Association of incident dementia with hospitalizations

Reform influences location of death: Interrupted time-series analysis on older adults and persons with dementia

Background

Norway instituted a Coordination Reform in 2012 aimed at maximizing time at home by providing in-home care through community services. Dying in a hospital can be highly stressful for patients and families. Persons with dementia are particularly vulnerable to negative outcomes in hospital. This study aims to describe changes in the proportion of older adults with and without dementia dying in nursing homes, home, hospital and other locations over an 11-year period covering the reform.

Methods and findings

This is a repeated cross-sectional, population-level study using mortality data from the Norwegian Cause of Death Registry hosted by the Norwegian Institute of Public Health. Participants were Norwegian older adults 65 years or older with and without dementia who died from 2006 to 2017. The policy intervention was the 2012 Coordination Reform that increased care infrastructure into communities. The primary outcome was location of death listed as a nursing home, home, hospital or other location. The trend in the proportion of location of death, before and after the reform was estimated using an interrupted time-series analysis. All analyses were adjusted for sex and seasonality. Of the 417,862 older adult decedents, 61,940 (14.8%) had dementia identified on their death certificate. Nursing home deaths increased over time while hospital deaths decreased for the total population (adjusted Relative Risk Ratio (aRRR) 0.87, 95% CI 0.82–0.92) and persons with dementia (aRRR: 0.93, 95%CI 0.91–0.96) after reform implementation.

Conclusion

This study provides evidence that the 2012 Coordination Reform was associated with decreased older adults dying in hospital and increased nursing home death; however, the number of people dying at home did not change.

Dementia and the Critically Ill Older Adult

Dementia is a terminal illness that leads to progressive cognitive and functional decline. As the elderly population grows, the incidence of dementia in hospitalized older adults increases and is associated with poor short-term and long-term outcomes. Delirium is associated with an accelerated cognitive decline in hospitalized patients with dementia. The first step in the management of dementia is accurate and early diagnosis. Evidence-based management guidelines in the setting of critical illness and dementia are lacking. The cornerstone of management is defining goals of care early in the course of hospitalization and using palliative care and hospice when deemed appropriate.

Do Caregiving Factors Affect Hospitalization Risk Among Disabled Older Adults?

BACKGROUND/OBJECTIVES

Hospitalization is common among older adults with disability, many of whom receive help from a caregiver and have dementia. Our objective was to evaluate the association between caregiver factors and risk of hospitalization and whether associations differ by dementia status.

DESIGN

Longitudinal observational study.

SETTING

The 1999 and 2004 National Long-Term Care Survey and the 2011 and 2015 National Health and Aging Trends Study, linked caregiver surveys, and Medicare claims.

PARTICIPANTS

A total of 2,589 community-living Medicare fee-for-service beneficiaries, aged 65 years or older (mean age = 79 years; 63% women; 31% with dementia), with self-care or mobility disability and their primary family or unpaid caregiver.

MEASUREMENTS

Self-reported characteristics of older adults and their caregivers were assessed from older adult and caregiver survey interviews. Older adult hospitalization over the subsequent 12 months was identified in Medicare claims. Multivariable Cox proportional hazards models adjusted for older adult characteristics and were stratified by dementia status.

RESULTS

In this nationally representative cohort, 38% of older adults with disabilities were hospitalized over 12 months following interview. Increased hospitalization risk was associated with having a primary caregiver who helped with healthcare tasks (adjusted hazard ratio (aHR) = 1.22; 95% confidence interval (CI) = 1.05-1.40), reported physical strain (aHR = 1.21; 95% CI = 1.04-1.42), and provided more than 40 hours of care weekly (aHR = 1.26; 95% CI = 1.04-1.54 vs ≤20 hours). Having a caregiver who had helped for 4 years or longer (vs <1 year) was associated with 38% lower risk of hospitalization (aHR = 0.62; 95% CI = 0.49-0.79). Older adults with and without dementia had similar rates of hospitalization (39.5% vs 37.3%; P = .4), and caregiving factors were similarly associated with hospitalization regardless of older adults' dementia status.

CONCLUSION

Select caregiving characteristics are associated with hospitalization risk among older adults with disability. Hospitalization risk reduction strategies may benefit from understanding and addressing caregiving circumstances.

Which Nursing Home Residents With Pneumonia Are Managed On-Site and Which Are Hospitalized? Results from 2 Years' Surveillance in 14 US Homes

OBJECTIVES

Pneumonia is a frequent cause of hospitalization among nursing home (NH) residents, but little information is available as to how clinical presentation and other characteristics relate to hospitalization, and the differential use of antimicrobials based on hospitalization status. This study examined how hospitalized and nonhospitalized NH residents with pneumonia differ.

DESIGN

Data from a 2-year prospective study of residents who participated in a randomized controlled trial.

SETTING AND PARTICIPANTS

All residents from 14 NHs in North Carolina followed for pneumonia over a 2-year period.

METHODS

Clinical features, antimicrobial treatment, hospitalization, and demographic data on residents with a pneumonia diagnosis were abstracted from charts; NH information was obtained from NH administrators.

RESULTS

A total of 509 pneumonia episodes were reported for 395 unique residents; the incidence was not higher in the winter months, and 28% were hospitalized. The likelihood of hospitalization did not differ by clinical characteristics except that residents with a respiratory rate >25 breaths per minute were more likely to be hospitalized. Being on hospice [odds ratio (OR) 3.3, 95% confidence interval (CI) 1.5-7.4] and not having dementia (OR 1.9, 95% CI 1.1-3.2) also related to increased likelihood of hospitalization. Fluoroquinolone (usually levofloxacin) monotherapy was the most common treatment (54%) in both settings, and ceftriaxone monotherapy varied by hospitalization status (7% of hospitalized vs 16% treated on-site). Approximately 36% of nonhospitalized residents received antimicrobials for more than 7 days.

CONCLUSIONS/IMPLICATIONS

Respiratory rate is associated with hospitalization but was not documented for more than a quarter of residents, suggesting the clinical benefit of more consistently conducting this assessment. Differential hospitalization rates for persons with dementia and on hospice suggest that care is being tailored to individuals' wishes, but this assumption merits study, as does use of fluoroquinolones (due to side effects) and treatment duration (due to potential contribution to antibiotic resistance).

Non-pharmacological interventions to prevent hospital or nursing home admissions among community-dwelling older people with dementia: A systematic review and meta-analysis

Older people with dementia more frequently experience episodes of hospital care, transferal to nursing home and adverse events when they are in these environments. This study synthesised the available evidence examining non-pharmacological interventions to prevent hospital or nursing home admissions for community-dwelling older people with dementia. Seven health science databases of all dates were searched up to 2 December 2019. Randomised controlled trials and comparative studies investigating non-pharmacological interventions for older people with dementia who lived in the community were included. Meta-analyses using a random-effect model of randomised controlled trials were used to assess the effectiveness of interventions using measures taken as close to 12 months into follow-up as reported. Outcomes were risk and rate of hospital and nursing home admissions. Risk ratio (RR) or rate ratios (RaR) with 95% confidence interval were used to pool results for hospital and nursing home admission outcomes. Sensitivity analyses were conducted to include pooling of results from non-randomised trails. Twenty studies were included in the review. Community care coordination reduced rate of nursing home admissions [(2 studies, n = 303 people with dementia and 86 patient-caregiver dyads), pooled RaR = 0.66, 95% CI (0.45, 0.97), I²  = 0%, p = .45]. Single interventions of psychoeducation and multifactorial interventions comprising of treatment and assessment clinics indicated no effect on hospital or nursing home admissions. The preliminary evidence of community care coordination on reducing the rate of nursing home admissions may be considered with caution when planning for community services or care for older people living with dementia.

Health-care use and cost for multimorbid persons with dementia in the National Health and Aging Trends Study

BACKGROUND

Most persons with dementia have multiple chronic conditions; however, it is unclear whether co-existing chronic conditions contribute to health-care use and cost.

METHODS

Persons with dementia and ≥2 chronic conditions using the National Health and Aging Trends Study and Medicare claims data, 2011 to 2014.

RESULTS

Chronic kidney disease and ischemic heart disease were significantly associated with increased adjusted risk ratios of annual hospitalizations, hospitalization costs, and direct medical costs. Depression, hypertension, and stroke or transient ischemic attack were associated with direct medical and societal costs, while atrial fibrillation was associated with increased hospital and direct medical costs. No chronic condition was associated with informal care costs.

CONCLUSIONS

Among older adults with dementia, proactive and ambulatory care that includes informal caregivers along with primary and specialty providers, may offer promise to decrease use and costs for chronic kidney disease, ischemic heart disease, atrial fibrillation, depression, and hypertension.

Continuity of care and health care cost among community-dwelling older adult veterans living with dementia

OBJECTIVES

To estimate the causal impact of continuity of care (COC) on total, institutional, and noninstitutional cost among community-dwelling older veterans with dementia.

DATA SOURCES

Combined Veterans Health Administration (VHA) and Medicare data in Fiscal Years (FYs) 2014-2015.

STUDY DESIGN

FY 2014 COC was measured by the Bice-Boxerman Continuity of Care (BBC) index on a 0-1 scale. FY 2015 total combined VHA and Medicare cost, institutional cost of acute inpatient, emergency department [ED], long-/short-stay nursing home, and noninstitutional long-term care (LTC) cost for medical (like skilled-) and social (like unskilled-) services were assessed controlling for covariates. An instrumental variable for COC (change of residence by more than 10 miles) was used to account for unobserved health confounders.

DATA COLLECTION

Community-dwelling veterans with dementia aged 66 and older, enrolled in Traditional Medicare (N = 102 073).

PRINCIPAL FINDINGS

Mean BBC in FY 2014 was 0.32; mean total cost in FY 2015 was $35 425. A 0.1 higher BBC resulted in (a) $4045 lower total cost; (b) $1597 lower acute inpatient cost, $119 lower ED cost, $4368 lower long-stay nursing home cost; (c) $402 higher noninstitutional medical LTC and $764 higher noninstitutional social LTC cost. BBC had no impact on short-stay nursing home cost.

CONCLUSIONS

COC is an effective approach to reducing total health care cost by supporting noninstitutional care and reducing institutional care.

Music-based interventions in the acute setting for patients with dementia: a systematic review

PURPOSE

The utilization of non-pharmacological interventions is increasingly recommended in dementia care. Among them, Music-based interventions seem promising options, according with numerous positive studies conducted in long-term care institutions. In this review, we aim to investigate its administration to patients with dementia in a less-researched setting-the acute hospital.

METHODS

A systematic review (PROSPERO registration: 81698), according to PRISMA recommendations, was performed. Embase, PubMed, PsycINFO, ASSIA and Humanities Index were searched from first records to June 2019 and the search was updated in June 2020. Manual screening of journals, trial registries and grey literature was undertaken. Risk of bias was assessed with the Downs and Black (1998) checklist.

RESULTS

345 records were initially retrieved and nine complied with the inclusion criteria. Data on 246 acute inpatients (224 PwD), with a mean age (reported only in 4 studies) varying from 74.1 to 86.5 was presented. Interventions varied significantly and practical details of their administration and development were poorly reported. Overall, quantitative results indicate a trend towards a positive effect in well-being, mood, engagement/relationship and global cognitive function, as well as a reduction in BPSD, resistive care, utilization of pro re nata medication and one-on-one care. Qualitative data also demonstrates acceptability and positive effects of music-based interventions.

CONCLUSION

Despite the lack of robust, adequately powered and controlled trials, identified studies suggest it is feasible to deliver music-based interventions, in the acute setting, to patients with dementia and there is a trend towards positive effects.

Disease severity at the time of initial cognitive assessment is related to prior health-care resource use burden

INTRODUCTION

Research has shown increased health-care resource use (HRU) among patients with Alzheimer's disease and related disorders (ADRD) well before diagnosis, but the degree to which HRU is correlated with disease severity at the time of initial assessment is not well documented.

METHODS

Retrospective analysis of linked medical records and claims data for three cohorts: mild ADRD (first [index] Mini-Mental State Examination [MMSE] ≥20), moderate/severe ADRD (index MMSE < 20), controls without cognitive impairment. HRU during the pre-index year was compared using multivariate regressions.

RESULTS

ADRD cohorts had significantly (P < .01) higher HRU than controls. Compared to mild ADRD patients, moderate/severe ADRD patients had higher rates of hospitalizations (relative risk [RR]: 1.57), emergency department visits (RR: 1.36), potentially avoidable hospitalizations (RR: 1.72), and accidental falls (RR: 1.58).

DISCUSSION

HRU before initial assessment increases with disease severity at the time of assessment, highlighting the need for timely evaluation and improved management in the earliest stages of ADRD.

Drug related problems in older adults living with dementia

BACKGROUND

Compared with those without dementia, older patients with dementia admitted to acute care settings are at higher risk for triad combination of polypharmacy (PP), potentially inappropriate medication (PIM), and drug-drug interaction (DDI), which may consequently result in detrimental health. The aims of this research were to assess risk factors associated with triad combination of PP, PIM and DDI among hospitalized older patients with dementia, and to assess prevalence and characteristics of PP, PIM and DDI in this population.

METHODS

In this retrospective cross-sectional study, 416 older inpatients diagnosed with dementia and referred for specialist geriatric consultation at a tertiary hospital in Brisbane, Australia during 2006-2016 were enrolled. Patients were categorized into two groups according to their exposure to the combination of PP, PIM and DDI: 'triad combination' and 'non-triad combination'. Data were collected using the interRAI Acute Care (AC) assessment instrument. Independent risk factors of exposure to the triad combination were evaluated using bivariate and multivariate logistic regression analyses.

RESULTS

Overall, 181 (43.5%) were classified as triad combination group. The majority of the population took at least 1 PIM (56%) or experienced at least one potential DDI (76%). Over 75% of the participants were exposed to polypharmacy. The most common prescribed PIMs were antipsychotics, followed by benzodiazepines. The independent risk factors of the triad combination were the presence of atrial fibrillation diagnosis and higher medications use in cardiac therapy, psycholeptics and psychoanaleptics.

CONCLUSIONS

The exposure to triad combination of PP, PIM and DDI are common among people with dementia as a result of their vulnerable conditions and the greater risks of adverse events from medications use. This study identified the use of cardiac therapy, psycholeptics and psychoanaleptics as predictors of exposure to PP, PIM and DDI. Therefore, use of these medications should be carefully considered and closely monitored. Furthermore, comprehensive medication reviews to optimize medication prescribing should be initiated and continually implemented for this vulnerable population.

Trajectories of health system use and survival for community-dwelling persons with dementia: a cohort study

OBJECTIVES

To determine the long-term trajectories of health system use by persons with dementia as they remain in the community over time.

DESIGN

Population-based cohort study using health administrative data.

SETTING

Ontario, Canada from 1 April 2007 to 31 March 2014.

PARTICIPANTS

62 622 community-dwelling adults aged 65+ years with prevalent dementia on 1 April 2007 matched 1:1 to persons without dementia based on age, sex and comorbidity.

MAIN OUTCOME MEASURES

Rates of health service use, long-term care placement and mortality over time.

RESULTS

After 7 years, 49.0% of persons with dementia had spent time in long-term care (6.8% without) and 64.5% had died (30.0% without). Persons with dementia were more likely than those without to use home care (rate ratio (RR) 3.02, 95% CI 2.93 to 3.11) and experience hospitalisations with a discharge delay (RR 2.36, 95% CI 2.30 to 2.42). As they remained in the community, persons with dementia used home care at a growing rate (10.7%, 95% CI 10.0 to 11.3 increase per year vs 6.7%, 95% CI 4.3 to 9.0 per year among those without), but rates of acute care hospitalisation remained constant (0.6%, 95% CI -0.6 to 1.9 increase per year).

CONCLUSIONS

While persons with dementia used more health services than those without dementia over time, the rate of change in use differed by service type. These results, particularly enumerating the increased intensity of home care service use, add value to capacity planning initiatives where limited budgets require balancing services.

National Trends in Potentially Preventable Hospitalizations of Older Adults with Dementia

BACKGROUND/OBJECTIVES

Dementia is associated with higher healthcare expenditures, in large part due to increased hospitalization rates relative to patients without dementia. Data on contemporary trends in the incidence and outcomes of potentially preventable hospitalizations of patients with dementia are lacking.

DESIGN

Retrospective cohort study using the National Inpatient Sample from 2012 to 2016.

SETTING

U.S. acute care hospitals.

PARTICIPANTS

A total of 1,843,632 unique hospitalizations of older adults (aged ≥65 years) with diagnosed dementia.

MEASUREMENTS

Annual trends in the incidence of hospitalizations for all causes and for potentially preventable conditions including acute ambulatory care sensitive conditions (ACSCs), chronic ACSCs, and injuries. In-hospital outcomes including mortality, discharge disposition, and hospital costs.

RESULTS

The survey weighted sample represented an estimated 9.27 million hospitalizations for patients with diagnosed dementia (mean [standard deviation] age = 82.6 [6.7] years; 61.4% female). In total, 3.72 million hospitalizations were for potentially preventable conditions (40.1%), 2.07 million for acute ACSCs, .76 million for chronic ACSCs, and .89 million for injuries. Between 2012 and 2016, the incidence of all-cause hospitalizations declined from 1.87 million to 1.85 million per year (P = .04) while the incidence of potentially preventable hospitalizations increased from .75 million to .87 million per year (P < .001), driven by an increased number of hospitalizations of community-dwelling older adults. Among patients with dementia hospitalized for potentially preventable conditions, inpatient mortality declined from 6.4% to 6.1% (P < .001), inflation-adjusted median costs increased from $7,319 to $7,543 (P < .001), and total annual costs increased from $7.4 to $9.3 billion. Although 86.0% of hospitalized patients were admitted from the community, only 32.7% were discharged to the community.

CONCLUSION

The number of potentially preventable hospitalizations of older adults with dementia is increasing, driven by hospitalizations of community-dwelling older adults. Improved strategies for early detection and goal-directed treatment of potentially preventable conditions in patients with dementia are urgently needed. J Am Geriatr Soc 68:2240-2248, 2020.

The factors associated with inappropriate prescription patterns of benzodiazepines and related drugs among patients with dementia

BACKGROUND

It has been emphasised that benzodiazepines and related drugs (BZDRs) should be used cautiously in people with dementia. The aim of this study was to identify factors associated with inappropriate prescription patterns of BZDRs including polypharmacy, long-term treatment and high doses among patients with dementia taking BZDRs.

METHODS

This was a retrospective chart review study of patients with dementia who were treated at the study hospital. The date that the patient was issued a catastrophic illness certificate from the National Health Insurance Administration was used as the index date. Medical records of the 2-year period after the index date were reviewed.

RESULTS

A total of 308 patients with dementia were included in this study. Among them, 151 (49.0%) received at least one prescription of BZDRs. After adjusting for covariates, psychiatric comorbidities (adjusted odds ratio (aOR) = 4.74, 95% CI = 1.75-12.81), history of past suicidal behaviour (aOR = 4.25, 95% CI = 1.40-12.88) and long-term treatment with BZDRs (aOR = 3.38, 95% CI = 1.11-10.27) were associated with polypharmacy of BZDRs. Age (aOR = 1.05, 95% CI = 1.0-1.11) and polypharmacy (aOR = 3.57, 95% CI = 1.23-10.32) were associated with long-term treatment. Living with family (aOR = 3.33, 95% CI = 1.32-9.79) and fewer psychiatric admissions to the study hospital (aOR = 0.56, 95% CI = 0.36-0.86) were associated with treatment with high doses of BZDRs.

CONCLUSIONS

Treatment with BZDRs is prevalent in patients with dementia. Inappropriate prescription patterns of BZDRs are not uncommon in these patients and may be interlinked.

Associations between Cognitive Function, Hospitalizations and Costs in Nursing Homes: A Cross-sectional Study

In an Australian nursing home population, associations between cognitive function and 12-month hospitalizations and costs were examined. Participants with dementia had 57% fewer hospitalizations compared to those without dementia, with 41% lower mean hospitalization costs; poorer cognition scores were also associated with fewer hospitalizations. The cost per admission for those with dementia was 33% greater due to longer hospital stays (5.5 days versus 3.1 days for no dementia, p = .05). People with dementia were most frequently hospitalized for fractures. These findings have policy implications for increasing investment in accurate and timely diagnosis of dementia and fall and fracture prevention strategies to further reduce associated hospitalization costs.

New use of psychotropic medication after hospitalization among people with dementia

OBJECTIVES

Psychotropic medication is commonly used among people with dementia (PWD), but it shows modest efficacy and it has been associated with severe adverse events. Hospitalizations are an opportunity for medication management as well as treatment recommendations for outpatient physicians. The aim of this study was to asses factors associated with new use of psychotropic medication after hospitalization among PWD.

METHODS

We conducted a retrospective dynamic cohort study from 2004 to 2015 using claims data from a German health insurance company. PWD were identified by an algorithm that included ICD-10 diagnosis and diagnostic measures. The medication classes included were antidepressants, antipsychotics, anxiolytics or hypnotics/sedatives, and Alzheimer's medication. The assessment period was up to 30 days after discharge from the hospital across four hospitalizations.

RESULTS

The main predictors for new use of psychotropic medication were similar across medication classes. Neuropsychiatric symptoms (NPS) and the need of care were associated with higher odds of new use of antidepressants, antipsychotics, and anxiolytics or hypnotics/sedatives. A hospital stay due to dementia was an independent predictor for new use across medication classes as well. Delirium increased the odds for new use of antipsychotics and anxiolytics or hypnotics/sedatives.

CONCLUSIONS

Factors associated with new use of psychotropic medication included delirium, NPS, and the need of care in PWD. The findings highlight the need for preventive interventions and non-medical treatment options in regards to delirium and NPS as well as for a more intensive use of screening tools for inappropriate medication use among PWD. Key points The percentage of new users was 1.8%, 7.1%, 2.1%, and 2.5% across hospitalizations for antidepressants, antipsychotics, anxiolytics or hypnotics/sedatives, and Alzheimer's medication, respectively. 83.0%, 61.9%, 56.9%, and 88.1% of new users received antidepressants, antipsychotics, anxiolytics or hypnotics/sedatives, and Alzheimer's medication for more than 6 weeks. Delirium and neuropsychiatric symptoms were associated with significantly increased odds of new psychotropic medication use. Hospital stays due to dementia and the need of care were predictors for new use of psychotropic medication.

Approach to the Older Adult With New Cognitive Symptoms

Dementia affects nearly 50 million people worldwide, translating into one new case every 3 seconds. Dementia syndrome is one of the leading causes of disability among older adults, yet it remains vastly underdiagnosed. A timely diagnosis of dementia is essential to ensuring optimal care and support of individuals and their loved ones. Although there is no single test for dementia, health care providers can use a structured approach to the workup and management of new cognitive symptoms. Comprehensive MEDLINE and PubMed searches were performed to develop an unbiased, practical diagnostic approach to these symptoms. This review guides primary care providers in the workup, diagnosis, delivery, and initial management of patients presenting with new cognitive symptoms.

Association Between Sepsis and Microvascular Brain Injury

OBJECTIVES

Many survivors of sepsis suffer long-term cognitive impairment, but the mechanisms of this association remain unknown. The objective of this study was to determine whether sepsis is associated with cerebral microinfarcts on brain autopsy.

DESIGN

Retrospective cohort study.

SETTING AND SUBJECTS

Five-hundred twenty-nine participants of the Adult Changes in Thought, a population-based prospective cohort study of older adults carried out in Kaiser Permanente Washington greater than or equal to 65 years old without dementia at study entry and who underwent brain autopsy.

MEASUREMENTS AND MAIN RESULTS

Late-life sepsis hospitalization was identified using administrative data. We identified 89 individuals with greater than or equal to 1 sepsis hospitalization during study participation, 80 of whom survived hospitalization and died a median of 169 days after discharge. Thirty percent of participants with one or more sepsis hospitalization had greater than two microinfarcts, compared with 19% participants without (χ p = 0.02); 20% of those with sepsis hospitalization had greater than two microinfarcts in the cerebral cortex, compared with 10% of those without (χ p = 0.01). The adjusted relative risk of greater than two microinfarcts was 1.61 (95% CI, 1.01-2.57; p = 0.04); the relative risk for having greater than two microinfarcts in the cerebral cortex was 2.12 (95% CI, 1.12-4.02; p = 0.02). There was no difference in Braak stage for neurofibrillary tangles or consortium to establish a registry for Alzheimer's disease score for neuritic plaques between, but Lewy bodies were less significantly common in those with sepsis.

CONCLUSIONS

Sepsis was specifically associated with moderate to severe vascular brain injury as assessed by microvascular infarcts. This association was stronger for microinfarcts within the cerebral cortex, with those who experienced severe sepsis hospitalization being more than twice as likely to have evidence of moderate to severe cerebral cortical injury in adjusted analyses. Further study to identify mechanisms for the association of sepsis and microinfarcts is needed.

Education, Activity Engagement, and Cognitive Function in US Chinese Older Adults

OBJECTIVES

To examine whether and how early-life experiences such as years of schooling affect late-life cognitive function through a pathway of activity engagement.

DESIGN

Prospective.

SETTING

We used data from 2 waves of the Population Study of Chinese Elderly in Chicago (PINE).

PARTICIPANTS

PINE is the largest population-based epidemiological study of Chinese-American adults aged 60 and older in the greater Chicago area. Wave 1 data were collected for 2 years, from July 2011 to June 2013, and Wave 2 data were collected from 2013 to 2015; total sample size was 2,713.

MEASUREMENTS

Education was measured in years of schooling. Activity engagement was assessed using 15 items grouped into two clusters: cognitive activity and social activity. Cognitive function was evaluated using five instruments to assess general mental status (Chinese Mini-Mental State Examination (C-MMSE)), episodic memory, perceptual speed, working memory, global cognition score.

RESULTS

Adjusting for sociodemographic and health-related control variables, education measured at Wave 1 was associated with better global cognition (b = 0.025, p < .001), C-MMSE (b = .037, p < .001), episodic memory (b = .026, p < .001), Symbol Digit Modalities Test perceptual speed (b = .036, p < .001), and Digit Span Backward working memory (b = .047, p < .001) at Wave 2. Activity engagement, cognitive activity in particular, significantly mediates the effect of education on all cognitive tests, with the size of the mediating effect ranging from 16% to approximately 24%.

CONCLUSION

Amount of schooling early in life is significantly related to late-life cognitive function in virtually all domains, and cognitive activity is one of many links between the two. J Am Geriatr Soc 67:S525-S531, 2019.

The Prevalence and Impact of Undiagnosed Mild Cognitive Impairment in Elderly Patients Undergoing Thoracic Surgery: A Prospective Cohort Study

OBJECTIVES

The objective of this study was to explore the prevalence of undiagnosed mild cognitive impairment (MCI) and its association with adverse outcomes in elderly patients undergoing thoracic surgery.

DESIGN

A prospective cohort study.

SETTING

Large tertiary medical center.

PARTICIPANTS

The authors enrolled 170 patients aged 65 years or older who were scheduled for thoracic surgery between November 7, 2018, and April 1, 2019, at the Shanghai Chest Hospital. Patients with a history of schizophrenia or dementia disease, uncorrected vision or hearing impairment, and refusal to participate were excluded.

INTERVENTIONS

A total of 154 elderly patients completed the Chinese version of the Montreal Cognitive Assessment (MoCA) test preoperatively and were included in the final analysis. They were categorized into a normal group (MoCA ≥ 26 scores, group N) and an abnormal group (MoCA < 26 scores, group AN) based on test results. Delirium was assessed with the Confusion Assessment Method twice daily during the first 3 postoperative days.

MEASUREMENTS AND MAIN RESULTS

The primary outcome was the incidence of postoperative delirium (POD). Secondary outcomes included the incidence of postoperative pulmonary complications (PPCs), cardiovascular complications, other complications, intensive care unit (ICU) stay, and the hospital length of stay (LOS). The incidence of MCI before thoracic surgery in elderly patients was 49.4% (76 of 154). Compared with group N, MCI could increase the incidence of POD (14.1% v 30.3%, p = 0.016) and median LOS (4 d v 5 d, p = 0.016). However, the differences in pulmonary complications, cardiovascular and other complications, and ICU stay were not significant. Multivariable logistic regression analysis showed preoperative MCI (OR = 2.573, 95% CI =1.092 to 6.060, p = 0.031) as an independent risk factor of POD. Compared with the elderly patients without POD, POD could increase the risk of PPCs (17.5% v 35.3%, p = 0.026) and median LOS (4 d v 5 d, p < 0.001).

CONCLUSIONS

The incidence of MCI before thoracic surgery in elderly patients was higher and associated with a higher rate of adverse postoperative outcomes. The findings may be important for preoperative patient counseling, operative planning, and eventually reducing potential risk exposure and related outcomes.

Impact of Alzheimer's disease and related dementia diagnosis following treatment for bladder cancer

OBJECTIVES

Our objective was to assess the incidence of Alzheimer's Disease and related dementia diagnosis following treatment for muscle-invasive bladder cancer and impact on survival outcomes.

MATERIALS AND METHODS

A total of 4814 patients diagnosed with clinical stage T2-T4a, N0, M0 bladder cancer between January 1, 2002 to December 31, 2011 using the Surveillance, Epidemiology, and End Results (SEER)-Medicare database were identified. Alzheimer's disease and related dementia diagnosis was identified using International Statistical Classification of Disease-Ninth Edition outpatient and inpatient codes. Incidence of dementia following treatment were calculated and reported as dementia cases per 10,000 person-years. Cox proportional hazards models were used to assess the impact of dementia on survival outcomes.

RESULTS

Of the 4814 patients, 2403 (49.9%) underwent radical cystectomy (RC) and 2411 (50.1%) underwent radiotherapy (RTX) and/or chemotherapy (CTX). Overall, 837 (17.4%) patients developed Alzheimer's disease and related dementia following bladder cancer treatment. There was no significant difference in the incidence of Alzheimer's disease and related dementia following either treatment. Patients diagnosed with Alzheimer's disease and related dementia had worse overall (Hazard Ratio (HR), 2.64; 95% Confidence Interval (CI), 2.41-2.89) and cancer-specific (HR, 2.45; 95% CI, 2.18-2.76) survival than those without a dementia diagnosis following treatment.

CONCLUSION

While we observed no difference in new-onset Alzheimer's disease and related dementia diagnosis following RC or RTX and/or CTX, patients with a Alzheimer's and related dementia diagnosis was associated with worse overall and cancer-specific survival. These findings have important implications for screening and the development of targeted interventions for improving outcomes in older adults following complex cancer treatments, as observed in this bladder cancer population.

A training program for primary health care nurses on timely diagnosis and management of dementia in general practice: An evaluation study

BACKGROUND

Primary health care nurses can play an important role in assisting the diagnosis and management of dementia. This study describes the evaluation outcome of a training program developed on the 'Four Steps to Building Dementia Practice in Primary Care'.

OBJECTIVE

To evaluate a training program for primary health care nurses by assessing change in current practice and future intention; and their knowledge, confidence, and perceived importance about dementia diagnosis and management.

DESIGN

A longitudinal survey. Participants were surveyed at three time points: pre-training, immediately post-training and six months (+/- 3 months) following their training.

SETTING

All states and territories in Australia.

PARTICIPANTS

Primary health care nurses (n = 1,290).

METHODS

A face-to-face and online training program on timely diagnosis and management of dementia was offered to primary health care nurses. A questionnaire was administered face-to-face and online to assess whether certain processes and services were 'currently in practice', 'working towards', or 'not in current practice' in their primary care facility. Three 10-point Likert scales were created to assess self-perceived levels of importance, knowledge and confidence about the diagnosis and management of dementia. A paired t-test was used to examine the differences between (a) post and pre-scores, and (b) follow-up and post scores. Linear regressions were used to identify the significant factors associated with pre-training scores for importance, confidence and knowledge.

RESULTS

Of 1290 primary health care nurses who participated in the training, 471 attended face-to-face and 819 participated online. Participants demonstrated improvements in all items in all four steps of the survey, with considerably higher improvement in the face-to-face mode. The average post-training score was significantly higher than the pre-training score for perceived importance, knowledge and confidence. The average follow-up score was significantly higher than the post-training score for perceived knowledge and confidence but not for perceived importance. Primary health care nurses who had 20 or more years of experience reported significantly more knowledge in attending patients with dementia than those with less than five years of experience (0.56, 95% CI: 0.11-1.01).

CONCLUSIONS

With a growing ageing population, the demand for dementia care is rising. Primary health care nurses can lead practice change and promote the timely diagnosis and management of dementia in general practice. Training programs of this kind that build knowledge, confidence, awareness and skills should be made available to the primary care nursing workforce. Further research is recommended to examine the translation of this training outcome into practice.

Association Between Critical Care Admissions and Cognitive Trajectories in Older Adults

OBJECTIVES

Patients requiring admission to an ICU may subsequently experience cognitive decline. Our objective was to investigate longitudinal cognitive trajectories in older adults hospitalized in ICUs. We hypothesized that individuals hospitalized for critical illness develop greater cognitive decline compared with those who do not require ICU admission.

DESIGN

A retrospective cohort study using prospectively collected cognitive scores of participants enrolled in the Mayo Clinic Study of Aging and ICU admissions retrospectively ascertained from electronic medical records. A covariate-adjusted linear mixed effects model with random intercepts and slopes assessed the relationship between ICU admissions and the slope of global cognitive z scores and domains scores (memory, attention/executive, visuospatial, and language).

SETTING

ICU admissions and cognitive scores in the Mayo Clinic Study of Aging from October 1, 2004, to September 11, 2017.

PATIENTS

Nondemented participants age 50 through 91 at enrollment in the Mayo Clinic Study of Aging with an initial cognitive assessment and at least one follow-up visit.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Of 3,673 participants, 372 had at least one ICU admission with median (25-75th percentile) follow-up after first ICU admission of 2.5 years (1.2-4.4 yr). For global cognitive z score, admission to an ICU was associated with greater decline in scores over time compared with participants not requiring ICU admission (difference in annual slope = -0.028; 95% CI, -0.044 to -0.012; p < 0.001). ICU admission was associated with greater declines in memory (-0.029; 95% CI, -0.047 to -0.011; p = 0.002), attention/executive (-0.020; 95% CI, -0.037 to -0.004; p = 0.016), and visuospatial (-0.013; 95% CI, -0.026 to -0.001; p = 0.041) domains. ICU admissions with delirium were associated with greater declines in memory (interaction p = 0.006) and language (interaction p = 0.002) domains than ICU admissions without delirium.

CONCLUSIONS

In older adults, ICU admission was associated with greater long-term cognitive decline compared with patients without ICU admission. These findings were more pronounced in those who develop delirium while in the ICU.

The association between dementia severity and hospitalisation profile in a newly assessed clinical cohort: the South London and Maudsley case register

OBJECTIVES

To evaluate the risk and common causes of hospitalisation in patients with newly diagnosed dementia and variation by severity of cognitive impairment.

SETTING

We used data from a large London mental healthcare case register linked to a national hospitalisation database.

PARTICIPANTS

Individuals aged ≥65 years with newly diagnosed dementia with recorded cognitive function and the catchment population within the same geography.

OUTCOME MEASURES

We evaluated the risk and duration of hospitalisation in the year following a dementia diagnosis. In addition we identified the most common causes of hospitalisation and calculated age-standardised and gender-standardised admission ratios by dementia severity (mild/moderate/severe) relative to the catchment population.

RESULTS

Of the 5218 patients with dementia, 2596 (49.8%) were hospitalised in the year following diagnosis. The proportion of individuals with mild, moderate and severe dementia who had a hospital admission was 47.9%, 50.8% and 51.7%, respectively (p= 0.097). Duration of hospital stay increased with dementia severity (median 2 days in mild to 4 days in severe dementia, p 0.0001). After excluding readmissions for the same cause, the most common primary hospitalisation discharge diagnoses among patients with dementia were urinary system disorders, pneumonia and fracture of femur, accounting for 15%, 10% and 6% of admissions, respectively. Overall, patients with dementia were hospitalised 30% more than the catchment population, and this trend was observed for most of the discharge diagnoses evaluated. Standardised admission ratios for urinary and respiratory disorders were higher in those with more severe dementia at diagnosis.

CONCLUSIONS

Individuals with a dementia diagnosis were more likely to be hospitalised than individuals in the catchment population. The length of hospital stay increased with dementia severity. Most of the common causes of hospitalisation were more common than expected relative to the catchment population, but standardised admission ratios only varied by dementia stage for certain groups of conditions.

CE: Acute Care for Patients with Dementia

Among adults ages 65 and older, dementia doubles the risk of hospitalization. Roughly one in four hospitalized patients has dementia, and the prevalence of dementia in the United States is rising rapidly. Patients with dementia have significantly higher rates of hospital-acquired complications, including urinary tract infections, pressure injuries, pneumonia, and delirium, which when unrecognized and untreated can accelerate physical and cognitive decline, precipitating nursing home placement and death. The authors discuss the unique needs of patients with dementia who require acute care, highlighting evidence-based strategies for nurses to incorporate into practice.

Health outcomes of patients with dementia in acute care settings-A systematic review

BACKGROUND

An ageing population has resulted in increased numbers of people with dementia attending acute care services; however, the impact of hospitalisation on this population is uncertain.

PURPOSE

This systematic review aimed to synthesise the available evidence on adverse health outcomes for people with dementia in acute care settings.

METHODS

A systematic search of CINAHL, PubMed, MEDLINE, EMBASE and Scopus databases for primary research articles in English language, published from 2000 to 2017, was conducted. A protocol for the review was registered on the PROSPERO database.

RESULTS

The initial search identified 5,520 records. Following removal of duplicates and assessment against inclusion criteria, 13 studies were included in the final review. Findings identify associations between patients with dementia, longer length of hospital stay and higher mortality in some situations. Heterogeneity across studies in data reporting and outcomes prevented meta-analysis; therefore, results are presented narratively.

CONCLUSIONS

Certainty of findings from this review is impacted by variation in patient condition and data reporting. Additional rigorous studies on health outcomes for people with dementia during acute hospitalisation will contribute to the evidence.

IMPLICATIONS FOR PRACTICE

These findings along with further research examining outcomes for patients with dementia in acute care settings will inform provision of safer, quality care and optimal health outcomes for this vulnerable population.

Health and long-term care of the elderly with dementia in rural Thailand: a cross-sectional survey through their caregivers

OBJECTIVE

To describe the circumstances of the elderly with dementia and their caregivers' characteristics in order to examine factors related to activities of daily living (ADL) and household income to propose a long-term care policy for rural areas of Thailand.

SETTING

A cross-sectional study at the household level in three rural regions of Thailand where there were initiatives relating to community care for people with dementia.

PARTICIPANTS

Caregivers of 140 people with dementia were recruited for the study.

PRIMARY AND SECONDARY OUTCOME MEASURES

Socioeconomic characteristics including data from assessment of ADL and instrumental ADL and the Thai version of Resource Utilisation in Dementia were collected. Descriptive statistics were used to explain the characteristics of the elderly with dementia and the caregivers while inferential statistics were used to examine the associations between different factors of elderly patients with dementia with their dependency level and household socioeconomic status.

RESULTS

Eighty-six per cent of the dementia caregivers were household informal caregivers as half of them also had to work outside the home. Half of the primary caregivers had no support and no minor caregivers. The elderly with dementia with high dependency levels were found to have a significant association with age, dementia severity, chance of hospitalisation and number of hospitalisations. Though most of these rural samples had low household incomes, the patients in the lower-income households had significantly lower dementia severity, but, with the health benefit coverage had significantly higher chances of hospitalisation.

CONCLUSION

As the informal caregivers are the principal human resources for dementia care and services in rural area, policymakers should consider informal care for the Thai elderly with dementia and promote it as the dominant pattern of dementia care in Thailand.

Health Care Utilization, Care Satisfaction, and Health Status for Medicare Advantage and Traditional Medicare Beneficiaries With and Without Alzheimer Disease and Related Dementias

Importance

Compared with traditional Medicare (TM) fee-for-service plans, Medicare Advantage (MA) plans may provide more-efficient care for beneficiaries with Alzheimer disease and related dementias (ADRD) without compromising care quality.

Objective

To determine differences in health care utilization, care satisfaction, and health status for MA and TM beneficiaries with and without ADRD.

Design, Setting, and Participants

A cohort study was conducted of MA and TM beneficiaries with and without ADRD from all publicly available years of the Medicare Current Beneficiary Survey between 2010 and 2016. To address advantageous selection into MA plans, county-level MA enrollment rate was used as an instrument. Data were analyzed between July 2019 and December 2019.

Exposures

Enrollment in MA.

Main Outcomes and Measures

Self-reported health care utilization, care satisfaction, and health status.

Results

The sample included 47 100 Medicare beneficiaries (25 900 women [54.9%]; mean [SD] age, 72.2 [11.4] years). Compared with TM beneficiaries with ADRD, MA beneficiaries with ADRD had lower utilization across the board, including a mean of -22.3 medical practitioner visits (95% CI, -24.9 to -19.8 medical practitioner visits), -2.3 outpatient hospital visits (95% CI, -3.6 to -1.1 outpatient hospital visits), -0.2 inpatient hospital admissions (95% CI, -0.3 to -0.1 inpatient hospital admissions), and -0.1 long-term care facility stays (95% CI, -0.2 to -0.1 long-term care facility stays). A similar trend was observed among beneficiaries without ADRD, but the difference was greater between MA and TM beneficiaries with ADRD than between MA and TM beneficiaries without ADRD (mean, -15.0 medical practitioner visits [95% CI, -18.7 to -11.3 medical practitioner visits], -1.7 outpatient hospital visits [95% CI, -3.0 to -0.3 outpatient hospital visits], and -0.1 inpatient hospital admissions [95% CI, -1.0 to 0.0 inpatient hospital admissions]). Overall, no or negligible differences were detected in care satisfaction and health status between MA and TM beneficiaries with and without ADRD.

Conclusions and Relevance

Compared with TM beneficiaries, MA beneficiaries had lower health care utilization without compromising care satisfaction and health status. This difference was more pronounced among beneficiaries with ADRD. These findings suggest that MA plans may be delivering health care more efficiently than TM, especially for beneficiaries with ADRD.

Under-coding of dementia and other conditions indicates scope for improved patient management: A longitudinal retrospective study of dementia patients in Australia

BACKGROUND

Under-coding of dementia during hospitalisation results in an inability to identify all patients with dementia using hospital administrative data. Clinical coding can be viewed as a proxy for management; therefore, under-coding indicates dementia was not considered in the patient's management. While under-coding of dementia is well established, there is sparse evidence on whether dementia is coded in subsequent hospitalisations among patients with a known diagnosis.

OBJECTIVE

(a) To describe patterns of dementia coding over 5 years after a first-coded (i.e. index) admission for dementia; (b) to identify factors associated with clinical coding of dementia; and (c) to identify patient subgroups at risk of not being coded to inform future interventions to improve hospital identification and management of dementia.

METHOD

Retrospective study of longitudinal hospital data from 1 July 2006 to 30 June 2015 for 7919 patients hospitalised during the 5 years' post-index admission for dementia in a regional local health district of New South Wales, Australia.

RESULTS

Dementia was coded in 63.9% of admissions in the 12 months following index admission for dementia; this decreased to 53.7% after 5 years. Patients were 20% more likely to have dementia actively managed when it co-occurred with delirium. Under-coding varied across conditions, with dementia more likely to be coded in admissions for falls and pneumonitis, and less likely for heart failure, pneumonia and urinary tract infection (UTI).

CONCLUSION

The frequency with which dementia was not coded highlights opportunities to improve identification and management of dementia through dementia-specific care, enhanced clinical protocols, and interventions focused around heart failure, pneumonia and UTI admissions.

Comorbid conditions and emergency department treat and release utilization in multimorbid persons with cognitive impairment

BACKGROUND

There is an increasing focus in the emergency department (ED) on addressing the needs of persons with cognitive impairment, most of whom have multiple chronic conditions. We investigated which common comorbidities among multimorbid persons with cognitive impairment conferred increased risk for ED treat and release utilization.

METHODS

We examined the association of 16 chronic conditions on use of ED treat and release visit utilization among 1006 adults with cognitive impairment and ≥ 2 comorbidities using the nationally-representative National Health and Aging Trends Study merged with Fee-For-Service Medicare claims data, 2011-2015.

RESULTS

At baseline, 28.5% had ≥6 conditions and 35.4% were ≥ 85 years old. After controlling for sex, age, race, education, urban-living, number of disabled activities of daily living, and sampling strata, we found significantly increased adjusted risk ratios (aRR) of ED treat and release visits for persons with depression (aRR 1.38 95% CI 1.15-1.65) representing 78/100 person-years, and osteoarthritis or rheumatoid arthritis (aRR 1.32 95% CI 1.12-1.57) representing 71/100 person-years. At baseline 93.9% had ≥1 informal caregiver and 69.7% had a caregiver that helped with medications or attended physician visits.

CONCLUSION

These results show that multimorbid cognitively impaired older adults with depression or osteoarthritis or rheumatoid arthritis are at higher risk of ED treat and release visits. Future ED research with multimorbid cognitively impaired persons may explore behavioral aspects of depression and/or pain and flairs associated with osteoarthritis or rheumatoid arthritis, as well as the role of informal caregivers in the care of these conditions.

Common Bacterial Infections and Risk of Dementia or Cognitive Decline: A Systematic Review

BACKGROUND

Bacterial infections may be associated with dementia, but the temporality of any relationship remains unclear.

OBJECTIVES

To summarize existing literature on the association between common bacterial infections and the risk of dementia and cognitive decline in longitudinal studies.

METHODS

We performed a comprehensive search of 10 databases of published and grey literature from inception to 18 March 2019 using search terms for common bacterial infections, dementia, cognitive decline, and longitudinal study designs. Two reviewers independently performed the study selection, data extraction, risk of bias and overall quality assessment. Data were summarized through a narrative synthesis as high heterogeneity precluded a meta-analysis.

RESULTS

We identified 3,488 studies. 9 met the eligibility criteria; 6 were conducted in the United States and 3 in Taiwan. 7 studies reported on dementia and 2 investigated cognitive decline. Multiple infections were assessed in two studies. All studies found sepsis (n = 6), pneumonia (n = 3), urinary tract infection (n = 1), and cellulitis (n = 1) increased dementia risk (HR 1.10; 95% CI 1.02-1.19) to (OR 2.60; 95% CI 1.84-3.66). The range of effect estimates was similar when limited to three studies with no domains at high risk of bias. However, the overall quality of evidence was rated very low. Studies on cognitive decline found no association with infection but had low power.

CONCLUSION

Our review suggests common bacterial infections may be associated with an increased risk of subsequent dementia, after adjustment for multiple confounders, but further high-quality, large-scale longitudinal studies, across different healthcare settings, are recommended to further explore this association.

Burden of Disease and Current Management of Dementia with Lewy Bodies: A Literature Review

INTRODUCTION

A significant proportion of dementia is concretely estimated to be attributable to dementia with Lewy bodies (DLB)-one of the most common types of progressive dementia; however, there is a paucity of literature on this disease. We aimed to examine available evidence to gain a better understanding of its treatment landscape, clinical management, and disease burden.

METHODS

A systematic literature review captured any DLB studies that report on randomised controlled trials (RCTs), epidemiology, disease progression, and economic data. An additional targeted literature review captured studies reporting on clinical management and quality of life (QoL) in this disease. Publication date was limited to 1 January 2007-26 March 2018, with the exception for RCTs, where no time restrictions were applied.

FINDINGS

Of the 3486 studies initially identified, 55 studies were eligible for inclusion. The studies were mainly from Europe (n = 29), the USA (n = 9), and Japan (n = 8). Mini-Mental State Examination and Neuropsychiatric Inventory scores were the most commonly reported clinical outcomes in RCTs (n = 14). The most frequently identified interventions reported in RCTs were donepezil and memantine. Patients with DLB typically reported worse outcomes in relation to efficacy and safety, cognitive impairment, survival, and QoL compared with those with Alzheimer's disease (AD). Additionally, patients with DLB were associated with higher hospitalisation rates and cost of care. Furthermore, there is a reliance on a small number of consensus guidelines. Of these, only one set of guidelines (DLB Consortium) was developed specifically for DLB.

CONCLUSION

The paucity of data indicates an unmet need in this therapy area. Although several studies look into the clinical and pathological aspects of DLB, consensus guidelines and studies on healthcare utilisation in patients with dementia have largely focused on AD. Additionally, most of the findings were made in comparison with AD.

FUNDING

Eisai Inc.

Trends in health service use and potentially avoidable hospitalizations before Alzheimer's disease diagnosis: A matched, retrospective study of US Medicare beneficiaries

INTRODUCTION

This study evaluates rates of all-cause emergency department visits, all-cause hospitalizations, potentially avoidable hospitalizations, and falls in 3 years preceding Alzheimer's disease (AD) diagnosis.

METHODS

Patients with AD and controls with no cognitive impairment were identified from the Medicare claims data. Patients were required to be aged ≥ 65 years and have continuous Medicare enrollment for ≥4 years before the index date (AD cohort: first AD diagnosis in 2012-2014; controls: randomly selected medical claim). Outcomes for each preindex year were compared among propensity score-matched cohorts.

RESULTS

Each year, before index, patients with AD were more likely to have all-cause emergency department visits, all-cause hospitalizations, potentially avoidable hospitalizations, and falls (P < .05 for all comparisons) than matched controls (N = 19,679 pairs). Increasing absolute and relative risks over time were observed for all outcomes.

DISCUSSION

The study findings highlight the growing burden of illness before AD diagnosis and emphasize the need for timely recognition and management of patients with AD.

[Dementia sensitivity in acute care hospitals : Why the implementation is so difficult, and how it can nevertheless succeed]

BACKGROUND

In Germany, the question arises as to why the dementia sensitivity of acute care hospitals is still so uncommon even though the first concepts were successfully tested more than 20 years ago.

OBJECTIVE

The aim of this article is to describe implementation barriers in an overview and to show ways to a better practice.

MATERIAL AND METHODS

The results presented are based on a document analysis, the evaluation of focus groups and network meetings as well as on interviews with experts within the framework of a study for the Robert Bosch Foundation. In addition, the results of an earlier investigation of the iso institut for the German Alzheimer Society are included.

RESULTS

Based on the experience gained in model projects, typical barriers for a dementia-sensitive orientation on individual, work organizational and superordinate levels are described. The systematization of the barriers provides a starting point for overcoming these hurdles. In addition, a number of success factors for the implementation of good practice can be worked out from the projects. It has been found to be crucial to work on the attitude of staff towards people with cognitive impairments and to adapt processes to the special needs of this patient group. In this context, management and a professionally sound structuring of change processes play a key role.

DISCUSSION

In the future, managers and employees in acute care hospitals will be able to find a wide range of suggestions in comprehensive guidelines from the iso-Institute on the modular implementation of dementia-sensitive hospitals, which is backed up by tried and tested and effective aids to action, instruments, process descriptions, etc. The guidelines will also be available in the form of a comprehensive list of recommendations.

Vitamin D Deficiency and Long-Term Cognitive Impairment Among Older Adult Emergency Department Patients

INTRODUCTION

Approximately 16% of acutely ill older adults develop new, long-term cognitive impairment (LTCI), many of whom initially seek care in the emergency department (ED). Currently, no effective interventions exist to prevent LTCI after an acute illness. Identifying early and modifiable risk factors for LTCI is the first step toward effective therapy. We hypothesized that Vitamin D deficiency at ED presentation was associated with LTCI in older adults.

METHODS

This was an observational analysis of a prospective cohort study that enrolled ED patients ≥ 65 years old who were admitted to the hospital for an acute illness. All patients were enrolled within four hours of ED presentation. Serum Vitamin D was measured at enrollment and Vitamin D deficiency was defined as serum concentrations <20 mg/dL. We measured pre-illness and six-month cognition using the short form Informant Questionnaire on Cognitive Decline in the Elderly (IQCODE), which ranges from 1 to 5 (severe cognitive impairment). Multiple linear regression was performed to determine whether Vitamin D deficiency was associated with poorer six-month cognition adjusted for pre-illness IQCODE and other confounders. We incorporated a two-factor interaction into the regression model to determine whether the relationship between Vitamin D deficiency and six-month cognition was modified by pre-illness cognition.

RESULTS

We included a total of 134 older ED patients; the median (interquartile range [IQR]) age was 74 (69, 81) years old, 61 (46%) were female, and 14 (10%) were nonwhite race. The median (IQR) vitamin D level at enrollment was 25 (18, 33) milligrams per deciliter and 41 (31%) of enrolled patients met criteria for vitamin D deficiency. Seventy-seven patients survived and had a six-month IQCODE. In patients with intact pre-illness cognition (IQCODE of 3.13), Vitamin D deficiency was significantly associated with worsening six-month cognition (β-coefficient: 0.43, 95% CI, 0.07 to 0.78, p = 0.02) after adjusting for pre-illness IQCODE and other confounders. Among patients with pre-illness dementia (IQCODE of 4.31), no association with Vitamin D deficiency was observed (β-coefficient: -0.1;, 95% CI, [-0.50-0.27], p = 0.56).

CONCLUSION

Vitamin D deficiency was associated with poorer six-month cognition in acutely ill older adult ED patients who were cognitively intact at baseline. Future studies should determine whether early Vitamin D repletion in the ED improves cognitive outcomes in acutely ill older patients.

Association Between Caregiver Depression and Emergency Department Use Among Patients With Dementia

Importance

Current attempts to gauge the acute care needs of patients with dementia have not effectively addressed the role of caregivers, despite their extensive involvement in decisions about acute care management.

Objective

To determine whether caregiver depression is associated with increased use of the emergency department (ED) among patients with dementia.

Design, Setting, and Participants

This longitudinal cohort study used data from the Care Ecosystem study, a randomized clinical trial examining telephone-based supportive care for patients with dementia and their caregivers. Patients were 45 years or older with any type of dementia. A total of 780 caregiver-patient dyads were enrolled from March 20, 2015, until February 28, 2017, and 663 dyads contributed baseline and 6-month data and were included in the analysis.

Exposures

Caregiver depression (9-item Patient Health Questionnaire score of ≥10). Secondary analyses examined caregiver burden and self-efficacy.

Main Outcomes and Measures

The primary outcome was the number of ED visits in a 6-month period.

Results

Among the 663 caregivers (467 women and 196 men; mean [SD] age, 64.9 [11.8] years), 84 caregivers (12.7%) had depression at baseline. The mean incidence rate of ED visits was 0.9 per person-year. Rates of ED presentation were higher among dyads whose caregiver did vs did not have depression (1.5 vs 0.8 ED visits per person-year). In a Poisson regression model adjusting for patient age, sex, severity of dementia, number of comorbidities, and baseline ED use, as well as caregiver age and sex, caregiver depression continued to be associated with ED use, with a 73% increase in rates of ED use among dyads with caregivers with depression (adjusted incident rate ratio, 1.73; 95% CI, 1.30-2.30). Caregiver burden was associated with higher ED use in the unadjusted model, but this association did not reach statistical significance after adjustment (incident rate ratio, 1.19; 95% CI, 0.93-1.52). Caregiver self-efficacy was inversely proportional to the number of ED visits in the unadjusted and adjusted models (adjusted incident rate ratio, 0.96; 95% CI, 0.92-0.99).

Conclusions and Relevance

Among patients with dementia, caregiver depression appears to be significantly associated with increased ED use, revealing a key caregiver vulnerability, which, if addressed with patient- and caregiver-centered dementia care, could improve health outcomes and lower costs for this high-risk population.

Dementia Care Across a Tertiary Care Health System: What Exists Now and What Needs to Change

OBJECTIVES

This study explored the process of care for persons living with dementia (PLWDs) in various care settings across a tertiary care system and considers challenges and opportunities for change.

DESIGN

Aimed at quality improvement, qualitative interviews were conducted with key stakeholders in dementia care across geriatric outpatient clinics, medical and psychiatric emergency departments, and the main hospital in 2016.

SETTING AND PARTICIPANTS

Forty-nine interactive interviews were conducted with a purposive and snowball sampling of health care professionals (physicians, nurses, social workers, administrators) and families in a large, academic health care system.

MEASURES

Qualitative interview guides were developed by the study team to assess the process of care for PLWDs and strengths and challenges to delivering that care.

RESULTS

Key themes emerging from the interviews in each care setting are presented. The outpatient setting offers expertise, a multidisciplinary clinic, and research opportunities, but needs to respond to long waitlists, space limitations, and lack of consensus about who owns dementia care. The emergency department offers a low nurse/patient ratio and expertise in acute medical problems, but experiences competing demands and staff turnover; additionally, dementia does not appear on medical records, which can impede care. The hospital offers consultative services and resources, yet the physical space is confined and chaotic; sitters and antipsychotics can be overused, and placement outside of the hospital for PLWDs can be a challenge.

CONCLUSIONS AND IMPLICATIONS

Five key recommendations are provided to help health systems proactively prepare for the coming boom of PLWD and their caregivers, including outpatient education, a dementia care management program to link services, Internet-based training for providers, and repurposing sitters as Elder Life specialists.

Predicting Risk of Potentially Preventable Hospitalization in Older Adults with Dementia

OBJECTIVES

Reducing potentially preventable hospitalization (PPH) among older adults with dementia is a goal of Healthy People 2020, yet no tools specifically identify patients with dementia at highest risk. The objective was to develop a risk prediction model to identify older adults with dementia at high imminent risk of PPH.

DESIGN

A 30-day risk prediction model was developed using multivariable logistic regression. Patients from fiscal years (FY) 2009 to 2011 were split into development and validation cohorts; FY2012 was used for prediction.

SETTING

Community-dwelling older adults (≥65 years of age) with dementia who received care through the Veterans Health Administration.

PARTICIPANTS

There were 1 793 783 participants.

MEASUREMENTS

Characteristics associated with hospitalization risk were (1) age and other demographic factors; (2) outpatient, emergency department, and inpatient utilization; (3) medical and psychiatric diagnoses; and (4) prescribed medication use including changes to psychotropic medications (eg, initiation or dosage increase). Model discrimination was determined by the C statistic for each of the three cohorts. Finally, to determine whether predicted 30-day risk strata were stable over time, the observed PPH rate was calculated out to 1 year.

RESULTS

In the development cohort, .6% of patients experienced PPH within 30 days. The C statistic for the development cohort was .83 (95% confidence interval [CI] = .83-.84) and .83 in the prediction cohort (95% CI = .82-.84). Patients in the top 10% of predicted 30-day PPH risk accounted for more than 50% of 30-day PPH admissions in all three cohorts. In addition, those predicted to be at elevated 30-day risk remained at higher risk throughout a year of follow-up.

CONCLUSION

It is possible to identify older adults with dementia at high risk of imminent PPH, and their risk remains elevated for an entire year. Given the negative outcomes associated with acute hospitalization for those with dementia, healthcare systems and providers may be able to engage these high-risk patients proactively to avoid unnecessary hospitalization. J Am Geriatr Soc 67:2077-2084, 2019.

Neighborhood social cohesion and cognitive function in U.S. Chinese older adults-findings from the PINE study

Objectives: The projected increase in the population of older adults in the United States entails a pressing need to examine risk and protective factors associated with cognitive function. This study aims to examine the association between neighborhood social cohesion and cognitive function among older Chinese adults in the United States. Method: Using the first epidemiological survey of older Chinese Americans and applying ordinary least squares and quantile regressions, this study examines the association between neighborhood social cohesion and various domains of cognitive function. Results: Results show that neighborhood social cohesion is independently associated with most domains of cognitive function (i.e. global cognition score, and its components such as the Chinese Mini-Mental State Examination and executive function and episodic memory measures). Conclusion: This study represents one of a few initial efforts that examined the association between neighborhood social cohesion and cognitive function for Chinese older adults in the United States. Our findings suggest that socially cohesive neighborhoods can provide enriched environments where active lifestyles can be encouraged, and cognitive skills and abilities can be stimulated, practiced, and preserved for older adults.

Association of Sensory and Cognitive Impairment With Healthcare Utilization and Cost in Older Adults

OBJECTIVES

To examine the association between self-reported vision impairment (VI), hearing impairment (HI), and dual-sensory impairment (DSI), stratified by dementia status, on hospital admissions, hospice use, and healthcare costs.

DESIGN

Retrospective analysis.

SETTING

Medicare Current Beneficiary Survey from 1999 to 2006.

PARTICIPANTS

Rotating panel of community-dwelling Medicare beneficiaries, aged 65 years and older (N = 24 009).

MEASUREMENTS

VI and HI were ascertained by self-report. Dementia status was determined by self-report or diagnosis codes in claims data. Primary outcomes included any inpatient admission over a 2-year period, hospice use over a 2-year period, annual Medicare fee-for-service costs, and total healthcare costs (which included information from Medicare claims data and other self-reported payments).

RESULTS

Self-reported DSI was present in 30.2% (n = 263/871) of participants with dementia and 17.8% (n = 4112/23 138) of participants without dementia. In multivariable logistic regression models, HI, VI, or DSI was generally associated with increased odds of hospitalization and hospice use regardless of dementia status. In a generalized linear model adjusted for demographics, annual total healthcare costs were greater for those with DSI and dementia compared to those with DSI without dementia ($28 875 vs $3340, respectively). Presence of any sensory impairment was generally associated with higher healthcare costs. In a model adjusted for demographics, Medicaid status, and chronic medical conditions, DSI compared with no sensory impairment was associated with a small, but statistically significant, difference in total healthcare spending in those without dementia ($1151 vs $1056; P < .001) but not in those with dementia ($11 303 vs $10 466; P = .395).

CONCLUSION

Older adults with sensory and cognitive impairments constitute a particularly prevalent and vulnerable population who are at increased risk of hospitalization and contribute to higher healthcare spending. J Am Geriatr Soc 67:1617-1624, 2019.

Stakeholder perspectives of care for people living with dementia moving from hospital to care facilities in the community: a systematic review

Background

People living with dementia in care homes are regularly admitted to hospital. The transition between hospitals and care homes is an area of documented poor care leading to adverse outcomes including costly re-hospitalisation. This review aims to understand the experiences and outcomes of care for people living with dementia who undergo this transition from the perspectives of key stakeholders; people living with dementia, their families and health care professionals.

Methods

A systematic search was conducted on the CINAHL, ASSIA, EMBASE, MEDLINE, PsychINFO, and Scopus databases without any date restrictions. We hand searched reference lists of included papers. Papers were included if they focused on people living with dementia moving from hospital to a short or long term care setting in the community including sub-acute, rehabilitation, skilled nursing facilities or care homes. Titles, abstracts and full texts were screened. Two authors independently evaluated study quality using a checklist. Themes were identified and discussed to reach consensus.

Results

In total, nine papers reporting eight studies met the inclusion criteria for the systematic review. A total of 257 stakeholders participated; 37 people living with dementia, 95 family members, and 125 health and social care professionals. Studies took place in Australia, Canada, United Kingdom (UK), and the United States of America (US). Four themes were identified as factors influencing the experience and outcomes of the transition from the perspectives of stakeholders; preparing for transition; quality of communication; the quality of care; family engagement and roles.

Conclusion

This systematic review presents a compelling case for the need for robust evidence to guide best practice in this important area of multi-disciplinary clinical practice. The evidence suggests this transition is challenging for all stakeholders and that people with dementia have specific needs which need attention during this period.

Trial registration

PROSPERO Registration Number: CRD42017082041.

The dementia-friendly emergency department: An innovation to reducing incompatibilities at the local level

Emergency Departments (EDs) are an integral part of the Canadian healthcare system. Older people living with dementia challenge EDs. They have complex health profiles that pose multiple challenges for staff. The current one-size-fits-all approach that aids efficiency in a technologically dependent hospital setting may not always serve older people living with dementia, their caregivers, or staff well. The premise that older people living with dementia are a problem for Canadian EDs must be reconsidered. Understanding the complexity of the situation is aided by the dementia-friendly ED framework. We propose one way to enhance communication between those living with dementia who receive ED services and those providing the service.

High-Intensity Telemedicine Reduces Emergency Department Use by Older Adults With Dementia in Senior Living Communities

OBJECTIVES

Individuals with dementia have high rates of emergency department (ED) use for acute illnesses. We evaluated the effect of a high-intensity telemedicine program that delivers care for acute illnesses on ED use rates for individuals with dementia who reside in senior living communities (SLCs; independent and assisted living).

DESIGN

We performed a secondary analysis of data for patients with dementia from a prospective cohort study over 3.5 years that evaluated the effectiveness of high-intensity telemedicine for acute illnesses among SLC residents.

SETTING AND PARTICIPANTS

We studied patients cared for by a primary care geriatrics practice at 22 SLCs in a northeastern city. Six SLCs were selected as intervention facilities and had access to patient-to-provider high-intensity telemedicine services to diagnose and treat illnesses. Patients at the remaining 15 SLCs served as controls. Participants were considered to have dementia if they had a diagnosis of dementia on their medical record problem list, were receiving medications for the indication of dementia, or had cognitive testing consistent with dementia.

MEASURES

We compared the rate of ED use among participants with dementia and access to high-intensity telemedicine services to control participants with dementia but without access to services.

RESULTS

Intervention group participants had 201 telemedicine visits. In participants with dementia, it is estimated that 1 year of access to telemedicine services is associated with a 24% decrease in ED visits (rate ratio 0.76, 95% confidence interval 0.61, 0.96).

CONCLUSIONS/IMPLICATIONS

Telemedicine in SLCs can effectively decrease ED use by individuals with dementia, but further research is needed to confirm this secondary analysis and to understand how to best implement and optimize telemedicine for patients with dementia suffering from acute illnesses.

Hospitalization after Oral Antibiotic Initiation in Finnish Community Dwellers with and without Alzheimer's Disease: Retrospective Register-Based Cohort Study

BACKGROUND

Persons with Alzheimer's disease (AD) are frequently hospitalized from infection-related causes. There are no previous studies investigating hospitalization associated with antibiotic initiation in persons with AD.

OBJECTIVE

To investigate the frequency and risk of hospitalization associated with oral antibiotic initiation among community dwellers with and without AD.

METHODS

We performed a retrospective register-based study utilizing register-based Medication Use and Alzheimer's disease (MEDALZ) cohort. It includes all community dwellers diagnosed with AD during 2005-2011 in Finland and their matched comparison persons without AD. Antibiotic use was initiated by 34,785 persons with and 36,428 without AD. Drug use data were collected from Prescription Register and comorbidities from Special Reimbursement and Hospital Care Registers. Infection diagnoses were collected from the Hospital Care Register. Factors associated with hospitalization were estimated utilizing logistic regression models.

RESULTS

Risk of hospitalization following antibiotic initiation was higher among antibiotic initiators with AD than without AD (adjusted odds ratio, aOR, 1.37, 95% Cl 1.28-1.46).Strongest association with hospitalization was found for oral glucocorticoid use, aOR 1.41 (1.25-1.59); epilepsy, aOR 1.33 (1.10-1.63); and active cancer, aOR 1.30 (1.14-1.49). Among initiators of cephalexin, pivmecillinam, amoxicillin/amoxicillin, and enzyme inhibitor and doxycycline, persons with AD were more frequently hospitalized than persons without AD. A quarter of hospitalized antibiotic initiators had infection diagnosis in their hospital care records.

CONCLUSIONS

Persons with AD initiating an antibiotic had a higher risk for hospitalization than antibiotic initiators without AD. Further research is needed to determine whether infection-related hospitalization could be reduced.