Dementia and Hearing Aid Use and Cessation: A National Study

PURPOSE

The current standard for management of hearing loss in the United States involves the use of a hearing aid. Anecdotal evidence suggests that the use of a hearing aid may be less effective in the context of dementia, though national data on use and cessation are not described.

METHOD

This longitudinal analysis of the National Health and Aging Trends Study followed participants who self-reported hearing aid use to estimate risk of hearing aid cessation over 9 years. We examine whether hearing aid cessation differs by dementia status using generalized estimating equations logistic regression accounting for loss to follow-up. Supplemental analyses were undertaken to examine the contribution of caregiving and environmental factors on hearing aid cessation.

RESULTS

Of 1,310 older adults who reported hearing loss (25% 80-84 years, 51% women, 74% White), 22% with dementia and 57% baseline hearing aid use. Dementia increased likelihood of ceasing hearing aid use during the first year after adoption (OR = 2.07, 95% CI [1.33, 3.23], p interaction = .11). In later years, older adults with either a previous or recent diagnosis of dementia had a 95% higher odds of hearing aid cessation (OR = 1.95, 95% CI [1.31, 2.90]), a decrease in odds with respect to the first year after adoption, when compared to participants without dementia, after adjusting for demographic, health, and economic factors. Economic and social factors that may influence care demands (more caregivers, income-to-poverty ratio, and additional insurance) increased likelihood for cessation for those with dementia.

CONCLUSIONS

Older adults with (vs. without) dementia are more likely to cease hearing aid use over time, most notably during the first year after adoption. Strategies to support hearing ability, such as self-management or care partner education, may improve communication for those living with co-occurring hearing loss and dementia.

"At least we finally found out what it was": Dementia diagnosis in minoritized populations

BACKGROUND

Disparities in diagnosis persist among persons living with dementia (PLWD); most research on delayed diagnosis relies on medical records or administrative claims. This study aimed to identify factors that delay or facilitate dementia diagnoses in racial or ethnic minoritized PLWD and elicit care partner perspectives on timing and effects of diagnosis.

METHODS

Maryland-based participants cared for a PLWD age 60 or older, self-identified as Black/African/African-American, Asian, or Hispanic/Latino, and spoke English. Nineteen care partner in-depth, semi-structured interviews were conducted and analyzed using conventional qualitative content analysis methods.

RESULTS

Biological, sociocultural, and environmental factors delayed dementia diagnosis. Memory loss was the most common early symptom, but the onset was often subtle or perceived as normal aging. Stigma and secrecy surrounding dementia influenced recognition and discussion of dementia among families and communities. Diagnoses were family-initiated and started in primary care. Care partners were divided in their perceptions of diagnosis timeliness and whether earlier diagnosis would have changed outcomes. Family reactions to dementia diagnoses varied; most participants expressed a strong sentiment of service and duty to care for older family members. Participants overwhelmingly felt the benefits of obtaining a dementia diagnosis outweighed harms.

CONCLUSIONS

Numerous factors affect dementia diagnosis in racial and ethnic minoritized PLWD. Normalization of brain health discussions and systematic, proactive discussion and detection of dementia in primary care may address multilevel barriers and facilitators to diagnosis. Systems-level and community-led public health interventions may also help address disparities in brain health education and dementia diagnosis.

The role of care partners in medical visits of older adults with hearing loss and dementia: A national study

BACKGROUND

Dementia and hearing loss (HL) are conditions, which restrict communication ability and amplify the difficulty of implementing effective care coordination and communication with medical providers. We examined how the presence of HL and dementia influence communication with medical providers, and the role of involved care partners during medical visits.

METHODS

Drawing on responses from 7070 community-dwelling older adults who participated in the 2015 National Health and Aging Trends Study, we used logistic regression to quantify care partner accompaniment to medical visits and the role care partners assume during visits by older adult hearing and dementia status.

RESULTS

Nearly 4 in 10 older adults with dementia also reported HL. Eighty-two percent of older adults with both HL and dementia were accompanied to medical visits by a care partner. Those with HL and dementia were six times more likely to be accompanied by a care partner to medical visits than those with neither condition (OR: 6.04; 95% CI:4.06, 8.99). Care partners of older adults with both (vs neither) HL and dementia were more actively engaged in: (1) facilitating understanding between the older adult and doctor (OR: 4.55, 95% CI:2.68, 7.71); (2) asking or telling the doctor information (OR: 6.13, 95% CI:3.44, 10.9); and (3) reminding the older adult of their questions (OR: 2.52, 95% CI: 1.66, 3.83).

CONCLUSIONS

Care partners have an active role during medical visits of older adults with HL and dementia. Efforts to support care partner engagement and teach advocacy skills may close gaps in care quality for the subgroup of older adults who are living with HL and dementia.

Medication Costs and Use of Older Americans in Assisted Living Settings: a Nationally Representative Cross-Sectional Study

BACKGROUND

Assisted-living (AL) settings are an important residential care option for old and disabled Americans, but there are no national data characterizing medication use in AL.

OBJECTIVE

To investigate medication costs and use of older adults living in the AL settings compared to those in the community, independent living, and nursing home settings.

DESIGN

2015 National Health and Aging Trends Study; nationally representative cross-sectional study.

PATICIPANTS

Respondents ≥ 65 years with Medicare Part D prescription drug coverage (n = 5980, representing 32.34 million older adults).

MEASURES

Total Part D medication costs; number of 30-day prescription fills; binary indicators for overall polypharmacy (≥ 5 and ≥ 10 concurrent medications), prescription fills of opioid and psychotropic medications including antipsychotics, benzodiazepines, gabapentinoids, antidepressants, and central nervous system-active (CNS-active) polypharmacy.

RESULTS

Adjusting for demographics, the annual medication costs among AL residents, at $3890, were twice as high as those of their community-dwelling counterparts ($1932; p < .01). All medication outcomes except opioids were higher for older adults in AL compared to community settings. While the adjusted number of 30-day prescription fills among AL residents was slightly lower than that of nursing home residents (89.5 vs. 106.2; p < .05), AL residents experienced equivalent rates of overall polypharmacy ≥ 10 medications (30.2% vs. 23.5%), antipsychotics (30.8% vs. 27.8%), benzodiazepines (30.7% vs. 32.6%), gabapentinoids (21.2% vs. 16.1%), and CNS-active polypharmacy (26.0% vs. 36.9%; p > .05 for all). Patterns of use across settings were consistent when limited to older adults with dementia.

CONCLUSIONS

Older Americans in AL experience a prescription medication burden similar to those in nursing homes. AL settings have an important opportunity to ensure their medication-related clinical services and supports match the needs of their residents.

The associations between unmet needs with protective factors, risk factors and outcomes among care partners of community-dwelling persons living with dementia

OBJECTIVES

Describe the prevalence and types of unmet needs among community-dwelling dementia care partners (CPs) and determine associations between unmet needs with protective factors, risk factors and outcomes.

METHOD

A cross-sectional analysis of 638 racially and cognitively diverse community-dwelling persons living with dementia (PLWD) and their CPs participating in a comprehensive in-home assessment of dementia-related needs. Unmet CP needs (19 items, 6 domains) were rated by a clinician using the Johns Hopkins Dementia Care Needs Assessment (JHDCNA). Multivariate linear regression models were used to examine associations between total percent unmet CP needs with demographic, protective and risk factors.

RESULTS

Nearly all CPs had at least one unmet need (99.53%), with a mean of 5.7 (±2.6). The most common domains with ≥1 unmet need were memory disorder education, care skills and knowledge of resources (98%), legal issues/concerns (73.8%), CP mental health (44.6%) and access to informal support (42.7%). Adjusted multivariate models suggest the strongest consistent predictive factors relate to informal emotional support, CP physical health, use or difficulty getting formal services/supports (both for CPs and PLWD), and CP time spent with PLWD. Greater levels of unmet needs were associated with worse PLWD outcomes and CP outcomes, after adjusting for demographics.

CONCLUSIONS

CPs have high rates of diverse, but modifiable unmet needs. Data suggest optimal approaches to dementia care should take a family-centered home-based approach that includes routine CP needs assessment, offer targeted interventions that include both traditional medical supports as well as strategies to increase and leverage informal social networks, and ones that can bridge and coordinate medical with non-medical supports. These findings can be used to inform new approaches to support CPs, improve PLWD and CP outcomes, and target groups most at risk for inequities.

Artificial Intelligence Tools to Evaluate Language and Speech Patterns in Alzheimer's Disease

BACKGROUND

Speech and language problems are one of the earliest signs of neurodegenerative diseases including Alzheimer's disease (AD), but they are often difficult to detect especially in the early stages. Utility of assessing speech and language problems using artificial intelligence (AI) has been examined in the past. However, the accuracy of different methods has been variable, preventing incorporation of these techniques in clinical use. In this study, we present different speech-based machine learning techniques. We focused on the automatic extraction of a wide array of interpretable features from the speech signals, then compared these features across different neurological disorders.

METHOD

Spoken responses to four different tasks (i.e., Cookie Theft Picture (CTP) and Stroop Task) were recorded from 80 participants, 5 with AD, 28 with Parkinson's disease (PD), 18 normal controls (NCs), and the remaining with other neurological diseases (OTRs). We automatically extracted several acoustic and linguistic features using speech and language technologies. We conducted pairwise Kruskal-Wallis tests to assess how speech and language abilities differed between different neurodegenerative disease vs. control groups. We used SciPy Python library.

RESULT

The total amount of speech time and pauses as well as the average duration and the variance of the number pauses significantly differed between AD and NC and between PD and NC in almost every task (p <0.05). Prosodic features based on F0 contour and F0 on the first and last voiced segment resulted in significant differences across tasks between AD and NC, AD and PD, AD and OTR (p <0.05). The phonological posterior for the phonological classes of consonantal, voiced, labial, nasal, velar, trill, and close significantly differed in almost every task between AD and NC, AD and PD and AD and OTR (p <0.05). Moreover, from the transcriptions of the CTP task, the number of sentences and noun phrases differed significantly between AD and NC, whereas the number of contrastive connectives and the moving average type-token ratio were significant between NC and OTR (p <0.05).

CONCLUSION

Automated analysis of speech employing machine learning techniques can provide objective assessment of patients with AD that may be useful in distinguishing AD from other neurological disorders.

Transcending inequities in dementia care in Black communities: Lessons from the maximizing independence at home care coordination program

Purpose

We examine care partners’ experience of the Maximizing Independence at Home (MIND) intervention, a multicomponent, home-based dementia care coordination program designed to provide high quality, wholistic care coordination for people and families living with dementia. The goal of the study was to understand 1. the unique dementia-related needs of Black care partners and barriers and challenges to caregiving experienced within the Black community, 2. perceived benefits of the MIND program, and 3. ways to improve the program and make it more culturally responsive to the Black community.

Method

We conducted three focus groups totaling 20 care partners of people living with dementia; who participated in the MIND intervention (2014–2019); all Black/African American and English speaking. Verbatim transcriptions were independently analyzed line-by-line by two coders using inductive approaches.

Findings

Participants noted three overarching themes related to dementia care needs and challenges in the Black community: difficulty finding and accessing dementia information and relevant services and supports; familial conflict/lack of sibling and familial support; and lack of effective communication about dementia within Black Communities. Regarding MIND at home program benefits, four themes emerged: 1. perceived to help locate resources (formal and informal); 2. provided care partners an opportunity for socialization and interaction; 3. included comprehensive assessments and helpful linked information; and 4. resulted in a “much needed break for care partners.” Increased diversity of the MIND program personnel, greater clarity and consistency in MIND program promotion, and better communications were themes for how the program could be improved.

Conclusion

Care partners participating in the MIND program perceived common benefits in aspects related to care for the persons living with dementia as well as benefits to themselves, believed the program addressed important challenges and gaps in education, services, and social support, and could be enhanced in its delivery and cultural responsiveness.

Acute care utilization risk among older adults living undiagnosed or unaware of dementia

BACKGROUND

Dementia is associated with increased risk of hospitalization and emergency department (ED) visits. Many persons with dementia are undiagnosed or unaware of their diagnosis, however. Our objective was to determine whether undiagnosed dementia or unawareness affects risk of hospitalization or ED visits.

METHODS

Retrospective longitudinal cohort study of 3537 community-living adults age ≥65 enrolled in the 2011-2017 National Health and Aging Trends Study with linked fee-for-service Medicare claims. Using self or proxy reported diagnosis, proxy dementia screening questionnaire, cognitive testing, and Medicare claims diagnosis, participants were classified as having (1) no dementia or dementia, for which they were classified as (2) undiagnosed, (3) diagnosed but unaware, or (4) diagnosed and aware. Proportional hazards models evaluated all-cause and potentially preventable hospitalization and ED visit risk by time-varying dementia status, adjusting for older adult characteristics.

RESULTS

Most participants (n = 2879) had no dementia at baseline. Among participants with dementia at baseline (n = 658), 187 were undiagnosed, 300 diagnosed but unaware, and 171 diagnosed and aware. In multivariable adjusted proportional hazards models, persons with undiagnosed dementia had lower risk of hospitalization and ED visits compared to persons diagnosed and aware (all-cause hospitalization aHR 0.59 [0.44, 0.79] and ED visit aHR 0.63 [0.47, 0.85]) and similar risks of these outcomes compared to persons without dementia. Individuals diagnosed but unaware had greater risk compared to those without dementia: aHR 1.37 (1.18, 1.59) for all-cause hospitalization and 1.48 (1.28, 1.71) for ED visits; they experienced risk comparable to individuals diagnosed and aware.

CONCLUSION

Older adults with undiagnosed dementia are not at increased risk of acute care utilization after accounting for differences in other characteristics. Individuals unaware of diagnosed dementia demonstrate risk similar to individuals aware of the diagnosis. Increasing diagnosis alone may not affect acute care utilization. The role of awareness warrants further investigation.

From research to realization: How a Texas health plan implemented an academic model of care for Alzheimer's disease

MIND at Home is a comprehensive, home-based care coordination intervention for people with Alzheimer's disease or related dementias (A/D) who live in the community and for their family caregivers. Developed by researchers at Johns Hopkins University (JHU), the model has been shown to extend the time a person with A/D remains at home for almost two years, as well as improved quality of life and quality of care and reduced caregiver burden. The MIND at Home pilot at Superior HealthPlan is a collaboration between Centene Corporation, JHU, and Superior HealthPlan (Superior). The goal of the MIND at Home pilot is to adapt, implement, and evaluate the impact of MIND at Home within Superior's Medicaid population. The pilot is structured as an interventional study of the MIND at Home program versus a propensity score-matched (PSM) comparison group receiving standard-of-care. The duration of the pilot is approximately 12 months, with longitudinal follow-up at 18 and 24 months. The pilot population includes Superior HealthPlan Medicaid members (receiving Long-Term Services & Supports) who are community-residing and have a confirmed diagnosis of A/D. The study has enrolled approximately 300 participants who have received the intervention. An analysis of claims data for participants receiving the MIND at Home intervention indicates the program increased primary care utilization (+10.0%) while reducing emergency department (ED) utilization (-15.8%), polypharmacy (-5.0%), and total spend (-1.35%). Consumer survey results indicate high levels of satisfaction among both pilot participants and their family caregivers and case studies anecdotally illustrate the significant impacts the MIND at Home program has had on participant and caregiver quality of life. Preliminary outcomes of the pilot indicate the MIND at Home program reduces high cost healthcare utilization - particularly ED and polypharmacy - and overall participant costs. Additional outcomes illustrate participants are highly satisfied with the MIND at Home program and have experienced dramatic increases in quality of life. This pilot showcases the value of operationalizing this evidence-based academic care model for A/D in a Medicaid population and that collaboration across academic research, industry, and government-sponsored healthcare programs can result in improved outcomes for individuals with A/D.

Establishment of a Patient-Centered Outcomes Research Network for Individuals with TBI and Neuropsychiatric Symptoms

Aims: The overarching goal of this project was to establish a group comprised of a variety of TBI stakeholders for the purpose of: (1) determining facilitators and barriers in management of neuropsychiatric symptoms after TBI; (2) identifying strategies for maintaining a TBI PCOR network; (3) enumerating research topics related to TBI neuropsychiatry; and (4) highlighting policy changes related to TBI neuropsychiatry.Methods: Twenty-nine TBI stakeholders participated in focus group discussions. Qualitative analyses were conducted both manually and using Dedoose software.Results: Participant-identified barriers included stigma associated with experiencing neuropsychiatric symptoms and poor insurance coverage. Facilitators included treatment focused on education of neuropsychiatric symptoms after TBI and having a comprehensive caregiver plan. Best strategies for maintaining TBI PCOR network included having a well-defined project, continued regular meetings, and on-going education of network members. Pertinent research topics included TBI and aging, factors influencing outcomes after TBI, substance use disorders related to TBI, and effectiveness of telemental health services. Needed policy changes included making TBI neuropsychiatry education accessible to stakeholders and improving accessibility of TBI neuropsychiatric care.Conclusion: TBI stakeholders identified several facilitators of care for neuropsychiatric symptoms after TBI and suggested research topics and best practices for conducting PCOR in this area.

Cost-Effective Care Coordination for People With Dementia at Home

Background and Objectives

People with dementia (PWD) represent some of the highest-need and highest-cost individuals living in the community. Maximizing Independence (MIND) at Home is a potentially cost-effective and scalable home-based dementia care coordination program that uses trained, nonclinical community workers as the primary contact between the PWD and their care partner, supported by a multidisciplinary clinical team with expertise in dementia care.

Research Design and Methods

Cost of care management services based on actual time spent by care management personnel over first 12 months of MIND at Home intervention was calculated for 342 MIND at Home recipients from Baltimore, Maryland and surrounding areas participating in a Centers for Medicare and Medicaid Services (CMS) funded Health Care Innovation Award demonstration project. Difference-in-differences analysis of claims-based Medicaid spending of 120 dually-eligible MIND at Home participants with their propensity score matched comparison group (n = 360).

Results

The average cost per enrollee per month was $110, or $1,320 per annum. Medicaid expenditures of dually-eligible participants grew 1.12 percentage points per quarter more slowly than that of the matched comparison group. Most savings came from slower growth in inpatient and long-term nursing home use. Net of the cost of the 5-year MIND at Home intervention, 5-year Medicaid savings are estimated at $7,052 per beneficiary, a 1.12-fold return on investment.

Discussion and Implications

Managed care plans with the flexibility to engage community health workers could benefit from a low-cost, high-touch intervention to meet the needs of enrollees with dementia. Limitations for using and reimbursing community health workers exist in Medicare fee-for-service, which CMS should address to maximize benefit for PWD.

GOING FOR THE WIN-WIN-WIN: HARNESSING THE POWER OF SENIOR VOLUNTEERISM TO ADDRESS DEMENTIA CARE AND PROMOTE HEALTH

The public health implications of Alzheimer’s disease or related dementias (ADRDs) are significant and have placed considerable pressure on the U.S. healthcare system. Training and mobilizing a critical mass of volunteers to address unmet dementia care needs may be a potent, scalable, and cost efficient approach to address gaps in dementia care and to support family caregivers. Further, by engaging older volunteers to do this work and remain in productive and impactful post-retirement roles, additive population health benefits may be possible. This session will focus on ways we might harness the power of senior volunteers to meet the public health challenges associated with ADRD. Presentations will draw from three innovative community-based projects that utilize senior volunteers to support and enhance health in aging and dementia care. Dr. Carlson will provide an update on the evaluation and scaling Experience Corps, an intergenerational program that engages senior volunteers to work in elementary schools. Dr. Gaugler will discuss the Porchlight Project, a new multicomponent training approach for senior volunteers in Minnesota to enhance dementia care capabilities and support to underserved older persons. Dr. Samus will introduce the MEMORI Corps program, a novel activity-based companion care program for home-residing persons with ADRD delivered by trained senior volunteers. Given the current and impending shortages in the geriatric work force and family caregivers, respectively, innovative and readily available long term service and support options are needed to offset potential care gaps. The current session proposes the novel incorporation of volunteers as one solution to do so.

COMMON UNMET NEEDS OF DEMENTIA CAREGIVERS AND HOW THESE DIFFER BY DISEASE STAGE AND RACE

This presentation (co-presentation Samus and Sloan) will use combined cross-sectional, baseline data from two intervention studies (n=-642) conducted in Maryland evaluating the impact of dementia care coordination model (MIND at home) to provide a detailed description of common modifiable unmet care needs of family caregivers of community-living persons with dementia (PWD), explore how care needs may differ by the disease stage of the PWD, and presence of racial disparities in care needs. Unmet caregiver needs were identified based on comprehensive in-home assessments using a standardized tool (JHDCNA 2.0) with 6 care domains and 18 items covering caregiver needs. Family caregivers were 77% women; 63 years old (mean); 60% White; and 52% adult children. The most prevalent needs were for education/resources (98%), legal (74%), mental health (44%), and informal support (43%). Needs varied based on dementia severity. African American caregivers (vs. white) had significantly more unmet caregiver needs at baseline (p<.001).

MAKING ENGAGEMENT MEANINGFUL THROUGH ORGANIZED ROUTINE INTERACTION (MEMORI) CORPS TRIAL: AN INTRODUCTION

This presentation will review the design, methods, and early lessons learned from the Making Engagement Meaningful through Organized Routine Interaction (MEMORI) Corps trial recently funded by NIA. This trial is evaluating the feasibility and efficacy of the MEMORI Corps program, a novel 12-week activity-based companion care model designed to mobilize and equip senior volunteers to deliver individualized, evidence-based activity programming to persons with dementia PWD living at home and offer family CGs needed respite. The intervention synthesizes and adapts prior evidence-based work from the Tailored Activities Program® (an activity-based intervention persons with dementia), Experience Corps® (an intergenerational civic engagement program that engages senior volunteers to work in elementary schools), and MIND at Home® (a home-based dementia care coordination program) to simultaneously address unmet respite care needs of family CGs, provide PWD structured meaningful activities and social engagement, and provide meaningful engagement and peer support opportunities for senior volunteers.

ACUTE CARE UTILIZATION IN OLDER ADULTS LIVING UNDIAGNOSED OR UNAWARE OF DEMENTIA

Most individuals with dementia are undiagnosed or they/their families are unaware of the diagnosis. Implications of dementia diagnosis and awareness are poorly understood. Our objective was to determine whether undiagnosed dementia or unawareness increases risk of hospitalization or emergency department (ED) visits, outcomes with recognized risk in diagnosed dementia. We linked National Health and Aging Trends Study (NHATS) data to fee-for-service Medicare claims for 4,311 community-living participants in the nationally representative cohort. We assessed probable versus no dementia using validated NHATS dementia criteria, undiagnosed versus diagnosed using Medicare claims, and aware versus unaware using NHATS self or proxy report of diagnosis. Cox proportional hazards models evaluated hospitalization and ED visit risk by time-varying dementia diagnosis and awareness status, adjusting for sociodemographic characteristics, functional impairment, medical comorbidities, and prior hospitalization. Compared to no dementia, persons with dementia who were unaware but diagnosed had greater risk of hospitalization (HR 1.66, 95% CI 1.26-2.19) and ED visits (HR 1.63, 95% CI 1.28-2.08). Persons unaware but diagnosed also had greater risk compared to persons aware and diagnosed (hospitalization HR 1.34, 95% CI 0.98-1.82; ED HR 1.38, 95% CI 1.05-1.83). Persons with undiagnosed dementia demonstrated hospitalization risk similar to persons with no dementia (HR 1.02, 95% CI 0.79-1.31) and similar or potentially lower than persons aware and diagnosed (HR 0.82, 95% CI 0.61-1.10); ED visit findings were similar. Results suggest that being unaware of dementia diagnosis may affect healthcare utilization. Strategies to improve communication and understanding of dementia could potentially reduce hospitalizations and ED visits.

HOME IS WHERE THE HEART IS: OPTIMIZING AND TAILORING HOME AND COMMUNITY-BASED SUPPORT FOR DEMENTIA CAREGIVERS

Family caregivers, often “de facto” members of the care team for persons with dementia, play a central role in ensuring safety, support, quality of life, and continuity of care. Most often, they provide this care for loved ones at home and over a long period of time, as the illness progresses and care need intensifies. This session will provide a unique understanding of potential ways to optimize support for family caregivers in provision of day-to-day care in the home by examining often-overlooked factors influential in the health and wellbeing for both caregiver and persons with dementia. Presentations will draw from three large community-based trials testing interventions to support dementia caregivers. Drs. Samus and Sloan will present on common unmet needs identified by family caregivers and explore how needs differ by disease stage and race. Dr. Fortinsky will present baseline caregiver care-related challenges in a diverse cohort of caregivers and the effects of a caregiver intervention designed to mitigate these challenges. Dr. Hodgson will present the common symptoms clusters among home-dwelling persons with dementia patients and how these are associated with caregiver distress. Dr. Jutkowitz will discuss factors influencing dementia caregiver’s willingness to pay for help at home. Findings from this session will help elucidate care needs that matter most to family caregivers in diverse community-living cohorts and how we might optimize and tailor supportive home-based interventions to target these needs and challenges.

Before Hospice: Symptom Burden, Dementia, and Social Participation in the Last Year of Life

Background: Little is known about clinical symptom burden, dementia, and social isolation in the last year of life among older adults. Objective: To describe and contrast the type and severity of symptom burden for older decedents with and without dementia, and whether specific symptoms and presence of dementia are associated with limitations in social participation in the last year of life. Design: Cross-sectional logistic regression analysis of a population-based study. Setting/Subjects: A total of 1270 community-dwelling adults of age ≥65 years in the United States participated in the 2011 National Health and Aging Trends Study and died by 2015. Measurements: Dementia status, 13 clinical symptoms, and limitations in 6 social activities were drawn from the interview preceding death. Severity of sensory, physical, and psychiatric symptom burden was examined in tertiles. Results: Decedents with dementia (37.3%) had higher prevalence of all symptoms (p's < 0.05), except insomnia and breathing problems. Dementia was associated with greater likelihood of high versus low burden of sensory (odds ratio [OR] 4.52 [95% confidence interval {CI} 3.08-6.63]), physical (OR 3.49 [95% CI 2.48-4.91]), and psychiatric (OR 2.80 [95% CI 1.98-3.95]) symptoms. Dementia and physical symptoms (problems with speaking, leg strength/movement, and balance) were independently associated with limitations in at least three social activities (p's < 0.05 for adjusted ORs). Conclusion: Symptom burden is higher in patients with dementia. Dementia and physical symptoms are associated with social activity limitations. Older patients with dementia or physical symptoms may benefit from earlier emphasis on palliative care and quality of life.

MIND at Home-Streamlined: Study protocol for a randomized trial of home-based care coordination for persons with dementia and their caregivers

BACKGROUND

Dementia is associated with high health care costs, premature long-term care (LTC) placement, medical complications, reduced quality of life, and caregiver burden. Most health care providers and systems are not yet organized or equipped to provide comprehensive long-term care management for dementia, although a range of effective symptoms and supportive care approaches exist. The Maximizing Independence at Home-Streamlined (MIND-S) is a promising model of home-based dementia care coordination designed to efficiently improve person-centered outcomes, while reducing care costs. This report describes the rationale and design of an NIA-funded randomized controlled trial to test the impact of MIND-S on time to LTC placement, person with dementia outcomes (unmet needs, behavior, quality of life), family caregiver outcomes (unmet needs, burden), and cost offset at 18 (primary end point) and 24 months, compared to an augmented usual care group.

METHODS

This is a 24-month, parallel group, randomized trial evaluating MIND-S in a cohort of 304 community-living persons with dementia and their family caregivers in Maryland. MIND-S dyads receive 18 months of care coordination by an interdisciplinary team comprised of trained non-clinical community workers (e.g. Memory Care Coordinators), a registered nurse, and a geriatric psychiatrist. Intervention components include in-home dementia-related needs assessments; individualized care planning; implementation of standardized evidence-based care strategy protocols; and ongoing monitoring and reassessment. Outcomes are assessed by blinded evaluators at baseline, 4.5, 9, 13.5, 18, and 24 months.

DISCUSSION

Trial results will provide rigorous data to inform innovations in effective system-level approaches to dementia care.

Underdiagnosis of Dementia: an Observational Study of Patterns in Diagnosis and Awareness in US Older Adults

BACKGROUND

Many older adults living with dementia have not been formally diagnosed. Even when clinicians document the diagnosis, patients and families may be unaware of the diagnosis. Knowledge of how individual characteristics affect detection and awareness of dementia is limited.

OBJECTIVE

To identify characteristics associated with dementia diagnosis and awareness of diagnosis.

DESIGN

Cross-sectional observational study.

PARTICIPANTS

Five hundred eighty-five adults aged ≥ 65 in the National Health and Aging Trends Study who met assessment-based study criteria for probable dementia in 2011 and had 3 years of continuous, fee-for-service Medicare claims prior to 2011.

MAIN MEASURES

Using multivariable logistic regression, we compared participants with undiagnosed versus diagnosed dementia (based on Medicare claims) on demographic, social/behavioral, functional, medical, and healthcare utilization characteristics. Among those diagnosed, we compared characteristics of participants unaware versus aware of the diagnosis (based on self or proxy report).

KEY RESULTS

Among older adults with probable dementia, 58.7% were either undiagnosed (39.5%) or unaware of the diagnosis (19.2%). In adjusted analyses, individuals who were Hispanic (OR 2.48, 95% CI 1.19, 5.14), had less than high school education (OR 0.54 for at least high school education, 95% CI 0.32, 0.91), attended medical visits alone (OR 1.98, 95% CI 1.11, 3.51), or had fewer functional impairments (OR 0.79 for each impairment, 95% CI 0.69, 0.90) were more likely to be undiagnosed. Similarly, among those diagnosed, having less education (OR 0.42), attending medical visits alone (OR 1.97), and fewer functional impairments (OR 0.72) were associated with unawareness of diagnosis (all ps < 0.05).

CONCLUSIONS

The majority of older adults with dementia are either undiagnosed or unaware of the diagnosis, suggesting shortcomings in detection and communication of dementia. Individuals who may benefit from targeted screening include racial/ethnic minorities and persons who have lower educational attainment, any functional impairment, or attend medical visits alone.

Comprehensive home-based care coordination for vulnerable elders with dementia: Maximizing Independence at Home-Plus-Study protocol

INTRODUCTION

Despite availability of effective care strategies for dementia, most health care systems are not yet organized or equipped to provide comprehensive family-centered dementia care management. Maximizing Independence at Home-Plus is a promising new model of dementia care coordination being tested in the U.S. through a Health Care Innovation Award funded by the Centers for Medicare and Medicaid Services that may serve as a model to address these delivery gaps, improve outcomes, and lower costs. This report provides an overview of the Health Care Innovation Award aims, study design, and methodology.

METHODS

This is a prospective, quasi-experimental intervention study of 342 community-living Medicare-Medicaid dual eligibles and Medicare-only beneficiaries with dementia in Maryland. Primary analyses will assess the impact of Maximizing Independence at Home-Plus on risk of nursing home long-term care placement, hospitalization, and health care expenditures (Medicare, Medicaid) at 12, 18 (primary end point), and 24 months, compared to a propensity-matched comparison group.

DISCUSSION

The goals of the Maximizing Independence at Home-Plus model are to improve care coordination, ability to remain at home, and life quality for participants and caregivers, while reducing total costs of care for this vulnerable population. This Health Care Innovation Award project will provide timely information on the impact of Maximizing Independence at Home-Plus care coordination model on a variety of outcomes including effects on Medicaid and Medicare expenditures and service utilization. Participant characteristic data, cost savings, and program delivery costs will be analyzed to develop a risk-adjusted payment model to encourage sustainability and facilitate spread.

Home is where the future is: The BrightFocus Foundation consensus panel on dementia care

INTRODUCTION

A national consensus panel was convened to develop recommendations on future directions for home-based dementia care (HBDC).

METHODS

The panel summarized advantages and challenges of shifting to HBDC as the nexus of care and developed consensus-based recommendations.

RESULTS

The panel developed five core recommendations: (1) HBDC should be considered the nexus of new dementia models, from diagnosis to end of life in dementia; (2) new payment models are needed to support HBDC and reward integration of care; (3) a diverse new workforce that spans the care continuum should be prepared urgently; (4) new technologies to promote communication, monitoring/safety, and symptoms management must be tested, integrated, and deployed; and (5) targeted dissemination efforts for HBDC must be employed.

DISCUSSION

HBDC represents a promising paradigm shift to improve care for those living with dementia and their family caregivers: these recommendations provide a framework to chart a course forward for HBDC.

Health Services Utilization in Older Adults with Dementia Receiving Care Coordination: The MIND at Home Trial

OBJECTIVE

To investigate effects of a novel dementia care coordination program on health services utilization.

DATA SOURCES/STUDY SETTING

A total of 303 community-dwelling adults aged ≥70 with a cognitive disorder in Baltimore, Maryland (2008-2011).

STUDY DESIGN

Single-blind RCT evaluating efficacy of an 18-month care coordination intervention delivered through community-based nonclinical care coordinators, supported by an interdisciplinary clinical team.

DATA COLLECTION/EXTRACTION METHODS

Study partners reported acute care/inpatient, outpatient, and home- and community-based service utilization at baseline, 9, and 18 months.

PRINCIPAL FINDINGS

From baseline to 18 months, there were no significant group differences in acute care/inpatient or total outpatient services use, although intervention participants had significantly increased outpatient dementia/mental health visits from 9 to 18 months (p = .04) relative to controls. Home and community-based support service use significantly increased from baseline to 18 months in the intervention compared to control (p = .005).

CONCLUSIONS

While this dementia care coordination program did not impact acute care/inpatient services utilization, it increased use of dementia-related outpatient medical care and nonmedical supportive community services, a combination that may have helped participants remain at home longer. Future care model modifications that emphasize delirium, falls prevention, and behavior management may be needed to influence inpatient service use.

Potentially Unsafe Activities and Living Conditions of Older Adults with Dementia

OBJECTIVES

To examine the prevalence of dementia in the absence of a reported dementia diagnosis and whether potentially unsafe activities and living conditions vary as a function of dementia diagnosis status in a nationally representative sample of older adults.

DESIGN

Observational cohort study.

SETTING

Community.

PARTICIPANTS

Medicare beneficiaries aged 65 and older enrolled in the National Health and Aging Trends Study (N = 7,609).

MEASUREMENTS

Participants were classified into four groups based on self-report of dementia diagnosis, proxy screening interview, and cognitive testing: probable dementia with reported dementia diagnosis (n = 457), probable dementia without reported dementia diagnosis (n = 581), possible dementia (n = 996), or no dementia (n = 5,575). Potentially unsafe activities (driving, preparing hot meals, managing finances or medications, attending doctor visits alone) and living conditions (falls, living alone, and unmet needs) were examined according to dementia status subgroups in stratified analyses and multivariate models, adjusting for sociodemographic factors, medical comorbidities, and physical capacity.

RESULTS

The prevalence of driving (22.9%), preparing hot meals (31.0%), managing finances (21.9%), managing medications (36.6%), and attending doctor visits alone (20.6%) was lowest in persons with probable dementia; however, but in persons with probable dementia, the covariate-adjusted rates of driving, preparing hot meals, managing finances, managing medications, and attending doctor visits alone were significantly higher in those without reported dementia diagnosis than in those with reported diagnosis (all odds ratios ≥2.00, all P < .01).

CONCLUSION

Older adults with probable dementia who are not aware of a dementia diagnosis are more likely to report engaging in potentially unsafe behaviors. Understanding the prevalence of potentially unsafe activities and living conditions can help clinicians focus safety screening and counseling in older adults with diagnosed or suspected dementia.

A Multipronged, Adaptive Approach for the Recruitment of Diverse Community-Residing Elders with Memory Impairment: The MIND at Home Experience

OBJECTIVE

To provide a critical review of a multipronged recruitment approach used to identify, recruit, and enroll a diverse community-based sample of persons with memory disorders into an 18-month randomized, controlled dementia care coordination trial.

METHODS

Descriptive analysis of a recruitment approach comprised five strategies: community liaison ("gatekeepers") method, letters sent from trusted community organizations, display and distribution of study materials in the community, research registries, and general community outreach and engagement activities. Participants were 55 community organizations and 63 staff of community organizations in Baltimore, Maryland. Participant referral sources, eligibility, enrollment status, demographics, and loss to follow-up were tracked in a relational access database.

RESULTS

In total, 1,275 referrals were received and 303 socioeconomically, cognitively, and racially diverse community-dwelling persons with cognitive disorders were enrolled. Most referrals came from letters sent from community organizations directly to clients on the study's behalf (39%) and referrals from community liaison organizations (29%). African American/black enrollees were most likely to come from community liaison organizations.

CONCLUSION

A multipronged, adaptive approach led to the successful recruitment of diverse community-residing elders with memory impairment for an intervention trial. Key factors for success included using a range of evidence-supported outreach strategies, forming key strategic community partnerships, seeking regular stakeholder input through all research phases, and obtaining "buy-in" from community stakeholders by aligning study objectives with perceived unmet community needs.

Innovative care models for high-cost Medicare beneficiaries: delivery system and payment reform to accelerate adoption

OBJECTIVES

About a third of Medicare beneficiaries are covered by Medicare Advantage (MA) plans or accountable care organizations (ACOs). As a result of assuming financial risk for Medicare services and/or being eligible for shared savings, these organizations have an incentive to adopt models of delivering care that contribute to better care, improved health outcomes, and lower cost. This paper identifies innovative care models across the care continuum for high-cost Medicare beneficiaries that MA plans and ACOs could adopt to improve care while potentially achieving savings. It suggests policy changes that would accelerate testing and spread of promising care delivery model innovations.

STUDY DESIGN AND METHODS

Targeted review of the literature to identify care delivery models focused on high-cost or high-risk Medicare beneficiaries.

RESULTS

This paper presents select delivery models for high-risk Medicare beneficiaries across the care continuum that show promise of yielding better care at lower cost that could be considered for adoption by MA plans and ACOs. Common to these models are elements of the Wagner Chronic Care Model, including practice redesign to incorporate a team approach to care, the inclusion of nonmedical personnel, efforts to promote patient engagement, supporting provider education on innovations,and information systems allowing feedback of information to providers. The goal of these models is to slow the progression to long-term care, reduce health risks, and minimize adverse health impacts, all while achieving savings.These models attempt to maintain the ability of high-risk individuals to live in the home or a community-based setting, thereby avoiding costly institutional care. Identifying and implementing promising care delivery models will become increasingly important in launching successful population health initiatives.

CONCLUSIONS

MA plans and ACOs stand to benefit financially from adopting care delivery models for high-risk Medicare beneficiaries that reduce hospitalization. Spreading these models to other organizations will require provider payment policy changes. Integration of acute and long-term care would further spur adoption of effective strategies for reducing or delaying entry into long-term institutional care.

A randomized controlled trial of a community-based dementia care coordination intervention: effects of MIND at Home on caregiver outcomes

OBJECTIVE

To assess whether MIND at Home, a community-based, multicomponent, care coordination intervention, reduces unmet caregiving needs and burden in informal caregivers of persons with memory disorders.

METHODS

An 18-month randomized controlled trial of 289 community-living care recipient (CR)-caregiver (informal caregivers, i.e., unpaid individuals who regularly assisted the CR) dyads from 28 postal code areas of Baltimore, Maryland was conducted. All dyads and the CR's primary care physician received the written needs assessment results and intervention recommendations. Intervention dyads then received an 18-month care coordination intervention delivered by nonclinical community workers to address unmet care needs through individualized care planning, referral and linkage to dementia services, provision of caregiver dementia education and skill-building strategies, and care progress monitoring by an interdisciplinary team. Primary outcome was total percent of unmet caregiver needs at 18 months. Secondary outcomes included objective and subjective caregiver burden measures, quality of life (QOL), and depression.

RESULTS

Total percent of unmet caregiver needs declined in both groups from baseline to 18 months, with no statistically significant between-group difference. No significant group differences occurred in most caregiver burden measures, depression, or QOL. There was a potentially clinically relevant reduction in self-reported number of hours caregivers spent with the CR for MIND participants compared with control subjects.

CONCLUSION

No statistically significant impacts on caregiver outcomes were found after multiple comparison adjustments. However, MIND at Home appeared to have had a modest and clinically meaningful impact on informal caregiver time spent with CRs.

Unmet needs of community-residing persons with dementia and their informal caregivers: findings from the maximizing independence at home study

OBJECTIVES

To determine the prevalence and correlates of unmet needs in a sample of community-residing persons with dementia (PWD) and their informal caregivers.

DESIGN

Analysis of cross-sectional, baseline participant characteristics before randomization in a care coordination intervention trial.

SETTING

Baltimore, Maryland.

PARTICIPANTS

Community-residing PWD (n=254) and their informal caregivers (n=246).

MEASUREMENTS

In-home assessments of dementia-related needs based on the Johns Hopkins Dementia Care Needs Assessment. Bivariate and multivariate regression analyses were conducted to identify demographic, socioeconomic, clinical, functional, and quality-of-life correlates of unmet needs.

RESULTS

The mean number of unmet needs was 7.7±4.8 in PWD and 4.6±2.3 in caregivers, with almost all PWD (99%) and caregivers (97%) having one or more unmet needs. Unmet needs in PWD were significantly greater in those with higher cognitive function. Ninety percent of PWD had unmet safety needs, more than half had unmet needs for meaningful activities, and almost one-third had not received a prior evaluation or diagnosis. Higher unmet needs in PWD was significantly associated with nonwhite race, lower income, less impairment in activities of daily living, and more symptoms of depression. For caregivers, more than 85% had unmet needs for resource referrals and caregiver education. Higher unmet caregiver needs was significantly associated with nonwhite race, less education, and more symptoms of depression.

CONCLUSION

Many community-residing PWD and their caregivers have unmet dementia-related needs for care, services, and support. Providers should be aware that unmet needs may be higher in minority and low-income community residents, caregivers with lower education, and individuals with early-stage dementia. Identifying and treating symptoms of depression in PWD and caregivers may enable them to address their other unmet needs.

Childless Elders in Assisted Living: Findings from the Maryland Assisted Living Study

We compared data drawn from a random sample of 399 current assisted living (AL) residents and a subsample of 222 newly admitted residents for two groups: childless AL residents and AL residents with children. The percentage of childless AL residents (26%) in our study was slightly higher than US population estimates of childless persons age 65 and over (20%). In the overall sample, the two groups differed significantly by age, race and women's years of education. The childless group was slightly younger, had a higher percentage of African American residents, and had more years of education than the group with children. In the subsample, we looked at demographic, functional, financial and social characteristics and found that compared to residents with children, fewer childless residents had a dementia diagnosis, received visits from a relative while more paid less money per month for AL and reported having private insurance. As childlessness among older adults continues to increase, it will become increasingly important to understand how child status affects the need for and experience of long-term care.

Separate may not be equal: a preliminary investigation of clinical correlates of electronic psychiatric record accessibility in academic medical centers

OBJECTIVES

Electronic Medical Records (EMR) have the potential to improve the coordination of healthcare in this country, yet the field of psychiatry has lagged behind other medical disciplines in its adoption of EMR.

METHODS

Psychiatrists at 18 of the top US hospitals completed an electronic survey detailing whether their psychiatric records were stored electronically and accessible to non-psychiatric physicians. Electronic hospital records and accessibility statuses were correlated with patient care outcomes obtained from the University Health System Consortium Clinical Database available for 13 of the 18 top US hospitals.

RESULTS

44% of hospitals surveyed maintained most or all of their psychiatric records electronically and 28% made psychiatric records accessible to non-psychiatric physicians; only 22% did both. Compared with hospitals where psychiatric records were not stored electronically, the average 7-day readmission rate of psychiatric patients was significantly lower at hospitals with psychiatric EMR (5.1% vs. 7.0%, p = .040). Similarly, the 14 and 30-day readmission rates at hospitals where psychiatric records were accessible to non-psychiatric physicians were lower than those of their counterparts with non-accessible records (5.8% vs. 9.5%, p = .019, 8.6% vs. 13.6%, p = .013, respectively). The 7, 14, and 30-day readmission rates were significantly lower in hospitals where psychiatric records were both stored electronically and made accessible than at hospitals where records were either not electronic or not accessible (4% vs 6.6%, 5.8% vs 9.1%, 8.9 vs 13%, respectively, all with p = 0.045).

CONCLUSIONS

Having psychiatric EMR that were accessible to non-psychiatric physicians correlated with improved clinical care as measured by lower readmission rates specific for psychiatric patients.

Memory training interventions for older adults: a meta-analysis

A systematic review and meta-analysis of memory training research was conducted to characterize the effect of memory strategies on memory performance among cognitively intact, community-dwelling older adults, and to identify characteristics of individuals and of programs associated with improved memory. The review identified 402 publications, of which 35 studies met criteria for inclusion. The overall effect size estimate, representing the mean standardized difference in pre-post change between memory-trained and control groups, was 0.31 standard deviations (SD; 95% confidence interval (CI): 0.22, 0.39). The pre-post training effect for memory-trained interventions was 0.43 SD (95% CI: 0.29, 0.57) and the practice effect for control groups was 0.06 SD (95% CI: 0.05, 0.16). Among 10 distinct memory strategies identified in studies, meta-analytic methods revealed that training multiple strategies was associated with larger training gains (p=0.04), although this association did not reach statistical significance after adjusting for multiple comparisons. Treatment gains among memory-trained individuals were not better after training in any particular strategy, or by the average age of participants, session length, or type of control condition. These findings can inform the design of future memory training programs for older adults.

Quality of life of community-residing persons with dementia based on self-rated and caregiver-rated measures

PURPOSE

To identify correlates of self-rated and caregiver-rated quality of life (QOL) in community-residing persons with dementia (PWD) for intervention development.

METHODS

Cross-sectional data of 254 PWD and their caregivers participating in a clinical trial were derived from in-home assessments. Self-rated QOL was measured with the Quality of Life-Alzheimer Disease (QOL-AD) scale, and caregiver-rated QOL was measured using the QOL-AD and Alzheimer Disease-Related Quality of Life (ADRQL) scales. Multivariate modeling identified correlates of the PWD' QOL.

RESULTS

Self-rated QOL was related significantly to participant race, unmet needs, depression, and total medications. Caregiver-rated QOL-AD scores were significantly associated with participant function, unmet needs, depression, and health problems and with caregiver burden and self-rated health. Significant correlates of ADRQL scores included neuropsychiatric symptom severity, functional and cognitive impairment, and caregiver burden and depression.

CONCLUSIONS

Correlates of QOL in community-residing PWD depend on who rates the PWD's QOL and which measure is used. Addressing health problems, medication use, and dementia-related unmet needs, reducing functional dependency, and treating neuropsychiatric symptoms in PWD, while reducing caregiver burden and depression, may maximize QOL in those with dementia.

A Descriptive Study of Home Modifications for People with Dementia and Barriers to Implementation

This study describes home environmental features, safety issues, and health-related modifications in a community dwelling sample of 82 elderly people with dementia. Main barriers to the accessibility of the homes were steps, both inside and outside the house. The majority of the caregivers had made home modifications, which pertained mainly to physical limitations. Home modifications to support cognitive deficits were made to a lesser extent. The main barrier to the implementation of home modifications to accommodate the care recipient's memory loss was skepticism about their usefulness. Regarding the removal of physical barriers, financial constraints were most frequently mentioned.

Identification of community-residing individuals with dementia and their unmet needs for care

BACKGROUND

Innovative approaches to the widespread delivery of evidence-based dementia care are needed. The aims of this study were to determine whether a telephone screening method could efficiently identify individuals in the community in need of care for dementia and to develop a multidimensional needs assessment tool for identifying the type and frequency of unmet needs related to memory disorders in the home setting.

METHODS

This was a cross-sectional evaluation of 292 community-residing individuals aged 70 and older in Maryland. Participants were given a brief cognitive telephone screen. A subsample (n=43) received a comprehensive in-home assessment for dementia and dementia-related needs. Cognitive, functional, behavioral, and clinical factors were assessed. The Johns Hopkins Dementia Care Needs Assessment (JHDCNA) was used to identify unmet needs related to dementia.

RESULTS

Telephone screening for the sample took 350 h, and 27% screened positive for dementia. Virtually all participants with dementia who received an in-home assessment had at least one unmet need, with the most frequent unmet needs being for a dementia workup, general medical care, environmental safety, assistance with ADL impairments, and access to meaningful activities. Caregivers, when present, also had a number of unmet needs, with the most common being caregiver education about dementia, knowledge of community resources, and caregiver mental health care.

CONCLUSIONS

Effective and efficient means for identifying community-residing individuals with dementia are needed so that dementia care interventions can be provided to address unmet care needs of patients and their caregivers.

Association of the spatial layout of the home and ADL abilities among older adults with dementia

We investigated the relationship between architectural space syntax measures describing the spatial layout of a home and activities of daily living (ADL) among people with dementia. We visited the homes of 82 participants in a dementia care comparative effectiveness clinical trial and measured the space syntax variables intelligibility and convexity along with several clinical variables, including ADLs. In regression models, we estimated the cross-sectional association between space syntax measures and ADLs. Higher convexity was associated with worse performance of basic but not instrumental ADLs (adjusted β =19.2, P = .02). Intelligibility was not associated with ADLs. These results imply that enclosed rooms with a clearly legible meaning and function might be better memorized and associated with the spatial layout of the home resulting in better basic ADL performance. These results warrant further research on space syntax measures in the home environment of people with dementia, including longitudinal study, which we are pursuing.

The physical environment influences neuropsychiatric symptoms and other outcomes in assisted living residents

OBJECTIVE

Although the number of elderly residents living in assisted living (AL) facilities is rising, few studies have examined the AL physical environment and its impact on resident well-being. We sought to quantify the relationship of AL physical environment with resident outcomes including neuropsychiatric symptoms (NPS), quality of life (QOL), and fall risk, and to compare the effects for demented and non-demented residents.

METHODS

Prospective cohort study of a stratified random sample of 326 AL residents living in 21 AL facilities. Measures included the Therapeutic Environmental Screening Scale for Nursing Homes and Residential Care (TESS-NH/RC) to rate facilities and in-person assessment of residents for diagnosis (and assessment of treatment) of dementia, ratings on standardized clinical, cognitive, and QOL measures. Regression models compared environmental measures with outcomes. TESS-NH/RC is modified into a scale for rating the AL physical environment AL-EQS.

RESULTS

The AL Environmental Quality Score (AL-EQS) was strongly negatively associated with Neuropsychiatric Inventory (NPI) total score (p < 0.001), positively associated with Alzheimer Disease Related Quality of Life (ADRQL) score (p = 0.010), and negatively correlated with fall risk (p = 0.042). Factor analysis revealed an excellent two-factor solution, Dignity and Sensory. Both were strongly associated with NPI and associated with ADRQL.

CONCLUSION

The physical environment of AL facilities likely affects NPS and QOL in AL residents, and the effect may be stronger for residents without dementia than for residents with dementia. Environmental manipulations that increase resident privacy, as well as implementing call buttons and telephones, may improve resident well-being.

Anxiety symptoms among assisted living residents: implications of the "no difference" finding for participants with and without dementia

Anxiety is a distressing experience at any age but may be particularly disabling when coupled with dementia. Dementia-related anxiety is associated with a range of additional problems among community-dwelling older adults, but little is known about its occurrence in assisted living environments. The purpose of this article is to describe the prevalence of anxiety symptoms among older adults who participated in Phase I of the Maryland Assisted Living Study, a cross-sectional study of 198 participants who underwent comprehensive dementia evaluations. Participants with dementia diagnoses (n=134) were compared with those without dementia (n=64) using two measures of anxiety. Anxiety was common in both groups: 22% of each group were assessed to have one or more anxiety symptoms using proxyrated methods, and 45% had at least mild anxiety using direct observation and interview. Factors that contribute to variability in reports of dementia-related anxiety are reviewed.

Correlates of functional dependence among recently admitted assisted living residents with and without dementia

OBJECTIVES

To describe and contrast functional dependency (FD) levels among recently admitted AL residents with and without dementia and to assess the differential contribution of cognitive, behavioral, medical, and social factors on FD within each group.

DESIGN

A cross-sectional study.

SETTING

A random sample of 28 AL facilities in the Central Maryland region.

PARTICIPANTS

Two hundred and sixty-two AL residents assessed less than 1 year after admission.

MEASUREMENTS

Participants were given comprehensive in-person dementia assessments. Cognitive, behavioral, medical, and social factors were also assessed. FD was operationalized as impairment in activities of daily living.

RESULTS

The 59% of residents with dementia had higher levels of FD (P < .001) and were more likely to require assistance in all assessed task-specific ADL domains (P < .001) except mobility (P = .653). In multivariate models, global cognition, medical health status, and presence of diabetes explained 43% of the variance in FD in the dementia group. Twenty-five percent of the variance in FD was explained by depression, neuropsychiatric symptoms, and global cognition in those without dementia.

CONCLUSIONS

Recently admitted AL residents have substantial levels of FD. FD is higher among residents with dementia compared with those without and the association of cognitive, mental health, and medical variables with FD differ as a function of dementia status. Future research should examine how these dimensions affect FD longitudinally and whether they may serve as targets for interventions and quality of care improvement initiatives.

The spectrum of medical illness and medication use among residents of assisted living facilities in central Maryland

BACKGROUND

Although increasing numbers of older adults are living in assisted living facilities, there is little information on the types and amount of chronic medical illness and the medications required by such residents. To better inform efforts to optimize care in this setting, we sought to quantify chronic medical illnesses and their treatment.

METHODS

Medical diagnoses and treatments were derived from chart reviews and interviews of 198 residents of 22 randomly selected assisted living facilities (AL) in central Maryland. To evaluate the burden of medical illnesses, chronic conditions were categorized and quantified according to general (organ system) diseases, as well as 7 specific long-term care Clinical Practice Guidelines (CPG). Using logistic regression, we calculated the associations between facility-level characteristics and those residents with a) conditions from 3 or more general disease categories and, b) 2 or more CPG conditions. To evaluate medical treatment complexity, we categorized oral and certain non-oral medications, as well medications that typically require additional monitoring.

RESULTS

Almost one-half (46%) of AL residents had chronic conditions in 3 or more different general disease categories and one-fourth (25.2%) had 2 or more specific Clinical Practice Guideline (CPG) conditions. Residents with chronic conditions in 3 or more different general disease groups were more likely to live in larger facilities; otherwise, no other facility-level characteristics that we assessed were associated with residents having conditions from 3 or more general disease categories or 2 or more CPG conditions. One-half of all residents were taking medications that typically require additional monitoring and 25% of residents were receiving treatments of respiratory inhalers, eye drops and/or injections.

CONCLUSIONS

Many AL residents have multiple medical illnesses of different types and complexity. Given the increasing role of AL providers in the management of such conditions, appropriate adjustments in care provision will be needed for facilities to meet the needs of these residents.

Insomnia and daytime sleepiness in people with dementia residing in assisted living: findings from the Maryland Assisted Living Study

OBJECTIVE

To estimate the frequency and correlates of insomnia and daytime sleepiness among people with dementia in AL facilities.

METHODS

Participants were randomly selected from 22 different assisted living facilities in Maryland. A total of 124 dementia participants were included in the analysis. All participants were rated on an 11-item sleep questionnaire regarding insomnia and daytime sleepiness.

RESULTS

Sleep disturbance was present in 59.2% of people with dementia. Of the total sample, 21.8% had insomnia only (IN); 21.6% had excessive daytime sleepiness only (DS); and 16.8% had both IN and DS. 40.8% had no sleep disturbance. IN and DS scores were not significantly associated with each other (r=0.07, p=0.43). Of those in the IN group, the majority had mild and moderate dementia and of those in the DS only group the majority had severe dementia. Those with IN only performed the best and DS only performed the worst on both cognitive measures (the Mini Mental State Examination) (F=3.26, p=0.014), and on physical measures (the physical subscale of the psychogeraitric dependency rating scale) (F=6.09, p<0.001). There was no significant difference between the groups on the Cornell scale for depression in dementia.

CONCLUSION

The frequency of insomnia and daytime sleepiness in dementia subjects in AL is similar to that found in nursing homes. Daytime sleepiness is associated with poorer cognitive and day-to-day functioning. Effective management of DS may lead to improved functioning in the AL residents. Insomnia is associated with the best outcomes, even better than those with no sleep disturbance. This finding needs to be replicated.