Using the biopsychosocial model in practice. Improving the care of patients with late-life depression

The clinical course and interrelations of dementia related symptoms

ABSTRACTBackground:Dementia is a neurodegenerative syndrome that interferes with multiple aspects of life, including cognition, daily functioning, and behavior. Despite the large heterogeneity in symptom development, these three domains are seldom studied simultaneously. This study investigates how trajectories of these domains are interrelated within individuals over time, and how they in turn are related to dementia severity and quality of life (QoL).

METHODS

We used data from a longitudinal clinical cohort study, including 331 dementia patients. Cognitive status was measured using the Mini-Mental State Examination, daily functioning was measured with the disability assessment for dementia and neuropsychiatric symptoms (NPS) were scored using the neuropsychiatric inventory. We investigated the relationships in the time course of the various dementia domains using random effects multilevel models and parallel-process growth models.

RESULTS

Changes in cognition and daily functioning were highly correlated over time (r = 0.85, p < 0.01), as were changes in NPS and functioning (r = -0.60, p < 0.01), while changes in cognition and NPS were not (r = -0.20, p = 0.06). All three domains were strongly associated with dementia severity over time (p < 0.01). Decreased functioning and increased NPS were both associated with decreased QoL (β = 2.97, p < 0.01 and β = -2.41, p < 0.01, respectively), while cognition was not (β = 0.01, p = 0.93).

CONCLUSION

This study demonstrates the heterogeneity of dementia progression between individuals and between different dementia domains within individuals. To improve our understanding of dementia progression, future research should embrace a broader perspective encompassing multiple outcome measures along with the patient's profile, including neurological factors as well as physical, social, and psychiatric health.

Predicting 12-month mortality for persons with dementia

OBJECTIVES

We develop and test a model of 12-month mortality among persons (N=3858) with organic dementia.

METHODS

Data are from caregiver interviews and claims records for persons enrolled in the Medicare Alzheimer's Disease Demonstration Evaluation. Information covers the year prior to enrollment through 36 months. We used Proportional hazards models to predict time to death. We estimated two starting points: first, the date of randomization, and second, the date of maximum difficulty in performing two or more activities of daily living (ADLs).

RESULTS

The final model includes age, gender, ADL difficulty, medical conditions, prior year hospitalizations, and whether a daughter was the primary caregiver. We combined hazard ratios to produce a cumulative mortality risk score. Model discrimination is reasonable for both models (c statistics of.72 and.69, respectively), and calibration tests were nonsignificant.

DISCUSSION

The model's efficiency, as measured by the ratio of false positives (those predicted to die, but who lived) to true positives (those predicted to die and who did die) ranged from fewer than 1:1 to more than 4:1 as the model's sensitivity increased. This ratio was lower in the two or more ADL difficulty model. A validation test of the prediction model found comparable sensitivity and specificity (c statistic of.69) to the reference model.

Variation in perceptions of treatment and self-care practices in elderly with osteoarthritis: a comparison between African American and white patients

OBJECTIVE

To compare elderly African American and white patients with osteoarthritis of the knee or hip with respect to their perceptions of the efficacy of traditional and complementary treatments and their self-care practices.

METHODS

An observational, cross-sectional study design using structured questionnaires was employed.

RESULTS

The sample consisted of 593 patients (44% African American and 56% white). The 2 groups were comparable with respect to age, disease severity or functional status, and comorbidities. African Americans were more likely than whites to report lower educational level and household income. African Americans were also more likely than whites to perceive various traditional and complementary care modalities as efficacious. However, they were less likely than whites to perceive joint replacement therapy as efficacious (odds ratio 0.52, 95% confidence interval 0.28-0.98). African American patients were more likely than white patients to rely on self-care measures for their arthritis.

CONCLUSION

African American and white patients with osteoarthritis of the knee or hip differ with respect to their perceptions of traditional and complementary treatments for arthritis and their self-care practices.

Improving functional outcomes in older patients: lessons from an acute care for elders unit

BACKGROUND

Hospitalization often marks the beginning, and may be partially responsible for, a downward trajectory characterized by declining function, worsening quality of life, placement in a long term care facility, and death. At the University Hospitals of Cleveland, an Acute Care for Elders (ACE) unit that reengineered the process of caring for older patients (> or = 70 years of age) to improve functional outcomes was established in September 1990.

DESCRIPTION OF INTERVENTION

The general principles of ACE included an approach to care guided by the biopsychosocial model and recognition of the importance of fitting the hospital environment to the patient's needs. The design of the intervention was consistent with principles of comprehensive geriatric assessment and continuous quality improvement. Care, which focused on maintaining function, was directed by an interdisciplinary team that considered the patient's needs both at home and in the hospital. The major components of the ACE Unit intervention included patient-centered nursing care (daily assessment of functional needs by nursing, nursing-based protocols to improve outcomes, daily rounds by a multidisciplinary team), a prepared environment, planning for discharge, and medical care review.

RESULTS

In a randomized trial comparing ACE with usual care, patients receiving ACE had improved functional outcomes at discharge. The costs to the hospital for ACE unit care were less than for usual care. The functional status of ACE and usual care patients was similar 90 days after discharge.

FUTURE DIRECTIONS

The ACE unit intervention is being expanded to preserve the improvements observed during the hospitalization in the outpatient setting. In addition, needs other than function which are critical to patients' long-term quality of life are being considered.