12 months were -2.7 (95% CI -0.5 to -4.9) in the intervention group and -10.1 (95% CI -7.0 to -13.3) in the control group (p < 0.001). The exercise intervention proved effective in preventing falls among patients with advanced AD, with an incidence rate ratio of 0.47 (95% CI 0.37-0.60; p < 0.001).

CONCLUSIONS

Regular exercise may slow the rate of functional deterioration in mild AD and reduce falls in patients suffering from advanced AD.

How Do Community-Dwelling Persons with Alzheimer Disease Fall? Falls in the FINALEX Study

BACKGROUND

People with dementia are at high risk for falls. However, little is known of the features causing falls in Alzheimer disease (AD). Our aim was to investigate how participants with AD fall.

METHODS

In the FINALEX (Finnish Alzheimer Disease Exercise Trial) study, participants' (n = 194) falls were followed up for 1 year by diaries kept by their spouses.

RESULTS

The most common reason for falls (n = 355) was stumbling (n = 61). Of the falls, 123 led to injuries, 50 to emergency department visits, and 13 to fractures. The participants without falls (n = 103) were younger and had milder dementia than those with 1 (n = 34) or ≥2 falls (n = 57). Participants with a Mini Mental State Examination score of around 10 points were most prone to fall. In adjusted regression models, good nutritional status, good physical functioning, and use of antihypertensive medication (incident rate ratio [IRR] 0.68, 95% confidence interval [CI] 0.54-0.85) protected against falls, whereas fall history (IRR 2.71, 95% CI 2.13-3.44), osteoarthritis, diabetes mellitus, chronic obstructive pulmonary disease, higher number of drugs, drugs with anticholinergic properties, psychotropics, and opioids (IRR 4.27, 95% CI 2.92-6.24) were risk factors for falls.

CONCLUSIONS

Our study provides a detailed account on how and why people with AD fall, suggesting several risk and protective factors.

Do you want to live to be 100? Answers from older people

BACKGROUND

little is known about the oldest-olds' views on ageing.

OBJECTIVE

to investigate older people's desire and the reasons they give for wanting to live to 100.

DESIGN

a postal questionnaire, analysed both quantitatively and qualitatively.

SETTING

population based in Helsinki, Finland.

SUBJECTS

a random sample (response rate 64%; N = 1,405) of community-dwelling older people (aged 75-96).

METHODS

a structured self-completed questionnaire with an open-ended question on the reasons why/why not participants wished/did not wish to live to 100.

RESULTS

one-third (32.9%) of home-dwelling older people wanted to live to be 100. Those who did were older, more often male and self-rated their health better than those who did not. Often the desire for long life was conditional: 'Yes, if I stay healthy'. Among the reasons is that many were curious to see what would happen. Many stated that they loved life, they had twinkle in their eye or significant life roles. Those who did not want to live extremely long lives gave various rationales: they would become disabled, life would be meaningless, they were reluctant to become a burden to others or they feared loss of autonomy or suffering pain or loneliness. Some people also shared the view that they should not intervene in destiny or they felt that they had accomplished what they wanted in life.

CONCLUSIONS

one-third of the oldest-old participants wanted to live to 100. Identifying what motivated them to desire long life could be a resource in their care plans.

Effects of Self-Management Groups for People with Dementia and Their Spouses--Randomized Controlled Trial

OBJECTIVES

To investigate the effect of self-management group rehabilitation for persons with dementia (PwD) and their spouses on their health-related quality of life (HRQoL), the cognition of the PwD, and the costs of health and social services.

DESIGN

A randomized controlled trial.

SETTING

Primary care and memory clinics in the Helsinki metropolitan area, Finland.

PARTICIPANTS

PwD (N = 136) and their spouses (N = 136).

INTERVENTION

Couples were randomized to usual care or eight-session self-management groups for PwD and concurrently for their spouses. Sessions aim to enhance self-efficacy and problem-solving skills and to provide peer support.

MEASUREMENTS

The primary outcome measures were the HRQoL of PwD (measured using a generic, comprehensive (15-dimensional), self-administered instrument (15D)) and spouses (measured using the RAND-36) and the spousal Sense of Competence Questionnaire (SCQ). Secondary outcome measures were PwD cognition (Verbal Fluency (VF), Clock Drawing Test (CDT)) and costs of health and social services during 24 months.

RESULTS

At 3 months, the spouse physical component of the RAND-36 improved (mean change 1.0, 95% confidence interval (CI) = -0.5 to 2.4) for those undergoing the intervention and worsened for controls (mean change -2.0, 95% CI = -3.5 to -0.4) (P = .006 adjusted for age, sex, baseline value of the physical component of the RAND-36). There were no differences between the groups on the mental component of the RAND-36, the SCQ, or the 15D. At 9 months, PwD change in VF was -0.38 (95% CI = -1.03 to 0.27) in intervention group and -1.60 (95% CI = -2.26 to -0.94) for controls (P = .011 adjusted for age, sex, baseline MMSE score). CDT changes were similar to VF changes. Differences in incremental costs between the groups was -436 € per person per year (95% CI = -4,986 to 4,115) for PwD (P = .35 adjusted for age, CDR) and -896 € per person per year (95% CI = -3,657 to 1,864) for spouses (P = .51 adjusted for PwD age, CDR).

CONCLUSIONS

The intervention had beneficial effects on the HRQoL of spouses and the cognitive function of PwD without increasing total costs.

TRIAL REGISTRATION

anzctr.org.au Identifier: ACTRN12611001173987.

Effects of Exercise on Cognition: The Finnish Alzheimer Disease Exercise Trial: A Randomized, Controlled Trial

OBJECTIVES

To examine whether a regular, long-term exercise program performed by individuals with Alzheimer's disease (AD) at home or as group-based exercise at an adult daycare center has beneficial effects on cognition; to examine secondary outcomes of a trial that has been published earlier.

DESIGN

Randomized, controlled trial.

SETTING

Community.

PARTICIPANTS

Community-dwelling dyads (N = 210) of individuals with AD and their spousal caregivers randomized into three groups.

INTERVENTION

Two types of intervention comprising customized home-based exercise (HE) and group-based exercise (GE), each twice a week for 1 year, were compared with a control group (CG) receiving usual community care.

MEASUREMENTS

Cognitive function was measured using the Clock Drawing Test (CDT), Verbal Fluency (VF), Clinical Dementia Rating (CDR), and Mini-Mental State Examination (MMSE) at baseline and 3, 6, and 12 months of follow-up.

RESULTS

Executive function, measured using CDT, improved in the HE group, and changes in the score were significantly better than those of the CG at 12 months (adjusted for age, sex, and CDR, P = .03). All groups deteriorated in VF and MMSE score during the intervention, and no significant differences between the groups were detected at 12-month follow-up when analyses were adjusted for age, sex, and CDR.

CONCLUSION

Regular, long-term, customized HE improved the executive function of community-dwelling older people with memory disorders, but the effects were mild and were not observed in other domains of cognition.

Effects of the Finnish Alzheimer disease exercise trial (FINALEX): a randomized controlled trial

IMPORTANCE

Few rigorous clinical trials have investigated the effectiveness of exercise on the physical functioning of patients with Alzheimer disease (AD).

OBJECTIVES

To investigate the effects of intense and long-term exercise on the physical functioning and mobility of home-dwelling patients with AD and to explore its effects on the use and costs of health and social services.

DESIGN

A randomized controlled trial.

SETTING AND PARTICIPANTS

A total of 210 home-dwelling patients with AD living with their spousal caregiver.

INTERVENTIONS

The 3 trial arms included (1) group-based exercise (GE; 4-hour sessions with approximately 1-hour training) and (2) tailored home-based exercise (HE; 1-hour training), both twice a week for 1 year, and (3) a control group (CG) receiving the usual community care.

MAIN OUTCOME MEASURES

The Functional Independence Measure (FIM), the Short Physical Performance Battery, and information on the use and costs of social and health care services.

RESULTS

All groups deteriorated in functioning during the year after randomization, but deterioration was significantly faster in the CG than in the HE or GE group at 6 (P = .003) and 12 (P = .015) months. The FIM changes at 12 months were -7.1 (95% CI, -3.7 to -10.5), -10.3 (95% CI, -6.7 to -13.9), and -14.4 (95% CI, -10.9 to -18.0) in the HE group, GE group, and CG, respectively. The HE and GE groups had significantly fewer falls than the CG during the follow-up year. The total costs of health and social services for the HE patient-caregiver dyads (in US dollars per dyad per year) were $25,112 (95% CI, $17,642 to $32,581) (P = .13 for comparison with the CG), $22,066 in the GE group ($15,931 to $28,199; P = .03 vs CG), and $34,121 ($24,559 to $43,681) in the CG.

CONCLUSIONS AND RELEVANCE

An intensive and long-term exercise program had beneficial effects on the physical functioning of patients with AD without increasing the total costs of health and social services or causing any significant adverse effects.

TRIAL REGISTRATION

anzctr.org.au Identifier: ACTRN12608000037303.

[Palliative (symptomatic) care of (imminently) dying patients]

The updated Current Care Guideline focuses on medical symptom treatment when curative treatment is no longer possible. Palliative care should be available to all dying patients at all health care levels. Pain should be treated prophylactically. Opioids are effective in cancer pain and should be chosen for moderate or severe pain in line with the WHO pain ladder. Treatment options for symptoms which call for acute interventions, such as intracranial hypertension, and options for dyspnoea, delirium, gastro-intestinal symptoms, ascites, dehydration and end-of-life treatment of elderly and demented patients are described.

Will-to-live and survival in a 10-year follow-up among older people

BACKGROUND

there is little research how older people's will-to-live predicts their survival.

OBJECTIVE

to investigate how many years home-dwelling older people wish to live and how this will-to-live predicts their survival.

METHODS

as a part of the Drugs and Evidence-Based Medicine in the Elderly (DEBATE) study, 400 home-dwelling individuals aged 75-90 were recruited into a cardiovascular prevention trial in Helsinki. In 2000, a questionnaire about the wishes of their remaining life was completed by 283 participants. Participants were inquired how many years they would still wish to live, and divided into three groups according to their response: group 1: wishes to live <5 years, group 2: 5-10 years, group 3: >10 years. Mortality was confirmed from central registers during a 10-year follow-up. The adjusted Cox proportional hazard model was used to determine how will-to-live predicted survival.

RESULTS

in group 1 wishing to live less than 5 years, the mean age and the Charlson comorbidity index were the highest, and subjective health the poorest. There were no differences between the groups in cognitive functioning or feeling depressed. Mortality was the highest (68.0%) among those wishing to live <5 years compared with those wishing to live 5-10 years (45.6%) or over 10 years (33.3%) (P < 0.001). With group 1 as referent (HR: 1.0) in the Cox proportional hazard model adjusting for age, gender, Charlson comorbidity index and depressive feelings, HR for mortality was 0.66 (95% CI: 0.45-0.95) (P = 0.027) and 0.47 (95% CI: 0.26-0.86) (P = 0.011) in groups 2 and 3, respectively.

CONCLUSION

the will-to-live was a strong predictor for survival among older people irrespective of age, gender and comorbidities.

Efficacy of physical exercise intervention on mobility and physical functioning in older people with dementia: a systematic review

Numerous trials have shown that physical activity and exercise training have beneficial effects in general older populations. However, few have studied its effectiveness among people with dementia. The aim of this systematic review is to examine the efficacy of trials using a rigorous randomised, controlled design and including physical activity or exercise as a major component of intervention on the physical functioning, mobility and functional limitations of people with dementia. We found 20 randomised controlled trials that included a total of 1378 participants. Of these, only three were of high methodological quality, and six of moderate quality. Nevertheless, these studies consistently show that intensive physical rehabilitation enhances mobility and, when administered over a long period, may also improve the physical functioning of patients with dementia.

Psychosocial group intervention to enhance self-management skills of people with dementia and their caregivers: study protocol for a randomized controlled trial

Background

After diagnosis of a dementing illness, patients and their spouses have many concerns related to the disease and their future. This often leads to poor psychological well-being and reduced health-related quality of life (HRQoL) of the family. Support for self-management skills has been proven to be an effective method to improve prognosis of asthma, heart failure and osteoarthritis. However, self-management interventions have not been studied in dementia. Therefore, our aim was to examine, in an objective-oriented group intervention, the efficacy of self-management support program (SMP) on the HRQoL of dementia patients and their spousal caregivers as well as on the sense of competence and psychological well-being of caregivers.

Methods

During the years 2011 to 12, 160 dementia patients and their spouses will be recruited from memory clinics and randomized into two arms: 80 patients for group-based SMP sessions including topics selected by the participants, 80 patients will serve as controls in usual community care. Sessions may include topics on dementia, community services, active lifestyle and prevention for cognitive decline, spousal relationship, future planning and emotional well-being. The patients and spouses will have their separate group sessions (ten participants per group) once a week for eight weeks. Main outcome measures will be patients’ HRQoL (15D) and spousal caregivers’ HRQoL (RAND-36), and sense of competence (SCQ). Secondary measures will be caregivers’ psychological well-being (GHQ-12) and coping resources, patients’ depression, cognition and signs of frailty. Data concerning admissions to institutional care and the use and costs of health and social services will be collected during a two-year follow-up.

Discussion

This is a ‘proof-of-concept’ study to explore the efficacy of group support for self-management skills among dementia families. It will also provide data on cost-effectiveness of the intervention.

Trial registration

ACTRN12611001173987

Reducing inappropriate, anticholinergic and psychotropic drugs among older residents in assisted living facilities: study protocol for a randomized controlled trial

BACKGROUND

Use of inappropriate drugs is common among institutionalized older people. Rigorous trials investigating the effect of the education of staff in institutionalized settings on the harm related to older people's drug treatment are still scarce. The aim of this trial is to investigate whether training professionals in assisted living facilities reduces the use of inappropriate drugs among residents and has an effect on residents' quality of life and use of health services.

METHODS AND DESIGN

During years 2011 and 2012, a sample of residents in assisted living facilities in Helsinki (approximately 212) will be recruited, having offered to participate in a trial aiming to reduce their harmful drugs. Their wards will be randomized into two arms: one, those in which staff will be trained in two half-day sessions, including case studies to identify inappropriate, anticholinergic and psychotropic drugs among their residents, and two, a control group with usual care procedures and delayed training. The intervention wards will have an appointed nurse who will be responsible for taking care of the medication of the residents on her ward, and taking any problems to the consulting doctor, who will be responsible for the overall care of the patient. The trial will last for twelve months, the assessment time points will be zero, six and twelve months. The primary outcomes will be the proportion of persons using inappropriate, anticholinergic, or more than two psychotropic drugs, and the change in the mean number of inappropriate, anticholinergic and psychotropic drugs among residents. Secondary endpoints will be, for example, the change in the mean number of drugs, the proportion of residents having significant drug-drug interactions, residents' health-related quality of life (HRQOL) according to the 15D instrument, cognition according to verbal fluency and clock-drawing tests and the use and cost of health services, especially hospitalizations.

DISCUSSION

To our knowledge, this is the first large-scale randomized trial exploring whether relatively light intervention, that is, staff training, will have an effect on reducing harmful drugs and improving QOL among institutionalized older people.

TRIAL REGISTRATION

ACTRN12611001078943.

Alzheimer's patients' spouses critiques of the support services

Introduction. Caregiving families of patients with dementia are often reluctant to use support services. The aim of this study was to describe their subjective critiques of these services. Material and Methods. A cross-sectional questionnaire was sent to a random sample (N = 1943) of Alzheimer's patients' spouses in Finland with an open-ended question: “What kind of problems have you faced with the services?” Their responses were analyzed with thematic content analysis. Results. Of the responders identifying themselves as caregivers (N = 1386), 728 (mean age 77.8, 65.1% females) responded. Opinions could be divided into two categories: (1) problems with the service application process (N = 296); (2) critiques of the services offered (N = 270) including either problems with community care support services or institutional care. 74 indicated that they had no need for services, and 15 praised the services they had received. Conclusions. From the caregiver's perspective, the service system is complicated, bureaucratic and works organization centredly.

Exercise rehabilitation on home-dwelling patients with Alzheimer's disease--a randomized, controlled trial. Study protocol

BACKGROUND

Besides cognitive decline, Alzheimer's disease (AD) leads to physical disability, need for help and permanent institutional care. The trials investigating effects of exercise rehabilitation on physical functioning of home-dwelling older dementia patients are still scarce. The aim of this study is to investigate the effectiveness of intensive exercise rehabilitation lasting for one year on mobility and physical functioning of home-dwelling patients with AD.

METHODS

During years 2008-2010, patients with AD (n = 210) living with their spousal caregiver in community are recruited using central AD registers in Finland, and they are offered exercise rehabilitation lasting for one year. The patients are randomized into three arms: 1) tailored home-based exercise twice weekly 2) group-based exercise twice weekly in rehabilitation center 3) control group with usual care and information of exercise and nutrition. Main outcome measures will be Guralnik's mobility and balance tests and FIM-test to assess physical functioning. Secondary measures will be cognition, neuropsychiatric symptoms according to the Neuropsychiatric Inventory, caregivers' burden, depression and health-related quality of life (RAND-36). Data concerning admissions to institutional care and the use and costs of health and social services will be collected during a two year follow-up.

DISCUSSION

To our knowledge this is the first large scale trial exploring whether home-dwelling patients with AD will benefit from intense and long-lasting exercise rehabilitation in respect to their mobility and physical functioning. It will also provide data on cost-effectiveness of the intervention.

TRIAL REGISTRATION

ACTRN12608000037303.

Family care as collaboration: effectiveness of a multicomponent support program for elderly couples with dementia. Randomized controlled intervention study

OBJECTIVES

To determine whether community care of people with dementia can be prolonged with a 2-year multicomponent intervention program and to analyze effects of the intervention on total usage and expenses of social and healthcare services.

DESIGN

Randomized controlled trial.

SETTING

Community-dwelling couples with one spouse caring for the other spouse with dementia.

PARTICIPANTS

Couples with dementia (N=125) were allocated at random to the intervention (n=63) or control group (n=62).

INTERVENTION

Intervention couples were provided with a multicomponent intervention program with a family care coordinator, a geriatrician, support groups for caregivers, and individualized services.

MEASUREMENTS

Time from enrollment to institutionalization of spouses with dementia and use of services and service expenditure of couples.

RESULTS

At 1.6 years, a larger proportion in the control group than in the intervention group was in long-term institutional care (25.8% vs 11.1%, P=.03). At 2 years, the difference was no longer statistically significant. The 2-year adjusted hazard ratio for the intervention group was 0.53 (95% confidence interval (CI)=0.23-1.19, P=.12). Intervention led to reduction in use of community services and expenditures. The difference for the benefit of intervention group was -7,985 Euro (95% CI=-16,081 to -1,499, P=.03). When the intervention costs were included, the differences between the groups were not significant.

CONCLUSION

Although the intervention did not result in a significant difference in the need for institutional care after 2 years, individualizing services in collaboration with families may lead to reduction in use of and expenditures on municipal services.

Predisposing and precipitating factors for delirium in a frail geriatric population

OBJECTIVE

The aim of this study was to assess the possible predisposing aetiologic and short-term precipitating factors for delirium in acutely ill hospital patients with a heavy burden of comorbidities and medications.

METHODS

Eighty-seven consecutive patients with acute delirium admitted to a general medicine unit were thoroughly examined, and the predisposing and precipitating factors of their delirium were assessed.

RESULTS

In this population, an average of 5.2 predisposing factors and 3.0 potential precipitating factors for delirium was revealed, meaning an average of over eight possible aetiological causes for each patient. The most common precipitating factors were infections (n=72), metabolic abnormalities (n=52), adverse drug effects (n=41), and cardiovascular events (n=38). In addition, a number of very rare conditions were diagnosed after thorough assessments.

CONCLUSION

Geriatric patients with acute delirium typically present with several concomitant predisposing factors for delirium exposing them to high vulnerability for the syndrome. In most patients, a number of possible etiological causes for delirium can be identified after a careful assessment, but their true pathogenetic pathway to the syndrome is unclear.

How do officially organized services meet the needs of elderly caregivers and their spouses with Alzheimer's disease?

The caregiving situation among caregivers and their spouses with Alzheimer's disease, the support and services received, the unmet needs, and the caregivers' satisfaction with the services are examined. The study included a survey of a random sample of 1943 caregivers of persons with Alzheimer's disease in Finland. Mean age of the caregivers was 78.2 years, and 35% had poor subjective health. Disabilities and behavioral symptoms were common among the spouses with Alzheimer's disease. The services most often offered were financial support (36%), technical devices (33%), physiotherapy (32%), and respite care in nursing homes (31%). Most often needed services were physiotherapy for the spouse with dementia (56%), financial support (50%), house-cleaning (41%), and home respite (40%). Only 39% of the caregivers were satisfied with the services, and 69% felt they did not have any influence on what services were offered. It was concluded that official services poorly meet the needs of these caregivers.

Older people's reasoning for resuscitation preferences and their role in the decision-making process

OBJECTIVES

To investigate older patients' reasoning for their cardiopulmonary resuscitation (CPR) preferences and the related decision-making process (DMP).

METHODS AND SUBJECTS

In a descriptive study 220 elderly home-dwelling cardiovascular patients were interviewed and asked to justify their CPR preferences according to the given statements. Questions related to DMP were asked and their physical function, cognition, mood, and quality of life were assessed.

RESULTS

Resuscitation preferences were associated with several patient characteristics, such as age, mood and quality of life. Patients preferring CPR (114/220, 52%) estimated their prognosis of CPR to be better than those preferring to forgo CPR. They justified their view: "Life is precious and worth living for me" (92%), "Maintaining life is a value of its own" (92%), "I feel needed by my family and my closest" (81%). Participants preferring to forgo CPR (106/220, 48%) justified: "I have already gained old age and led a full life" (88%), "People cannot decide these things" (72%). Only 9% of patients had discussed, and 38% would like to discuss preferences for life-sustaining treatments (LSTs) with their physician. However, 80% of respondents felt that the patients should take some part in the DMP; either alone (9%), together with a physician (23%), or together with a physician and a close relative (48%).

CONCLUSIONS

Older people justify their resuscitation preferences highlighting their experiences of meaningful life or fulfillment of their life, interpersonal relationships with their loved ones and presumed outcome of CPR. Less than a half of the patients wished to discuss CPR and LSTs preferences in their current situation with their physician, but nevertheless wanted to participate in the DMP of end-of-life treatment. Physicians should assess patients' own preferences in-depth.

Living Will, Resuscitation Preferences, and Attitudes towards Life in an Aged Population

BACKGROUND

The growth of life-sustaining medical technology and greater attention to medical care at the end of life have provoked interest in issues related to advance care planning.

OBJECTIVE

To investigate how having a living will (LW), resuscitation preferences, health condition, and life attitudes are related in home-dwelling elderly people.

METHODS

In a cross-sectional descriptive study, detailed assessments were made of 378 home-dwelling elderly individuals participating in a cardiovascular prevention study (DEBATE Study). The participants were inquired about a preexistence of a written document (LW) concerning life-sustaining care, preferences of cardiopulmonary resuscitation (CPR) in their current situation, and attitudes towards life. General health, physical and cognitive functioning, the presence of depression, and quality of life were also assessed.

RESULTS

Forty-four of the 378 participants (12%) had a LW. As compared with those without one (n = 334), there were more women [82% (36/44) vs. 63% (210/334)] and widows [57% (25/44) vs. 41% (135/334)] among those with a LW. They were also more educated and considered their health to be better. Despite having a LW, 46% (20/44) of them preferred CPR in their current condition, a proportion not statistically different from the 58% (194/334) of the individuals without a LW. In the whole sample, 39% (149/378) of the individuals preferred to forgo CPR. As compared with those preferring CPR, they were older, more often women, and widowed. Participants preferring to forgo CPR had a poorer quality of life, were more lonely, and showed signs of depression more often than those preferring CPR. The preference to forgo CPR was related to attitudes towards life regardless of physical or cognitive functioning.

CONCLUSIONS

Having a LW does not reduce the reported preference of CPR which is related more to current mental status and life attitudes. In-depth assessment of the patient's preferences should be performed in any comprehensive care plan.

Positive life orientation as a predictor of 10-year outcome in an aged population

OBJECTIVE

It is well known that depression predicts mortality in old age. However, little is known about the impact of positive emotions. We investigated the impact of positive life orientation on mortality and permanent institutional care in aged birth cohorts.

STUDY DESIGN AND SETTING

Participants (born 1904, 1909, and 1914) underwent detailed assessments with follow-up at 5 and at 10 years. Positive life orientation was determined as answering "yes" to all the following items: being satisfied with life, having zest for life, having plans for the future, feeling needed, seldom feeling lonely or depressed.

RESULTS

Of participants, 102 (20.8%) had a positive life orientation. After 10 years, 54.5% of them were alive, whereas in the rest of the sample 39.5% survived (P=.004). After controlling for age, gender, and health measures, the impact of positive life orientation was still significant (HR=0.89, 95% CI 0.83-0.93). At 5 years, only 2.9% of those having a positive life orientation but 17.5% of the rest of the sample were in permanent institutional care (P=0.003), with a positive life orientation remaining a significant protector against institutional care (OR 0.58, 95% CI 0.36-0.93).

CONCLUSION

Positive attitudes have a long-standing impact on prognosis in old age.

Advance orders to limit therapy in 67 long-term care facilities in Finland

OBJECTIVE

To assess the documentation of a do-not-attempt-resuscitation (DNAR) or do-not-hospitalize (DNH) orders in the medical record and to determine factors related to these orders.

MATERIALS AND METHODS

Five thousand six hundred and fifty four subjects from three different levels of institutional long-term care (LTC), chronic care hospitals (n = 1989), nursing homes (n = 3310), and assisted living (n = 335) in 67 LTC facilities in 19 municipalities were assessed.

RESULTS

Out of these patients, 751 (13%) had a DNAR order and only 36 (0.6%) had a DNH order. The variation in DNAR orders between individual LTC institutions was enormous, ranging from 0 to 92%. In logistic regression analysis, individual institutions and their local caring cultures had the strongest explanatory value (R(2) = 0.49) for advance orders to limit therapy. Impaired activity in daily living (ADL) function (R(2) = 0.11), impaired cognition (R(2) = 0.07), level of LTC (R(2) = 0.05), and diagnoses (R(2) = 0.04) did not provide adequate explanations. Terminal prognosis was not significantly associated with advance orders.

CONCLUSIONS

We found marked differences in the use of DNAR and DNH orders between caring units. Diseases and ADL status were only weakly significant as background factors. Open discussions, general guidelines, and research about the adequacy of DNAR decisions are needed to improve equality and self-empowerment among the elderly residing in institutions.