Successful Discharge to Community From Home Health Less Likely for People in Late Stages of Dementia

BACKGROUND AND PURPOSE

Several studies have established the efficacy of home health in meeting the health care needs of people with Alzheimer disease and related dementias (ADRD) and helping them to remain at home. However, transitioning to the community after discharge from home health presents challenges to patient safety and quality of life. The severity of an individual's functional impairments, cognitive limitations, and behavioral and psychological symptoms may compound these challenges. The purpose of this study was to examine the association between dementia severity and successful discharge to community (DTC) from home health.

METHODS

This was a retrospective study of 142 376 Medicare beneficiaries with ADRD. Successful DTC was defined as having no unplanned hospitalization or death within 30 days of DTC from home health. Successful DTC rates were calculated, and multilevel logistic regression was used to estimate the relative risk (RR) of successful DTC, by dementia severity category, adjusted for patient and clinical characteristics. Six dementia severity categories were identified using a crosswalk between items on the Outcome and Assessment Information Set and the Functional Assessment Staging Tool.

RESULTS AND DISCUSSION

Successful DTC occurred in 71.2% of beneficiaries. Beneficiaries in the 2 most severe dementia categories had significantly lower risk of successful DTC (category 6: RR = 0.90, 95% CI = 0.889-0.910; category 7: RR = 0.737, 95% CI = 0.704-0.770) than those in the least severe dementia category. The RR of successful DTC for people with ADRD decreased as the level of independence with oral medication management decreased and when there was an overall greater need for caregiver assistance.

CONCLUSIONS

Patient status at the time of admission to home health is associated with outcomes after discharge from home health. Early identification of people in advanced stages of ADRD provides an opportunity to implement strategies to facilitate successful DTC while people are still receiving home care services. The severity of ADRD and availability of caregiver assistance should be key considerations in planning for successful DTC for people with ADRD.

How impaired is too impaired? Exploring futile neuropsychological test patterns as a function of dementia severity and cognitive screening scores

Some older adults cannot meaningfully participate in the testing portion of a neuropsychological evaluation due to significant cognitive impairments. There are limited empirical data on this topic. Thus, the current study sought to provide an operational definition for a futile testing profile and examine cognitive severity status and cognitive screening scores as predictors of testing futility at both baseline and first follow-up evaluations. We analysed data from 9,263 older adults from the National Alzheimer's Coordinating Center Uniform Data Set. Futile testing profiles occurred rarely at baseline (7.40%). There was a strong relationship between cognitive severity status and the prevalence of futile testing profiles, χ² (4) = 3559.77, p < .001. Over 90% of individuals with severe dementia were unable to participate meaningfully in testing. Severity range on the Montreal Cognitive Assessment (MoCA) also demonstrated a strong relationship with testing futility, χ² (3) = 3962.35, p < .001. The rate of futile testing profiles was similar at follow-up (7.90%). There was a strong association between baseline dementia severity and likelihood of demonstrating a futile testing profile at follow-up, χ² (4) = 1513.40, p < .001. Over 90% of individuals with severe dementia, who were initially able to participate meaningfully testing, no longer could at follow-up. Similarly, there was a strong relationship between baseline MoCA score band and likelihood of demonstrating a futile testing profile at follow-up, χ² (3) = 1627.37, p < .001. Results can help to guide decisions about optimizing use of limited neuropsychological assessment resources.

Item response theory analysis of the Clinical Dementia Rating

INTRODUCTION

The Clinical Dementia Rating (CDR) is widely used in Alzheimer's disease research studies and has well established reliability and validity. To facilitate the development of an online, electronic CDR (eCDR) for more efficient clinical applications, this study aims to produce a shortened version of the CDR, and to develop the statistical model for automatic scoring.

METHODS

Item response theory (IRT) was used for item evaluation and model development. An automatic scoring algorithm was validated using existing CDR global and domain box scores as the reference standard.

RESULTS

Most CDR items discriminate well at mild and very mild levels of cognitive impairment. The bi-factor IRT model fits best and the shortened CDR still demonstrates very high classification accuracy (81%∼92%).

DISCUSSION

The shortened version of the CDR and the automatic scoring algorithm has established a good foundation for developing an eCDR and will ultimately improve the efficiency of cognitive assessment.

Classification of Dementia Severity in Taiwan Based on History-Based Clinical Diagnosis System

BACKGROUND/AIMS

This study used HAICDDS screening questionnaire to classify the severity of dementia in Taiwan based on the clinical dementia rating scale.

METHODS

LDA was applied to 6,328 Taiwanese clinical patients for classification purposes. Clustering method was used to identify the associated influential symptoms for each severity level.

RESULT

LDA shows only 36 HAICDDS questions are significant to distinguish the 5 severity levels with 80% overall accuracy and it increased to 85.83% when combining normal and MCI groups. Severe dementia patients have the most serious declination in most cognitive and functionality domains, follows by moderate dementia, mild dementia, MCI and normal patients.

CONCLUSION

HAICDDS is a reliable and time-saved diagnosis tool in classifying the severity of dementia before undergoing a more in-depth clinical examination. The modified CDR may be indicated for epidemiological study and provide a solid foundation to develop a machine-learning derived screening instrument to detect dementia symptoms.

Quantitative and qualitative features of executive dysfunction in frontotemporal and Alzheimer's dementia

Behavioral variant fronto-temporal degeneration (bvFTD) is typically distinguished from Alzheimer's disease (AD) by early, prominent dysexecutive findings, in addition to other clinical features. However, differences in executive functioning between these groups are not consistently found. The current study sought to investigate quantitative and qualitative differences in executive functioning between those with bvFTD and AD in a large sample, while controlling for dementia severity and demographic variables. Secondary data analyses were completed on a subset of cases from the National Alzheimer's Coordinating Center collected from 36 Alzheimer's Disease Research Centers and consisting of 1,577 individuals with AD and 406 individuals with bvFTD. Groups were compared on 1) ability to complete three commonly administered executive tasks (letter fluency, Trail Making Test Part B [TMTB], and digits backward); 2) quantitative test performance; and 3) errors on these tasks. Findings suggested that individuals with bvFTD were less likely to complete letter fluency, χ²(2) = 178.62, p < .001, and number span tasks, χ²(1) = 11.49, p < .001), whereas individuals with AD were less likely to complete TMTB, χ²(2) = 460.38, p < .001. Individuals with bvFTD performed more poorly on letter fluency, F(1) = 28.06, p = .013, but there were not group differences in TMTB lines per second or number span backwards. Errors generally did not differentiate the diagnostic groups. In summary, there is substantial overlap in executive dysfunction between those with bvFTD and AD, though individuals with bvFTD tend to demonstrate worse letter fluency performance.

Mapping modified Mini-Mental State Examination (MMSE) scores to dementia stages in a multi-ethnic Asian population

ABSTRACTThe MMSE is used to screen for cognitive impairment and estimate dementia severity. In clinical settings, conventional cut-off scores have been used to distinguish between dementia stages. However, these scores have not been validated for different populations. This study maps scores from the modified version of the MMSE to dementia stages delineated by the Diagnostic and Statistical Manual of Mental Disorders-3rd revised edition (DSM-III-R), the Clinical Dementia Rating (CDR) and Functional Assessment Staging Test (FAST). We used cross-sectional data from a tertiary hospital memory clinic. Subjects were stratified into "primary education and below" (PE) or "secondary education and above" (SE). Receiving operating characteristic (ROC) analyses and Cohen's κ were performed to determine MMSE cut-off scores for dementia stages. Our derived cut-off scores were lower compared to the conventional scores. Scores also differed between subjects of different education levels. MMSE cut-off scores were 19, 15, and 9 for CDR stages 1, 2, and 3 respectively in PE subjects, and 23, 17, and 10 for SE subjects. Cut-off scores were comparable for staging by DSM-III-R Criteria and FAST. There is a need for locally derived stage-specific MMSE cut-off scores for the Asian population adjusted for education.

Association Between Dementia Severity and Recommended Lifestyle Changes: A Retrospective Cohort Study

OBJECTIVE

Early diagnosis of dementia leads to early treatment which is beneficial to patients and the community. We reviewed initial evaluations from the Spectrum Health Medical Group Neurocognitive Clinic (SHMGNC) to evaluate dementia stage at the time of diagnosis.

METHODS

We retrospectively reviewed 110 randomly chosen initial evaluations from September 2008 to December 2015 at the SHMGNC. Patients underwent a neurological examination, Montreal Cognitive Assessment, and a battery of neuropsychological testing.

RESULTS

Of all, 78.9% had moderate or severe dementia at diagnosis. The SHMGNC recommended lifestyle changes (medication assistance, financial assistance, driving restrictions, and institutional care) in 75.8% of patients with dementia. The severity of dementia was associated with the number of lifestyle changes recommended. Cohabitation with a caregiver did not lead to an early diagnosis of dementia.

CONCLUSIONS

Patients are not undergoing evaluation at the onset of the dementia process. Diagnosis is delayed. Home-based, patient-centered care may improve early screening and detection of dementia.

Factors Underpinning Caregiver Burden in Frontotemporal Dementia Differ in Spouses and their Children

The objectives of this observational study were to (1) compare spousal and child caregiver burden; (2) compare co-resident and live-out child caregiver burden; and (3) investigate factors influencing spousal and child caregiver burden. Data was collected from 90 caregivers of people with frontotemporal degeneration (FTD) recruited from the Frontotemporal Dementia Research Group (Frontier) at Neuroscience Research, Australia. Of this caregiver group, 43 were spousal caregivers and 47 were child caregivers. Caregiver burden and emotional state were evaluated using the short Zarit Burden Interview and the short version of the Depression, Anxiety and Stress Scale-21. The Social Network Index was applied to ascertain the social network of the caregiver, while the Intimate Bond Measure was used to evaluate the current quality of the relationship between the caregiver and the person with dementia. The Frontotemporal Dementia Rating Scale was used to assess severity of dementia. Spousal and child caregivers experienced similar levels of burden, depression, anxiety, and stress, regardless of disease severity. Co-resident child caregivers had smaller social networks and greater burden than live-out caregivers. Dementia severity was key in spousal caregiver burden, whereas caregiver depression was most important in child caregiver burden. Child and spousal caregivers of individuals with FTD share similar levels of burden, influenced by different factors. Future interventions need to account for these differences.

Detecting clinical change with the CDR-FTLD: differences between FTLD and AD dementia

OBJECTIVE

To investigate the psychometric properties of the Clinical Dementia Scale-frontotemporal lobar degeneration (CDR-FTLD) psychometric properties using Rasch analysis and its sensitivity distinguishing disease progression between FTLD and Alzheimer's disease (AD).

METHODS

Of 603 consecutive patients from the National Alzheimer Coordinating Center dataset (FTLD = 350; AD = 253), 120 FTLDs were included in a Rasch analysis to verify CDR-FTLD psychometric properties; 483 (FTLD = 230; AD = 253) were included to analyse disease progression, with 195 (FTLD = 82; AD = 113) followed-up (24 months).

RESULTS

The CDR-FTLD demonstrated good consistency, construct and concurrent validity and correlated well with mini-mental state examination (MMSE) and disease duration (ps < 0.05). At baseline, FTLD showed greater dementia severity than AD after matched for MMSE and disease duration (p < 0.001). Independent Rasch analyses demonstrated different patterns of progression for FTLD and AD in terms of the domains initially and then subsequently affected with disease progression. At follow-up, although MMSE showed significant changes (p < 0.05), these were greater on the CDR-FTLD (p < 0.001).

CONCLUSION

The CDR-FTLD satisfactorily measures dementia severity and change in FTLD, distinguishing disease progression between FTLD and AD, with clear implications for care, prognosis and future clinical trials. © 2016 The Authors. International Journal of Geriatric Psychiatry published by John Wiley & Sons, Ltd.

Vascular disease burden in Indian subjects with vascular dementia

BACKGROUND

Vascular disease factors like hypertension, diabetes mellitus, dyslipidaemia, and ischaemic heart disease contribute to the development of vascular dementia. As comorbidity of vascular disease factors in vascular dementia is common, we investigated the vascular disease burden in subjects with vascular dementia.

AIMS

To investigate the vascular disease burden due to four vascular disease factors: hypertension, diabetes mellitus, dyslipidaemia, and ischaemic heart disease in Indian subjects with vascular dementia.

METHODS

In this study, 159 subjects with probable vascular dementia (as per NINDS-AIREN criteria) attending the memory clinic at a tertiary care hospital were assessed for the presence of hypertension, diabetes mellitus, dyslipidaemia, and ischaemic heart disease using standardised operational definitions and for severity of dementia on the Clinical Dementia Rating (CDR) scale. The data obtained was subjected to appropriate statistical analysis.

RESULTS

Dyslipidaemia (79.25 per cent) was the most common vascular disease factor followed by hypertension (73.58 per cent), ischaemic heart disease (58.49 per cent), and diabetes mellitus (40.80 per cent). Most subjects (81.1 per cent) had two or more vascular disease factors. Subjects with more severe dementia had more vascular disease factors (sig 0.001).

CONCLUSION

People with moderate to severe dementia have a significantly higher vascular disease burden; therefore, higher vascular disease burden may be considered as a poor prognostic marker in vascular dementia. Subjects with vascular dementia and their caregivers must manage cognitive impairment and ADL alongside managing serious comorbid vascular diseases that may worsen the dementia.

Cultural differences are reflected in variables associated with carer burden in FTD: a comparison study between India and Australia

There is great need to understand variables behind carer burden, especially in FTD. Carer burden is a complex construct, and its factors are likely to vary depending on the type of dementia, carer characteristics and cultural background.

Clinical dementia rating performed several years prior to death predicts regional Alzheimer's neuropathology

AIMS

To assess the relationships between early and late antemortem measures of dementia severity and Alzheimer disease (AD) neuropathology severity.

METHODS

40 residents of a nursing home, average age at death 82.0, participated in this longitudinal cohort study with postmortem assessment. Severity of dementia was measured by Clinical Dementia Rating (CDR) at two time points, averaging 4.5 and 1.0 years before death. Densities of postmortem neuritic plaques (NPs) and neurofibrillary tangles (NFTs) were measured in the cerebral cortex, hippocampus, and entorhinal cortex.

RESULTS

For most brain areas, both early and late CDRs were significantly associated with NPs and NFTs. CDRs assessed proximal to death predicted NFTs beyond the contribution of early CDRs. NPs were predicted by both early and late CDRs. NPs were predictive of both early and late CDRs after controlling for NFTs. NFTs were only associated significantly with late CDR in the cerebral cortex after controlling for NPs.

CONCLUSIONS

Even if assessed several years before death, dementia severity is associated with AD neuropathology. NPs are more strongly associated with dementia severity than NFTs. NFTs consistently associate better with late than early CDR, suggesting that these neuropathological changes may occur relatively later in the course of the disease.