Improving the quality of care in nursing home organizations with urgent quality issues: design and effectiveness of a Dutch government-funded support programme

BACKGROUND

Various societal developments are currently challenging the ability of European nursing home organizations to meet quality standards. To support nursing home organizations throughout the Netherlands in quality improvement (QI), the Dutch government launched a nationwide programme in 2016 entitled 'Dignity and pride' (D&p). As part of this programme, participating nursing home organizations followed a tailored trajectory centred around intensive, on-site support from external expert coaches. For this study, we evaluated to what extent quality improvements were realized in the programme, paying particular attention to the role of the expert coaches.

METHODS

Thirty-six nursing home organizations were included. At the start of D&p, the majority of these organizations (78%) had major quality issues as determined by the Health Care Inspectorate. Information on quality of care at the start versus end of the programme was obtained from improvement plans and final evaluation reports. Quality of person-centred care (PCC) and resident safety were quantified using a standardized assessment tool based on national guidelines, with improvements analysed using two-sided paired-sample T-tests. In addition, semi-structured interviews were conducted with 14 coaches and 29 healthcare professionals, focusing on the greatest benefits of programme participation and on the added value of the expert coaches.

RESULTS

After completion of the programme, 60% of the organizations scored a 4 (= good) on PCC and resident safety, and none scored a 2 or less (average improvement on a 5-point scale for both themes: 1.9 points, p < 0.001). Interviewees confirmed that the quality of care had both improved and become more person-centred. The expert coaches were credited with substantially contributing to the QI process by offering an outsider's perspective, bringing in experience and expertise, and helping the organization stay committed and focused.

CONCLUSIONS

Our study results suggest that the D&p programme was associated with improved quality of care in nursing home organizations with urgent quality issues. However, offering on-site tailored support through a nationally coordinated, government-funded programme is both time- and labour-intensive, and therefore not feasible in every healthcare setting. Nevertheless, the findings provide valuable insights for future QI support strategies.

[Quality improvement as a joint task]

This article presents the key elements of the quality measure included in the Dignity and Pride program of the Dutch Ministry of Health, Welfare and Sport in cooperation with Vilans, the national centre of expertise for long-term care in the Netherlands. Nursing homes take part in the quality measure at the start of the program to investigate where they stand with respect to the nursing home quality framework.

Cortical Microinfarcts and White Matter Connectivity in Memory Clinic Patients

Background and purpose: Cerebral microinfarcts (CMIs) are associated with cognitive impairment and dementia. CMIs might affect cognitive performance through disruption of cerebral networks. We investigated in memory clinic patients whether cortical CMIs are clustered in specific brain regions and if presence of cortical CMIs is associated with reduced white matter (WM) connectivity in tracts projecting to these regions.

Methods:164 memory clinic patients with vascular brain injury with a mean age of 72 ± 11 years (54% male) were included. All underwent 3 tesla MRI, including a diffusion MRI and cognitive testing. Cortical CMIs were rated according to established criteria and their spatial location was marked. Diffusion imaging-based tractography was used to reconstruct WM connections and voxel based analysis (VBA) to assess integrity of WM directly below the cortex. WM connectivity and integrity were compared between patients with and without cortical CMIs for the whole brain and regions with a high CMI burden.

Results:30 patients (18%) had at least 1 cortical CMI [range 1–46]. More than 70% of the cortical CMIs were located in the superior frontal, middle frontal, and pre- and postcentral brain regions (covering 16% of the cortical surface). In these high CMI burden regions, presence of cortical CMIs was not associated with WM connectivity after correction for conventional neuroimaging markers of vascular injury. WM connectivity in the whole brain and WM voxels directly underneath the cortical surface did not differ between patients with and without cortical CMIs.

Conclusion:Cortical CMIs displayed a strong local clustering in highly interconnected frontal, pre- and postcentral brain regions. Nevertheless, WM connections projecting to these regions were not disproportionally impaired in patients with compared to patients without cortical CMIs. Alternative mechanisms, such as focal disturbances in cortical structure and functioning, may better explain CMI associated cognitive impairment.

Brain imaging correlates of mild cognitive impairment and early dementia in patients with type 2 diabetes mellitus

BACKGROUND AND AIMS

The risk of mild cognitive impairment and dementia is increased in type 2 diabetes mellitus (T2DM). We aimed to identify the neuroanatomical correlates of mild cognitive impairment (MCI) and early dementia in patients with T2DM, using advanced multimodal MRI.

METHODS AND RESULTS

Twenty-five patients (≥70 years) with T2DM and MCI (n = 22) or early dementia (n = 3) were included. The reference group consisted of 23 patients with T2DM with intact cognition. All patients underwent a 3 T MRI. Brain volumes and white matter hyperintensity volumes were obtained with automated segmentation methods. White matter connectivity was assessed with diffusion tensor imaging and fiber tractography. Infarcts and microbleeds were rated visually. Compared to patients without cognitive impairment, those with impairment had a lower grey matter volume (effect size: -0.58, p=0.042), especially in the right temporal lobe and subcortical brain regions (effect sizes: -0.45 to -0.91, false discovery rate corrected p < 0.05). White matter volume (effect size: -0.47, p = 0.11) and white matter connectivity (effect size: 0.55, p = 0.054) were also reduced in patients with versus without cognitive impairment, albeit not statistically significant. White matter hyperintensity volumes and occurrence of other vascular lesions did not differ between the two patient groups.

CONCLUSION

In patients with T2DM, grey matter atrophy rather than vascular brain injury appears to be the primary imaging correlate of MCI and early dementia.

Intracranial atherosclerosis and cerebral small vessel disease in intracerebral hemorrhage patients

BACKGROUND

The association between cerebral small vessel diseases (cSVD) and intracranial atherosclerosis is debated and conflicting results have been reported. We sought to investigate this association in patients with intracerebral hemorrhage (ICH), due to severe cSVD.

METHODS

Consecutive ICH patients were divided into those meeting criteria for cerebral amyloid angiopathy (CAA) and those with deep hypertensive ICH consistent with hypertensive cSVD (HTN-SVD). White matter hyperintensity volumes (WMH) and microbleed counts (MB) were measured on MRI. CTA was rated for severity of intracranial carotid calcifications and for presence of >50% intracranial stenosis (ICS). Associations of intracranial atherosclerosis severity with type of SVD (CAA vs HTN-cSVD) and with imaging and clinical markers of cSVD burden were analyzed.

RESULTS

The cohort included 253 CAA and 90 HTN-SVD patients. In multivariable models, the type of cSVD (CAA vs. HTN-cSVD) was not associated with calcification severity (OR=1.04, 95% CI [0.62-3.5], p=0.37) or presence of ICS (OR=0.84, 95% CI [0.21-2.74], p=0.78). We found no association between intracranial atherosclerosis (calcifications and stenoses) and parenchymal markers of cSVD severity (WMH and MB, adjusted p≥0.2 for all comparisons) and no association with presence of dementia before ICH (adjusted p≥0.2 for both comparisons).

CONCLUSIONS

We found no association between intracranial atherosclerosis and parenchymal or clinical consequences of cSVD, suggesting that cSVDs while sharing some risk factors are not influenced by upstream larger vessel pathologies.

Cortical atrophy in patients with cerebral amyloid angiopathy: a case-control study

BACKGROUND

Loss of cortical grey matter is a diagnostic marker of many neurodegenerative diseases, and is a key mediator of cognitive impairment. We postulated that cerebral amyloid angiopathy (CAA), characterised by cortical vascular amyloid deposits, is associated with cortical tissue loss independent of parenchymal Alzheimer's disease pathology. We tested this hypothesis in patients with hereditary cerebral haemorrhage with amyloidosis-Dutch type (HCHWA-D), a monogenetic disease with minimal or no concomitant Alzheimer's disease pathology, as well as in patients with sporadic CAA and healthy and Alzheimer's disease controls.

METHODS

In this observational case-control study, we included six groups of participants: patients diagnosed with HCHWA-D using genetic testing; healthy controls age-matched to the HCHWA-D group; patients with probable sporadic CAA without dementia; two independent cohorts of healthy controls age-matched to the CAA group; and patients with Alzheimer's disease age-matched to the CAA group. De-identified (but unmasked) demographic, clinical, radiological, and genetic data were collected at Massachusetts General Hospital (Boston, MA, USA), at Leiden University (Leiden, Netherlands), and at sites contributing to Alzheimer's Disease Neuroimaging Initiative (ADNI). The primary outcome measure was cortical thickness. The correlations between cortical thickness and structural lesions, and blood-oxygen-level-dependent time-to-peak (BOLD-TTP; a physiological measure of vascular dysfunction) were analysed to understand the potential mechanistic link between vascular amyloid and cortical thickness. The radiological variables of interest were quantified using previously validated computer-assisted tools, and all results were visually reviewed to ensure their accuracy.

RESULTS

Between March 15, 2006, and Dec 1, 2014, we recruited 369 individuals (26 patients with HCHWA-D and 28 age-matched, healthy controls; 63 patients with sporadic CAA without dementia; two healthy control cohorts with 63 and 126 individuals; and 63 patients with Alzheimer's disease). The 26 patients with HCHWA-D had thinner cortices (2·31 mm [SD 0·18]) than the 28 healthy controls (mean difference -0·112 mm, 95% CI -0·190 to -0·034, p=0·006). The 63 patients with sporadic CAA without dementia had thinner cortices (2·17 mm [SD 0·11]) than the two healthy control cohorts (n=63, mean difference -0·14 mm, 95% CI -0·17 to -0·10, p<0·0001; and n=126, -0·10, -0·13 to -0·06, p<0·0001). All differences remained independent in multivariable analyses. The 63 patients with Alzheimer's disease displayed more severe atrophy than the patients with sporadic CAA (2·1 mm [SD 0·14], difference 0·07 mm, 95% CI 0·11 to 0·02, p=0·005). We found strong associations between cortical thickness and vascular dysfunction in the patients with HCHWA-D (ρ=-0·58, p=0·003) or sporadic CAA (r=-0·4, p=0·015), but not in controls. Vascular dysfunction was identified as a mediator of the effect of hereditary CAA on cortical atrophy, accounting for 63% of the total effect.

INTERPRETATION

The appearance of cortical thinning in patients with HCHWA-D indicates that vascular amyloid is an independent contributor to cortical atrophy. These results were reproduced in patients with the more common sporadic CAA. Our findings also suggest that CAA-related cortical atrophy is at least partly mediated by vascular dysfunction. Our results also support the view that small vessel diseases such as CAA can cause cortical atrophy even in the absence of Alzheimer's disease, a conclusion that can help radiologists, neurologists, and other clinicians who diagnose these common geriatric conditions.

FUNDING

National Institutes of Health.

Abstract TP462: Cognitive Profile of Non-demented Cerebral Amlyoid Angiopathy Patients

Objective: To characterize the neuropsychological profile of sporadic cerebral amyloid angiopathy (CAA) patients without dementia and to determine the association between cognitive performance in different domains and neuroimaging lesions characteristic of CAA.

Methods: Forty-eight CAA patients were compared to 138 cognitively normal subjects (CN) using a standard neuropsychological test battery designed to assess the cognitive profile in CAA patients without dementia. Total brain volume (TBV), white matter hyperintensities (WMH), number of cerebral microbleeds (CMBs), hippocampal volume (HV) and the presence of cerebral superficial siderosis (cSS) of all CAA patients were measured. The association between these neuroimaging markers and neuropsychological performance in different cognitive domains in the CAA group were analyzed.

Results: Patients with CAA had significantly worse performance on all individual neuropsychological domain tested when compared to the CN group. The cognitive decline of CAA patients was most noticeable in tests for processing speed (Z score -1.84±1.50), then followed by executive function (Z score -1.03±1.04), semantic fluency (Z score -0.71±1.07), episodic memory (Z score -0.68±1.08), and attention (Z score -0.48±1.00). Total brain volume of the CAA patients was correlated with processing speed (β=0.358, P=0.034) and executive function (β=0.507, P=0.002).

Conclusion: Non-demented patients with CAA had cognitive deficits in multiple areas. Lower total brain volume was related to slower processing speed and worse executive function.

Abstract 47: White Matter Atrophy in Cerebral Amyloid Angiopathy

Background/Purpose: Cerebral Amyloid Angiopathy (CAA) leads to leukoaraiosis, lacunar infarcts and cortical tissue loss. We hypothesized that CAA is also associated with white matter atrophy (WMA).

Methods: We have compared volumetric multimodal MRIs from 72 prospectively enrolled non-demented patients with probable CAA (per Boston criteria), to 3 other well-studied cohorts: 289 Healthy Controls (HC) from the Harvard Aging Brain (HAB) study, 231 HC and 198 patients with AD from the Alzheimer’s Disease Neuroimaging Initiative (ADNI). Validated FreeSurfer algorithms were used to calculate White Matter Volume (WMV), white matter hyperintensity volume (WMHv), and cortical thickness. Microbleeds (MBs) were counted on SWI-MRI. Measures were obtained from the contralateral hemisphere if intracerebral hemorrhage present. All volumes were corrected for total intracranial volume (ICV), so reported as percent of ICV.

Results: The CAA patients were significantly younger (mean age: 70.1) compared to both HC cohorts (ADNI-HC: 76.0, p<0.001, HAB-HC: 73.8, p < 0.001), and to patients with AD (75.5, p < 0.001). Despite being younger, patients with CAA presented significantly lower global WMV (28% ± 2.6) than both ADNI-HC (29.2% ± 2.2, p < 0.001), HAB-HC (29.0% ± 2.5, p = 0.001), and patients with AD (28.7% ± 2.2, p = 0.02) [Figure]. The association persisted after correcting for age, gender and WMHv. Within the CAA cohort, there was a negative correlation between WMV and lobar MB counts (rho = -0.26, p = 0.03), it remained significant after correcting for age, gender, WMHv (p=0.016). There were no significant associations however between WMV and neither WMHv, nor cortical thickness (both p>0.2).

Conclusions: Patients with CAA show WMA when compared to older HC and AD. WMA independently correlates with MBs, a marker of CAA severity. Consistent spatial patterns of atrophy especially in posterior regions when compared to both HC and AD [Figure] might represent the “WMA signature of CAA”.

White matter hyperintensity patterns in cerebral amyloid angiopathy and hypertensive arteriopathy

OBJECTIVE

To identify different white matter hyperintensity (WMH) patterns between 2 hemorrhage-prone cerebral small vessel diseases (SVD): cerebral amyloid angiopathy (CAA) and hypertensive arteriopathy (HA).

METHODS

Consecutive patients with SVD-related intracerebral hemorrhage (ICH) from a single-center prospective cohort were analyzed. Four predefined subcortical WMH patterns were compared between the CAA and HA groups. These WMH patterns were (1) multiple subcortical spots; (2) peri-basal ganglia (BG); (3) large posterior subcortical patches; and (4) anterior subcortical patches. Their associations with other imaging (cerebral microbleeds [CMBs], enlarged perivascular spaces [EPVS]) and clinical markers of SVD were investigated using multivariable logistic regression.

RESULTS

The cohort included 319 patients with CAA and 137 patients with HA. Multiple subcortical spots prevalence was higher in the CAA compared to the HA group (29.8% vs 16.8%; p = 0.004). Peri-BG WMH pattern was more common in the HA- vs the CAA-ICH group (19% vs 7.8%; p = 0.001). In multivariable logistic regression, presence of multiple subcortical spots was associated with lobar CMBs (odds ratio [OR] 1.23; 95% confidence interval [CI] 1.01-1.50, p = 0.039) and high degree of centrum semiovale EPVS (OR 2.43; 95% CI 1.56-3.80, p < 0.0001). By contrast, age (OR 1.05; 95% CI 1.02-1.09, p = 0.002), deep CMBs (OR 2.46; 95% CI 1.44-4.20, p = 0.001), total WMH volume (OR 1.02; 95% CI 1.01-1.04, p = 0.002), and high BG EPVS degree (OR 8.81; 95% CI 3.37-23.02, p < 0.0001) were predictors of peri-BG WMH pattern.

CONCLUSION

Different patterns of subcortical leukoaraiosis visually identified on MRI might provide insights into the dominant underlying microangiopathy type as well as mechanisms of tissue injury in patients with ICH.

Estimating Total Cerebral Microinfarct Burden From Diffusion-Weighted Imaging

BACKGROUND AND PURPOSE

Cerebral microinfarcts (CMI) are important contributors to vascular cognitive impairment. Magnetic resonance imaging diffusion-weighted imaging (DWI) hyperintensities have been suggested to represent acute CMI. We aim to describe a mathematical method for estimating total number of CMI based on the presence of incidental DWI lesions.

METHODS

We reviewed magnetic resonance imaging scans of subjects with cognitive decline, cognitively normal subjects and previously reported subjects with past intracerebral hemorrhage (ICH). Based on temporal and spatial characteristics of DWI lesions, we estimated the annual rate of CMI needed to explain the observed rate of DWI lesion detection in each group. To confirm our estimates, we performed extensive sampling for CMI in the brain of a deceased subject with past lobar ICH who found to have a DWI lesion during life.

RESULTS

Clinically silent DWI lesions were present in 13 of 343 (3.8%) cognitively impaired and 10 of 199 (5%) cognitively intact normal non-ICH patients, both lower than the incidence in the past ICH patients (23 of 178; 12.9%; P<0.0006). The predicted annual incidence of CMI ranges from 16 to 1566 for non-ICH and 50 to 5041 for ICH individuals. Histological sampling revealed a total of 60 lesions in 32 sections. Based on previously reported methods, this density of CMI yields an estimated total brain burden maximum likelihood estimate of 9321 CMIs (95% confidence interval, 7255-11 990).

CONCLUSIONS

Detecting even a single DWI lesion suggests an annual incidence of hundreds of new CMI. The cumulative effects of these lesions may directly contribute to small-vessel-related vascular cognitive impairment.

Abstract 43: Cortical Structure Alterations in Cerebral Amyloid Angiopathy

Background/Objective: Multiple lines of evidence suggest that Cerebral Amyloid Angiopathy (CAA) leads to ischemic subcortical tissue injury, but its relationship to cortical changes is unknown. We tested the hypothesis that CAA is associated with cortical tissue loss.

Methods: Three age-matched cohorts of 63 subjects each (non-demented patients with probable CAA, Healthy Controls [HC] and patients with Alzheimer’s Disease [AD], the latter two from AD Neuroimaging Initiative) underwent multimodal MRI. FreeSurfer was used to calculate cortical thickness, white matter hyperintensity (WMH), and hippocampal volumes (HV). In patients with intracerebral hemorrhage, the measures were obtained from the contralateral hemisphere, and all were corrected for intracranial volume. CAA patients also had functional MRI to calculate Blood-Oxygen-Level-Dependent Time-to-Peak (BOLD-TTP), a measure of vascular reactivity. Lobar microbleeds (LMB) were counted on SWI.

Results: The mean age of each cohort was 72±5. CAA patients had thinner cortices compared to HC (2.17±0.11 vs 2.31±0.07 in mm, p<0.001), especially in the occipital, temporal, posterior parietal, and medial frontal regions [Figure]. Patients with AD had significantly thinner cortices than both CAA and HC (2.1±0.14, p<0.01 for both comparisons, also see Figure). Similarly, HV was lower in CAA than controls but both CAA and HC had higher HV than AD (p<0.01 for all comparisons). The number of LMBs and WMH did not correlate with cortical measures in CAA (p>0.2). There was a significant negative correlation (r=-0.4) between BOLD-TTP delay and cortical thickness (p=0.005 after adjustment for covariates).

Conclusions: Cortical thickness of CAA patients is significantly reduced when compared to age-matched HC but higher than in AD. Analyses within the CAA cohort suggest that CAA-related vascular dysfunction might contribute to cortical atrophy.

Interrelationship of superficial siderosis and microbleeds in cerebral amyloid angiopathy

OBJECTIVE

We sought to explore the mechanisms leading to cerebral amyloid angiopathy (CAA)-related cortical superficial siderosis (cSS) by examining its neuroimaging and genetic association with cerebral microbleeds (CMBs).

METHODS

MRI scans of 84 subjects with probable or definite CAA participating in a longitudinal research study were graded for cSS presence and severity (focal, restricted to ≤ 3 sulci vs disseminated, ≥ 4 sulci), and CMB count. APOE ε variants were directly genotyped. We performed cross-sectional analysis comparing CMB counts and APOE ε2 and ε4 allele frequency between subjects with no, focal, or disseminated cSS.

RESULTS

cSS was present in 48% (n = 40) of the population. APOE ε2 was overrepresented among participants with focal (odds ratio [OR] 7.0, 95% confidence interval [CI] 1.7-29.3, p = 0.008) and disseminated (OR 11.5, 95% CI 2.8-46.2, p = 0.001) cSS relative to individuals without cSS. CMB counts decreased with increasing severity of cSS (median: 41, 38, and 15 for no cSS, focal cSS, and disseminated cSS, respectively, p = 0.09). The highest CMB count tertile was associated with APOE ε4 (OR 3.0, 95% CI 1.4-6.6, p = 0.006) relative to the lowest tertile.

CONCLUSIONS

Among individuals with advanced CAA, cSS tends to occur in individuals with relatively lower CMB counts and with a distinct pattern of APOE genotypes. These results suggest that CAA-related cSS and CMBs may arise from distinct vasculopathic mechanisms.