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Association between cardiopulmonary function, health-related quality of life and cognitive impairment among the older nursing home residents in Shanghai, China. Prim Health Care Res Dev 2023; 24:e18. [PMID: 36919826 PMCID: PMC10050953 DOI: 10.1017/s1463423623000075] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/16/2023] Open
Abstract
BACKGROUND This study aimed to examine the association between cardiopulmonary function, health-related quality of life (HRQOL) and cognitive function among nursing home residents aged 80 years and over. METHODS A nursing home-based, cross-sectional study was implemented among 677 aged over 80 years in Shanghai, China. A total of 197 participants underwent effective cardiopulmonary function examinations. Mini-Mental Status Examination (MMSE) and Short Form-36 scales (SF-36) were used to assess cognitive function and HRQOL, respectively. RESULTS Decline in left ventricular ejection fractions (LVEF) [adjusted odds ratio (AOR), 1.98; 95% confidential interval (CI), 1.03-3.81)] and vital capacity (VC) (AOR, 2.08; 95%CI, 1.07-4.04) was associated with cognitive impairment. After adjusting confounding factors, relationships between cognitive function and physical functioning (PF) (AOR, 0.98; 95%CI, 0.97-0.99) still existed. CONCLUSIONS Healthcare professionals should pay more attention to cardiopulmonary health and HRQOL in the nursing home residents. Actions of public health strategies focus on the improvement of cardiopulmonary function, and PF among older nursing home residents with cognitive impairment is required.
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Kiadaliri A, Lohmander LS, Dahlberg LE, Englund M. Incipient dementia and avoidable hospital admission in persons with osteoarthritis. OSTEOARTHRITIS AND CARTILAGE OPEN 2023; 5:100341. [PMID: 36798737 PMCID: PMC9926213 DOI: 10.1016/j.ocarto.2023.100341] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2022] [Revised: 01/11/2023] [Accepted: 01/17/2023] [Indexed: 01/21/2023] Open
Abstract
Objective To investigate the associations between incipient dementia (ID) and hospitalization for ambulatory care sensitive conditions (ACSCs) among people with osteoarthritis (OA) of the peripheral joints. Methods Among individuals aged 51-99 years residing in Skåne, Sweden, in 2009, we identified those with a doctor-diagnosed OA and no dementia during 1998-2009 (n = 57,733). Treating ID as a time-varying exposure, we followed people from January 1, 2010 or their 60th birthday (whichever occurred last) until hospitalization for ACSCs, death, 100th birthday, relocation outside Skåne, or December 31, 2019 (whichever occurred first). Using age as time scale, we applied flexible parametric survival models, adjusted for confounders, to assess the associations between ID and hospitalization for ACSCs. Results There were 58 and 33 hospitalizations for ACSCs per 1000 person-years among OA people with and without ID, respectively. The association between ID and hospitalization for any ACSCs was age-dependent with higher risk in ages<86 years and lower risks in older ages. Between ages 60 and 100 years, persons with ID had, on average, 5.8 (95% CI 0.9, 10.7), 1.6 (-2.6, 5.9) and 3.1 (2.3, 4.0) fewer hospital-free years for any, chronic and acute ACSCs, respectively, compared with persons without ID. Conclusions Among persons with OA, while ID was associated with increased risks of hospitalization for ACSCs in younger ages, it was associated with decreased risk in oldest ages. These results suggest the need for improvement in quality of ambulatory care including the continuity of care for people with OA having dementia.
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Affiliation(s)
- Ali Kiadaliri
- Clinical Epidemiology Unit, Orthopaedics, Department of Clinical Sciences Lund, Lund University, Lund, Sweden,Centre for Economic Demography, Lund University, Lund, Sweden,Corresponding author. Skåne University Hospital, Clinical Epidemiology Unit, Remissgatan 4, SE-221 85 Lund, Sweden.
| | - L Stefan Lohmander
- Department of Clinical Sciences Lund, Orthopaedics, Lund University, Lund, Sweden
| | - Leif E. Dahlberg
- Department of Clinical Sciences Lund, Orthopaedics, Lund University, Lund, Sweden
| | - Martin Englund
- Clinical Epidemiology Unit, Orthopaedics, Department of Clinical Sciences Lund, Lund University, Lund, Sweden
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Creavin ST, Noel-Storr AH, Langdon RJ, Richard E, Creavin AL, Cullum S, Purdy S, Ben-Shlomo Y. Clinical judgement by primary care physicians for the diagnosis of all-cause dementia or cognitive impairment in symptomatic people. Cochrane Database Syst Rev 2022; 6:CD012558. [PMID: 35709018 PMCID: PMC9202995 DOI: 10.1002/14651858.cd012558.pub2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND In primary care, general practitioners (GPs) unavoidably reach a clinical judgement about a patient as part of their encounter with patients, and so clinical judgement can be an important part of the diagnostic evaluation. Typically clinical decision making about what to do next for a patient incorporates clinical judgement about the diagnosis with severity of symptoms and patient factors, such as their ideas and expectations for treatment. When evaluating patients for dementia, many GPs report using their own judgement to evaluate cognition, using information that is immediately available at the point of care, to decide whether someone has or does not have dementia, rather than more formal tests. OBJECTIVES To determine the diagnostic accuracy of GPs' clinical judgement for diagnosing cognitive impairment and dementia in symptomatic people presenting to primary care. To investigate the heterogeneity of test accuracy in the included studies. SEARCH METHODS We searched MEDLINE (Ovid SP), Embase (Ovid SP), PsycINFO (Ovid SP), Web of Science Core Collection (ISI Web of Science), and LILACs (BIREME) on 16 September 2021. SELECTION CRITERIA We selected cross-sectional and cohort studies from primary care where clinical judgement was determined by a GP either prospectively (after consulting with a patient who has presented to a specific encounter with the doctor) or retrospectively (based on knowledge of the patient and review of the medical notes, but not relating to a specific encounter with the patient). The target conditions were dementia and cognitive impairment (mild cognitive impairment and dementia) and we included studies with any appropriate reference standard such as the Diagnostic and Statistical Manual of Mental Disorders (DSM), International Classification of Diseases (ICD), aetiological definitions, or expert clinical diagnosis. DATA COLLECTION AND ANALYSIS Two review authors screened titles and abstracts for relevant articles and extracted data separately with differences resolved by consensus discussion. We used QUADAS-2 to evaluate the risk of bias and concerns about applicability in each study using anchoring statements. We performed meta-analysis using the bivariate method. MAIN RESULTS We identified 18,202 potentially relevant articles, of which 12,427 remained after de-duplication. We assessed 57 full-text articles and extracted data on 11 studies (17 papers), of which 10 studies had quantitative data. We included eight studies in the meta-analysis for the target condition dementia and four studies for the target condition cognitive impairment. Most studies were at low risk of bias as assessed with the QUADAS-2 tool, except for the flow and timing domain where four studies were at high risk of bias, and the reference standard domain where two studies were at high risk of bias. Most studies had low concern about applicability to the review question in all QUADAS-2 domains. Average age ranged from 73 years to 83 years (weighted average 77 years). The percentage of female participants in studies ranged from 47% to 100%. The percentage of people with a final diagnosis of dementia was between 2% and 56% across studies (a weighted average of 21%). For the target condition dementia, in individual studies sensitivity ranged from 34% to 91% and specificity ranged from 58% to 99%. In the meta-analysis for dementia as the target condition, in eight studies in which a total of 826 of 2790 participants had dementia, the summary diagnostic accuracy of clinical judgement of general practitioners was sensitivity 58% (95% confidence interval (CI) 43% to 72%), specificity 89% (95% CI 79% to 95%), positive likelihood ratio 5.3 (95% CI 2.4 to 8.2), and negative likelihood ratio 0.47 (95% CI 0.33 to 0.61). For the target condition cognitive impairment, in individual studies sensitivity ranged from 58% to 97% and specificity ranged from 40% to 88%. The summary diagnostic accuracy of clinical judgement of general practitioners in four studies in which a total of 594 of 1497 participants had cognitive impairment was sensitivity 84% (95% CI 60% to 95%), specificity 73% (95% CI 50% to 88%), positive likelihood ratio 3.1 (95% CI 1.4 to 4.7), and negative likelihood ratio 0.23 (95% CI 0.06 to 0.40). It was impossible to draw firm conclusions in the analysis of heterogeneity because there were small numbers of studies. For specificity we found the data were compatible with studies that used ICD-10, or applied retrospective judgement, had higher reported specificity compared to studies with DSM definitions or using prospective judgement. In contrast for sensitivity, we found studies that used a prospective index test may have had higher sensitivity than studies that used a retrospective index test. AUTHORS' CONCLUSIONS Clinical judgement of GPs is more specific than sensitive for the diagnosis of dementia. It would be necessary to use additional tests to confirm the diagnosis for either target condition, or to confirm the absence of the target conditions, but clinical judgement may inform the choice of further testing. Many people who a GP judges as having dementia will have the condition. People with false negative diagnoses are likely to have less severe disease and some could be identified by using more formal testing in people who GPs judge as not having dementia. Some false positives may require similar practical support to those with dementia, but some - such as some people with depression - may suffer delayed intervention for an alternative treatable pathology.
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Affiliation(s)
| | | | - Ryan J Langdon
- MRC Integrative Epidemiology Unit, University of Bristol, Bristol, UK
| | - Edo Richard
- Department of Neurology, Donders Institute for Brain, Behaviour and Cognition, Radboud University Nijmegen Medical Center, Nijmegen, Netherlands
| | | | - Sarah Cullum
- Department of Psychological Medicine, University of Auckland, Auckland, New Zealand
| | - Sarah Purdy
- Population Health Sciences, University of Bristol, Bristol, UK
| | - Yoav Ben-Shlomo
- Population Health Sciences, University of Bristol, Bristol, UK
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Welch ML, Hodgson JL, Didericksen KW, Lamson AL, Forbes TH. Family-Centered Primary Care for Older Adults with Cognitive Impairment. CONTEMPORARY FAMILY THERAPY 2021; 44:67-87. [PMID: 34803217 PMCID: PMC8591316 DOI: 10.1007/s10591-021-09617-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/01/2021] [Indexed: 12/27/2022]
Abstract
Cognitive impairment (e.g. dementia) presents challenges for individuals, their families, and healthcare professionals alike. The primary care setting presents a unique opportunity to care for older adults living with cognitive impairment, who present with complex care needs that may benefit from a family-centered approach. This indepth systematic review was completed to address three aims: (a) identify the ways in which families of older-adult patients with cognitive impairment are engaged in primary care settings, (b) examine the outcomes of family engagement practices, and (c) organize and discuss the findings using CJ Peek's Three World View. Researchers searched PubMed, Embase, and PsycINFO databases through July 2019. The results included 22 articles out of 6743 identified in the initial search. Researchers provided a description of the emerging themes for each of the three aims. It revealed that family-centered care and family engagement yields promising results including improved health outcomes, quality care, patient experience, and caregiver satisfaction. Furthermore, it promotes and advances the core values of medical family therapy: agency and communion. This review also exposed the inconsistent application of family-centered practices and the need for improved interprofessional education of primary care providers to prepare multidisciplinary teams to deliver family-centered care. Utilizing the vision of Patient- and Family-Centered Care and the lens of the Three World View, this systematic review provides Medical Family Therapists, healthcare administrators, policy makers, educators, and clinicians with information related to family engagement and how it can be implemented and enhanced in the care of patients with cognitive impairment.
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Affiliation(s)
- Melissa L. Welch
- Department of Human Development and Family Science, East Carolina University, Greenville, NC USA
- Department of Community Health and Family Medicine, University of Florida College of Medicine, Gainesville, FL USA
| | - Jennifer L. Hodgson
- Department of Human Development and Family Science, East Carolina University, Greenville, NC USA
| | - Katharine W. Didericksen
- Department of Human Development and Family Science, East Carolina University, Greenville, NC USA
| | - Angela L. Lamson
- Department of Human Development and Family Science, East Carolina University, Greenville, NC USA
| | - Thompson H. Forbes
- Department of Advanced Nursing Practice and Education, East Carolina University, Greenville, NC USA
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Frost R, Rait G, Aw S, Brunskill G, Wilcock J, Robinson L, Knapp M, Hogan N, Harrison Dening K, Allan L, Manthorpe J, Walters K. Implementing post diagnostic dementia care in primary care: a mixed-methods systematic review. Aging Ment Health 2021; 25:1381-1394. [PMID: 32911966 DOI: 10.1080/13607863.2020.1818182] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
OBJECTIVES Concentrating post-diagnostic dementia care in primary care may lead to better and more cost-effective care closer to home. We aimed to assess which intervention components and contextual factors may contribute to the successful delivery and implementation of primary care-led post-diagnostic dementia care. METHODS Mixed-methods systematic review. We searched five databases (inception-March 2019) with reference list screening and citation tracking. We included studies evaluating post-diagnostic dementia care interventions where primary care had a significant role in dementia care, which assessed one or more implementation elements (acceptability, feasibility, adoption, sustainability, reach, costs, appropriateness or fidelity). Two authors independently critically appraised studies. RESULTS Out of 4528 unique references, we screened 380 full texts and included 49 evaluations of services collecting implementation process data. Most services had high acceptability ratings. The most acceptable components were information provision, social and emotional support and links to community organisations. Feasibility was chiefly influenced by provider engagement and leadership, building dementia care capacity, sufficient resources/funding and collaboration. Care quality was maximised through adding capacity from a dementia-specific health professional. On the basis of limited data, costs for various primary care-led models did not substantially differ from each other. CONCLUSION A range of primary care-led dementia care models appear feasible and acceptable. Future services should: add dementia-focussed health professionals into primary care, develop primary care leadership and provide sufficient funding and collaboration opportunities. Information, community service links and social and ongoing support should be part of services. Further exploration of service reach and formalised fidelity assessment are needed.
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Affiliation(s)
- Rachael Frost
- Research Department of Primary Care and Population Health, University College London, London, UK
| | - Greta Rait
- Research Department of Primary Care and Population Health, University College London, London, UK
| | - Su Aw
- Saw Swee Hock School of Public Health, National University of Singapore, Singapore, Singapore
| | - Greta Brunskill
- Population Health Sciences Institute, Newcastle University, Newcastle-upon-Tyne, UK
| | - Jane Wilcock
- Research Department of Primary Care and Population Health, University College London, London, UK
| | - Louise Robinson
- Population Health Sciences Institute, Newcastle University, Newcastle-upon-Tyne, UK
| | - Martin Knapp
- 4Care Policy and Evaluation Centre (CPEC), Department of Health Policy, London School of Economics and Political Science, London, UK
| | - Nicole Hogan
- 4Care Policy and Evaluation Centre (CPEC), Department of Health Policy, London School of Economics and Political Science, London, UK
| | | | - Louise Allan
- Institute of Health Research, University of Exeter Medical School, Exeter, UK
| | - Jill Manthorpe
- NIHR Policy Research Unit on Health and Social Care Workforce, Kings College London, London, UK
| | - Kate Walters
- Research Department of Primary Care and Population Health, University College London, London, UK
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Bryant J, Noble N, Freund M, Rumbel J, Eades S, Sanson-Fisher R, Lowe M, Walsh J, Piterman L, Koch S, Meyer C, Todd E. How can dementia diagnosis and care for Aboriginal and Torres Strait Islander people be improved? Perspectives of healthcare providers providing care in Aboriginal community controlled health services. BMC Health Serv Res 2021; 21:699. [PMID: 34271930 PMCID: PMC8283853 DOI: 10.1186/s12913-021-06647-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2021] [Accepted: 06/14/2021] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Aboriginal and/or Torres Strait Islander people experience dementia at a rate three to five times higher than the general Australian population. Aboriginal Community Controlled Health Services (ACCHSs) have a critical role to play in recognising symptoms of cognitive impairment, facilitating timely diagnosis of dementia, and managing the impacts of dementia. Little is known about the barriers and enablers to Aboriginal people receiving a timely dementia diagnosis and appropriate care once diagnosed. This study aims to explore, from the perspective of healthcare providers in the ACCHS sector across urban, regional and remote communities, the barriers and enablers to the provision of dementia diagnosis and care. METHODS A qualitative study involving semi-structured interviews with staff members working in the ACCHS sector. Aboriginal Health Workers, General Practitioners, nurses, practice or program managers, and Chief Executive Officers were eligible to participate. Consenting ACCHS staff completed a telephone interview administered by a trained interviewer. Interviews were audio-recorded, transcribed, and analysed using qualitative content analysis. RESULTS Sixteen staff from 10 ACCHSs participated. Most participants perceived their communities had a limited understanding of dementia. Symptoms of dementia were usually noticed by the GP or another healthcare worker at the ACCHS who had an ongoing relationship with the person. Most participants reported that their service had established referral pathways with either hospital-based geriatricians, geriatricians located with aged care assessment teams, or specialists who visited communities periodically. Key enablers to high quality dementia care included the use of routine health assessments as a mechanism for diagnosis; relationships within communities to support diagnosis and care; community and family relationships; comprehensive and holistic care models; and the use of tailored visual resources to support care. Key barriers to high quality care included: denial and stigma; dementia being perceived as a low priority health condition; limited community awareness and understanding of dementia; lack of staff education and training about dementia; and numerous gaps in service delivery. CONCLUSIONS Substantially increased investments in supporting best-practice diagnosis and management of dementia in Aboriginal communities are required. ACCHSs have key strengths that should be drawn upon in developing solutions to identified barriers to care.
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Affiliation(s)
- Jamie Bryant
- School of Medicine and Public Health, University of Newcastle, 2308, Callaghan, NSW, Australia.
- Priority Research Centre for Health Behaviour, University of Newcastle, 2308, Callaghan, NSW, Australia.
- Hunter Medical Research Institute, 2305, New Lambton Heights, NSW, Australia.
- Hunter Medical Research Institute, University Drive, NSW, 2308, Callaghan, Australia.
| | - Natasha Noble
- School of Medicine and Public Health, University of Newcastle, 2308, Callaghan, NSW, Australia
- Priority Research Centre for Health Behaviour, University of Newcastle, 2308, Callaghan, NSW, Australia
- Hunter Medical Research Institute, 2305, New Lambton Heights, NSW, Australia
| | - Megan Freund
- School of Medicine and Public Health, University of Newcastle, 2308, Callaghan, NSW, Australia
- Priority Research Centre for Health Behaviour, University of Newcastle, 2308, Callaghan, NSW, Australia
- Hunter Medical Research Institute, 2305, New Lambton Heights, NSW, Australia
| | - Jennifer Rumbel
- School of Medicine and Public Health, University of Newcastle, 2308, Callaghan, NSW, Australia
- Priority Research Centre for Health Behaviour, University of Newcastle, 2308, Callaghan, NSW, Australia
- Hunter Medical Research Institute, 2305, New Lambton Heights, NSW, Australia
| | - Sandra Eades
- Curtin Medical School, Curtin University, 6102, Bentley, WA, Australia
| | - Rob Sanson-Fisher
- School of Medicine and Public Health, University of Newcastle, 2308, Callaghan, NSW, Australia
- Priority Research Centre for Health Behaviour, University of Newcastle, 2308, Callaghan, NSW, Australia
- Hunter Medical Research Institute, 2305, New Lambton Heights, NSW, Australia
| | - Michael Lowe
- School of Medicine and Public Health, University of Newcastle, 2308, Callaghan, NSW, Australia
- Northern Territory Department of Health, 0800, Darwin, NT, Australia
| | - Justin Walsh
- School of Medicine and Public Health, University of Newcastle, 2308, Callaghan, NSW, Australia
- Priority Research Centre for Health Behaviour, University of Newcastle, 2308, Callaghan, NSW, Australia
- Hunter Medical Research Institute, 2305, New Lambton Heights, NSW, Australia
| | - Leon Piterman
- Faculty of Health and Medicine, University of Sydney Medical School, University of Sydney, 2006, NSW, Sydney, Australia
| | - Susan Koch
- Faculty of Health and Medicine, University of Newcastle, Callaghan, Australia
| | - Claudia Meyer
- Bolton Clarke Research Institute, 3204, Bentleigh, VIC, Australia
| | - Elaine Todd
- NSW Consumer Reference Group and Consumer Dementia Research Network, 2113, North Ryde, Dementia Australia, NSW, Australia
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Teles S, Paúl C, Sosa Napolskij M, Ferreira A. Dementia caregivers training needs and preferences for online interventions: A mixed-methods study. J Clin Nurs 2020; 31:2036-2054. [PMID: 32757354 DOI: 10.1111/jocn.15445] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2020] [Revised: 07/06/2020] [Accepted: 07/20/2020] [Indexed: 12/13/2022]
Abstract
AIM To explore how informal caregivers of persons with dementia perceive training needs and preferences in the context of online training and support interventions. BACKGROUND Informal dementia caregivers commonly present high needs across several domains. Paradoxically, they are more likely to have unmet needs and lower levels of service usage when compared to other caregivers. Most studies on unmet needs of dementia caregivers have been quantitative and resorted to assessment checklists, with a minority focusing on subjective needs. DESIGN Mixed-methods. METHODS Eighty-eight Portuguese digitally literate caregivers filled a web-based questionnaire collecting written statements on training needs and importance ratings on design preferences. Content analysis of text data was carried out by two independent researchers to check the reliability of the analytic process. Descriptive statistics were produced for ratings on design preferences, and associations with caregivers' sociodemographic and care-related variables were inspected. Reporting followed the criteria for reporting qualitative research checklist. RESULTS Five main categories of training needs have emerged: knowledge of dementia; care interactions; caregiver self-care; community resources; and laws or regulations affecting the caregiver and the care recipient. The most reported need was on care interactions, on the subcategory of providing good quality care. Thematic prominence was analysed according to the caregiver, caregiving and health perception characteristics, with trends found on formal education, relationship with the care recipient, number of hours caring per week, perceived level of dependence of the care recipient and perceived physical and psychological health status of the caregiver. Most valued design features included the use of plain language, easy to interact interface and communication with a professional. CONCLUSIONS Findings from this study further support the delivery of comprehensive interventions addressing the multiple needs of caregivers. RELEVANCE TO CLINICAL PRACTICE Clues are provided for the delivery of online interventions, and conclusions are useful to health professionals working with dementia caregivers.
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Affiliation(s)
- Soraia Teles
- Institute of Biomedical Sciences Abel Salazar, Department of Behavioral Sciences, University of Porto (ICBAS-UP), Porto, Portugal.,Center for Health Technology and Services Research (CINTESIS), Porto, Portugal.,Faculty of Medicine, University of Porto (FMUP), Porto, Portugal
| | - Constança Paúl
- Institute of Biomedical Sciences Abel Salazar, Department of Behavioral Sciences, University of Porto (ICBAS-UP), Porto, Portugal.,Center for Health Technology and Services Research (CINTESIS), Porto, Portugal
| | - Milaydis Sosa Napolskij
- Center for Health Technology and Services Research (CINTESIS), Porto, Portugal.,Faculty of Medicine, University of Porto (FMUP), Porto, Portugal
| | - Ana Ferreira
- Center for Health Technology and Services Research (CINTESIS), Porto, Portugal.,Faculty of Medicine, University of Porto (FMUP), Porto, Portugal
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Jennings LA, Laffan AM, Schlissel AC, Colligan E, Tan Z, Wenger NS, Reuben DB. Health Care Utilization and Cost Outcomes of a Comprehensive Dementia Care Program for Medicare Beneficiaries. JAMA Intern Med 2019; 179:161-166. [PMID: 30575846 PMCID: PMC6439653 DOI: 10.1001/jamainternmed.2018.5579] [Citation(s) in RCA: 53] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
IMPORTANCE An estimated 4 to 5 million Americans have Alzheimer disease or another dementia. OBJECTIVE To determine the health care utilization and cost outcomes of a comprehensive dementia care program for Medicare fee-for-service beneficiaries. DESIGN, SETTING, AND PARTICIPANTS In this case-control study, we used a quasiexperimental design to compare health care utilization and costs for 1083 Medicare fee-for-service beneficiaries enrolled in the University of California Los Angeles Health System Alzheimer and Dementia Care program between July 1, 2012, and December 31, 2015, with those of 2166 similar patients with dementia not participating in the program. Patients in the comparison cohort were selected using the zip code of residence as a sampling frame and matched with propensity scores, which included demographic characteristics, comorbidities, and prior-year health care utilization. We used Medicare claims data to compare utilization and cost outcomes for the 2 groups. INTERVENTIONS Patients in the dementia care program were comanaged by nurse practitioners and physicians, and the program consisted of structured needs assessments of patients and their caregivers, creation and implementation of individualized dementia care plans with input from primary care physicians, monitoring and revising care plans, referral to community organizations for dementia-related services and support, and access to a clinician for assistance and advice 24 hours per day, 7 days per week. MAIN OUTCOMES AND MEASURES Admissions to long-term care facilities; average difference-in-differences per quarter over the 3-year intervention period for all-cause hospitalization, emergency department visits, 30-day hospital readmissions, and total Medicare Parts A and B costs of care. Program costs were included in the cost estimates. RESULTS Program participants (n = 382 men, n = 701 women; mean [SD] age, 82.10 [7.90] years; age range 54-101 years) were less likely to be admitted to a long-term care facility (hazard ratio, 0.60; 95% CI, 0.59-0.61) than those not participating in the dementia care program (n = 759 men, n = 1407 women; mean [SD] age, 82.42 [8.50] years; age range, 34-103 years). There were no differences between groups in terms of hospitalizations, emergency department visits, or 30-day readmissions. The total cost of care to Medicare, excluding program costs, was $601 less per patient per quarter (95% CI, -$1198 to -$5). After accounting for the estimated program costs of $317 per patient per quarter, the program was cost neutral for Medicare, with an estimated net cost of -$284 (95% CI, -$881 to $312) per program participant per quarter. CONCLUSIONS AND RELEVANCE Comprehensive dementia care may reduce the number of admissions to long-term care facilities, and depending on program costs, may be cost neutral or cost saving. Wider implementation of such programs may help people with dementia stay in their communities.
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Affiliation(s)
- Lee A Jennings
- Reynolds Department of Geriatric Medicine at the University of Oklahoma Health Sciences Center, Oklahoma City
| | | | | | - Erin Colligan
- Centers for Medicare & Medicaid Services, Center for Medicare and Medicaid Innovation, Baltimore, Maryland
| | - Zaldy Tan
- Multicampus Program in Geriatric Medicine and Gerontology, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles
| | - Neil S Wenger
- Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles
| | - David B Reuben
- Multicampus Program in Geriatric Medicine and Gerontology, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles
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Harmand MGC, Meillon C, Rullier L, Taddé OB, Pimouguet C, Dartigues JF, Bergua V, Amieva H. Description of general practitioners' practices when suspecting cognitive impairment. Recourse to care in dementia (Recaredem) study. Aging Ment Health 2018; 22:1040-1049. [PMID: 28594237 DOI: 10.1080/13607863.2017.1330871] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
OBJECTIVE General practitioners (GPs) play a major role in the assessment of dementia but it is still unrecognized in primary care and its management is heterogeneous. Our objective is to describe the usual practices, and their determinants, of French GPs in this field. METHODS GPs' characteristics and practices when facing cognitive decline were collected through a telephone interview and a postal questionnaire. A descriptive analysis of all study variables was conducted. The study of quantitative explanatory variables was done by testing the equality of means and the choice of qualitative variables was based on the chi-square independence test or Fischer test. RESULTS Hundred two GPs completed the study. GPs were in majority men, working in urban areas. Mean age was 54.4 years old. GPs' feeling of confidence and self-perception of follow-up of national recommendations is linked with their practices. Performing a clinical interview to assess cognitive impairment is linked with good communication skills. GPs feel less confident to give information about resources for dementia. The main reason alleged for underdiagnosis is the limited effectiveness of drug therapy. CONCLUSIONS This study underlines the importance of GPs' feeling of confidence when managing cognitively impaired patients with dementia, and the need of increasing training in the field of dementia, which could improve the awareness of GPs about diagnosis and available resources.
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Affiliation(s)
| | - Céline Meillon
- a INSERM U 1219 , Université de Bordeaux , Bordeaux , France
| | | | | | | | - Jean-François Dartigues
- a INSERM U 1219 , Université de Bordeaux , Bordeaux , France.,b Institut des Maladies Neurodégénératives Clinique, Centre Hospitalier Universitaire de Bordeaux , France
| | - Valérie Bergua
- a INSERM U 1219 , Université de Bordeaux , Bordeaux , France
| | - Hélène Amieva
- a INSERM U 1219 , Université de Bordeaux , Bordeaux , France
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10
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Burke SL, Burgess A, Cadet T. Utilizing evidence-based assessment instruments to detect well-being and distress in English- and Spanish-speaking caregivers of individuals affected by dementia. DEMENTIA 2017; 18:2062-2084. [PMID: 29141448 DOI: 10.1177/1471301217739095] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Objective The purpose of this study was to examine the most effective and available English and Spanish language caregiver assessments for providers and caregivers. Methods Assessments were included if they screened for caregiving-related concerns, including stress, depression, and caregiving burden and could be administered directly to caregivers in person or online. Results Eighteen assessments are designed to assess caregiver burden, distress, depression, and grief. Six did not have psychometric data to support efficacy but are widely used in clinical and research settings. Six were validated in Spanish, and one other is available in Spanish but not validated. Conclusion As many as 80% of care recipients are cared for in the home by family members who act as informal caregivers. Caregivers of persons with dementia may experience depression symptoms, high caregiver burden, and feelings of being constrained. Due to the lack of psychometric evidence available, the validity of some assessments is questionable.
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Affiliation(s)
| | | | - Tamara Cadet
- Simmons College School of Social Work, Simmons College, USA; Harvard School of Dental Medicine, USA
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11
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Gutmanis I, Speziale J, Hillier LM, van Bussel E, Girard J, Simpson K. Health system redesign using Collective Impact: implementation of the Behavioural Supports Ontario initiative in Southwest Ontario. Neurodegener Dis Manag 2017; 7:261-270. [PMID: 28853640 DOI: 10.2217/nmt-2017-0015] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
This paper describes how the Collective Impact framework facilitated the design, implementation and development of a quality improvement initiative aimed at changing the way healthcare is provided to older adults living with mental health, addictions, neurocognitive and behavioral issues in southwestern Ontario. By promoting a common agenda, shared measurement systems, mutually reinforcing activities, continuous communication and with leadership from a backbone organization, system-wide change occurred. Outcomes, operational/strategic, clinical, capacity enhancement and community support structures as well as challenges are discussed. Improved coordination with primary care will further support enhanced clinical activities and capacity development strategies. Large-scale, multisectoral change is possible when aligned with a collaborative, problem-solving framework that promotes the commitment of many service providers/agencies to a common agenda.
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Affiliation(s)
- Iris Gutmanis
- Lawson Health Research Institute, London, ON, Canada
| | - Jennifer Speziale
- Specialty Mental Health Care, St. Joseph's Health Care London, London, ON, Canada
| | - Loretta M Hillier
- Geriatric Education & Research in Aging Sciences (GERAS) Centre, Hamilton, ON, Canada
| | | | - Julie Girard
- South West Local Health Integration Network, London, ON, Canada
| | - Kelly Simpson
- South West Local Health Integration Network, London, ON, Canada
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Verghese J, Malik R, Zwerling J. Montefiore-Einstein Center for the Aging Brain: Preliminary Data. J Am Geriatr Soc 2016; 64:2374-2377. [DOI: 10.1111/jgs.14473] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
- Joe Verghese
- Department of Neurology; Albert Einstein College of Medicine; Bronx New York
- Division of Geriatrics; Department of Medicine; Albert Einstein College of Medicine; Bronx New York
- Montefiore Medical Center; Bronx New York
| | - Rubina Malik
- Division of Geriatrics; Department of Medicine; Albert Einstein College of Medicine; Bronx New York
- Montefiore Medical Center; Bronx New York
| | - Jessica Zwerling
- Department of Neurology; Albert Einstein College of Medicine; Bronx New York
- Montefiore Medical Center; Bronx New York
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13
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Tan ZS, Jennings L, Reuben D. Coordinated care management for dementia in a large academic health system. Health Aff (Millwood) 2015; 33:619-25. [PMID: 24711323 DOI: 10.1377/hlthaff.2013.1294] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
Alzheimer's disease and other dementias are chronic, incurable diseases that require coordinated care that addresses the medical, behavioral, and social aspects of the disease. With funding from the Center for Medicare and Medicaid Innovation, we launched a dementia care program in which a nurse practitioner acting as a dementia care manager worked with primary care physicians to develop and implement a dementia care plan that offers training and support to caregivers, manages care transitions, and facilitates access to community-based services. Postvisit surveys showed high levels of caregiver satisfaction. As program enrollment grows, outcomes will be tracked based on the Triple Aim developed by the Institute for Healthcare Improvement and adopted by the Centers for Medicare and Medicaid Services: better care, better health, and lower cost and utilization. The program, if successful at achieving the Triple Aim, may serve as a national model for how dementia and other chronic diseases can be managed in partnership with primary care practices. It may also inform policy and reimbursement decisions for the recently released transitional care management codes and the complex chronic care management codes to be released by Medicare in 2015.
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Strom BL, Schinnar R, Karlawish J, Hennessy S, Teal V, Bilker WB. Statin Therapy and Risk of Acute Memory Impairment. JAMA Intern Med 2015; 175:1399-405. [PMID: 26054031 PMCID: PMC5487843 DOI: 10.1001/jamainternmed.2015.2092] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
IMPORTANCE Reports on the association between statins and memory impairment are inconsistent. OBJECTIVE To assess whether statin users show acute decline in memory compared with nonusers and with users of nonstatin lipid-lowering drugs (LLDs). DESIGN, SETTING, AND PARTICIPANTS Using The Health Improvement Network database during January 13, 1987, through December 16, 2013, a retrospective cohort study compared 482,543 statin users with 2 control groups: 482,543 matched nonusers of any LLDs and all 26,484 users of nonstatin LLDs. A case-crossover study of 68,028 patients with incident acute memory loss evaluated exposure to statins during the period immediately before the outcome vs 3 earlier periods. Analysis was conducted from July 7, 2013, through January 15, 2015. RESULTS When compared with matched nonusers of any LLDs (using odds ratio [95% CI]), a strong association was present between first exposure to statins and incident acute memory loss diagnosed within 30 days immediately following exposure (fully adjusted, 4.40; 3.01-6.41). This association was not reproduced in the comparison of statins vs nonstatin LLDs (fully adjusted, 1.03; 0.63-1.66) but was also present when comparing nonstatin LLDs with matched nonuser controls (adjusted, 3.60; 1.34-9.70). The case-crossover analysis showed little association. CONCLUSIONS AND RELEVANCE Both statin and nonstatin LLDs were strongly associated with acute memory loss in the first 30 days following exposure in users compared with nonusers but not when compared with each other. Thus, either all LLDs cause acute memory loss regardless of drug class or the association is the result of detection bias rather than a causal association.
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Affiliation(s)
- Brian L Strom
- Rutgers Biomedical and Health Sciences, Rutgers University, Newark, New Jersey2Center for Clinical Epidemiology and Biostatistics, Department of Biostatistics and Epidemiology, University of Pennsylvania Perelman School of Medicine, Philadelphia3Center fo
| | - Rita Schinnar
- Center for Clinical Epidemiology and Biostatistics, Department of Biostatistics and Epidemiology, University of Pennsylvania Perelman School of Medicine, Philadelphia3Center for Pharmacoepidemiology Research and Training, University of Pennsylvania Perelm
| | - Jason Karlawish
- Penn Memory Center, Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia5Department of Medical Ethics and Health Policy, University of Pennsylvania Perelman School of Medicine, Philadelphia
| | - Sean Hennessy
- Center for Clinical Epidemiology and Biostatistics, Department of Biostatistics and Epidemiology, University of Pennsylvania Perelman School of Medicine, Philadelphia3Center for Pharmacoepidemiology Research and Training, University of Pennsylvania Perelm
| | - Valerie Teal
- Center for Clinical Epidemiology and Biostatistics, Department of Biostatistics and Epidemiology, University of Pennsylvania Perelman School of Medicine, Philadelphia
| | - Warren B Bilker
- Center for Clinical Epidemiology and Biostatistics, Department of Biostatistics and Epidemiology, University of Pennsylvania Perelman School of Medicine, Philadelphia3Center for Pharmacoepidemiology Research and Training, University of Pennsylvania Perelm
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15
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Jennings LA, Reuben DB, Evertson LC, Serrano KS, Ercoli L, Grill J, Chodosh J, Tan Z, Wenger NS. Unmet needs of caregivers of individuals referred to a dementia care program. J Am Geriatr Soc 2015; 63:282-9. [PMID: 25688604 DOI: 10.1111/jgs.13251] [Citation(s) in RCA: 106] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVES To characterize caregiver strain, depressive symptoms, and self-efficacy for managing dementia-related problems and the relationship between these and referring provider type. DESIGN Cross-sectional observational cohort. SETTING Urban academic medical center. PARTICIPANTS Caregivers of community-dwelling adults with dementia referred to a dementia care management program. MEASUREMENTS Caregivers were surveyed and completed the Patient Health Questionnaire (PHQ-9) about themselves; the Modified Caregiver Strain Index; the Neuropsychiatric Inventory Questionnaire, which measures patient symptom severity and related caregiver distress; and a nine-item caregiver self-efficacy scale developed for the study. RESULTS Of 307 patient-caregiver dyads surveyed over a 1-year period, 32% of caregivers reported confidence in managing dementia-related problems, 19% knew how to access community services to help provide care, and 28% agreed that the individual's provider helped them work through dementia care problems. Thirty-eight percent reported high levels of caregiver strain, and 15% reported moderate to severe depressive symptoms. Caregivers of individuals referred by geriatricians more often reported having a healthcare professional to help work through dementia care problems than those referred by internists, family physicians, or other specialists, but self-efficacy did not differ. Low caregiver self-efficacy was associated with higher caregiver strain, more caregiver depressive symptoms, and caring for an individual with more-severe behavioral symptoms. CONCLUSION Most caregivers perceived inadequate support from the individual's provider in managing dementia-related problems, reported strain, and had low confidence in managing caregiving. New models of care are needed to address the complex care needs of individuals with dementia and their caregivers.
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Affiliation(s)
- Lee A Jennings
- Multicampus Program in Geriatric Medicine and Gerontology, University of California at Los Angeles, Los Angeles, California
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Reuben DB, Evertson LC, Wenger NS, Serrano K, Chodosh J, Ercoli L, Tan ZS. The University of California at Los Angeles Alzheimer's and Dementia Care program for comprehensive, coordinated, patient-centered care: preliminary data. J Am Geriatr Soc 2013; 61:2214-2218. [PMID: 24329821 DOI: 10.1111/jgs.12562] [Citation(s) in RCA: 75] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Dementia is a chronic disease that requires medical and social services to provide high-quality care and prevent complications. As a result of time constraints in practice, lack of systems-based approaches, and poor integration of community-based organizations (CBOs), the quality of care for dementia is poorer than that for other diseases that affect older persons. The University of California at Los Angeles (UCLA) Alzheimer's and Dementia Care (UCLA ADC) program partners with CBOs to provide comprehensive, coordinated, patient-centered care for individuals with Alzheimer's disease and other dementias. The goals of the program are to maximize function, independence, and dignity; minimize caregiver strain and burnout; and reduce unnecessary costs. The UCLA ADC program consists of five core components: recruitment and a dementia registry, structured needs assessments of individuals in the registry and their caregivers, creation and implementation of individualized dementia care plans based on needs assessments and input from the primary care physicians, monitoring and revising care plans as needed, and around-the-clock access for assistance and advice. The program uses a comanagement model with a nurse practitioner Dementia Care Manager working with primary care physicians and CBOs. Based on the first 150 individuals served, the most common recommendations in the initial care plans were referrals to support groups (73%) and Alzheimer's Association Safe Return (73%), caregiver training (45%), and medication adjustment (41%). The program will be evaluated on its ability to achieve the triple aim of better care for individuals, better health for populations, and lower costs.
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Affiliation(s)
- David B Reuben
- Multicampus Program in Geriatric Medicine and Gerontology, David Geffen School of Medicine, University of California at Los Angeles, Los Angeles, California
| | - Leslie C Evertson
- Multicampus Program in Geriatric Medicine and Gerontology, David Geffen School of Medicine, University of California at Los Angeles, Los Angeles, California
| | - Neil S Wenger
- Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine, University of California at Los Angeles, Los Angeles, California
| | - Katherine Serrano
- Multicampus Program in Geriatric Medicine and Gerontology, David Geffen School of Medicine, University of California at Los Angeles, Los Angeles, California
| | - Joshua Chodosh
- Geriatric Research, Education and Clinical Center, Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles, California
| | - Linda Ercoli
- Division of Geriatric Psychology, Department of Psychiatry, David Geffen School of Medicine, University of California at Los Angeles, Los Angeles, California
| | - Zaldy S Tan
- Multicampus Program in Geriatric Medicine and Gerontology, David Geffen School of Medicine, University of California at Los Angeles, Los Angeles, California
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Luppa M, Riedel-Heller SG, Stein J, Leicht H, König HH, van den Bussche H, Maier W, Scherer M, Bickel H, Mösch E, Werle J, Pentzek M, Fuchs A, Eisele M, Jessen F, Tebarth F, Wiese B, Weyerer S. Predictors of institutionalisation in incident dementia--results of the German Study on Ageing, Cognition and Dementia in Primary Care Patients (AgeCoDe study). Dement Geriatr Cogn Disord 2012; 33:282-8. [PMID: 22759566 DOI: 10.1159/000339729] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/25/2012] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND/AIMS In the past few decades, a number of studies investigated risk factors of nursing home placement (NHP) in dementia patients. The aim of the study was to investigate risk factors of NHP in incident dementia cases, considering characteristics at the time of the dementia diagnosis. METHODS 254 incident dementia cases from a German general practice sample aged 75 years and older which were assessed every 1.5 years over 4 waves were included. A Cox proportional hazard regression model was used to determine predictors of NHP. Kaplan-Meier survival curves were used to evaluate the time until NHP. RESULTS Of the 254 incident dementia cases, 77 (30%) were institutionalised over the study course. The mean time until NHP was 4.1 years. Significant characteristics of NHP at the time of the dementia diagnosis were marital status (being single or widowed), higher severity of cognitive impairment and mobility impairment. CONCLUSION Marital status seems to play a decisive role in NHP. Early initiation of support of sufferers may ensure remaining in the familiar surroundings as long as possible.
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Affiliation(s)
- Melanie Luppa
- Institute of Social Medicine, Occupational Health and Public Health, University of Leipzig, Leipzig, Germany.
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