Multidisciplinary team meetings (MDTM) in detection of Alzheimer's disease: data from the IDEM study

Diagnosis of dementia in Australia: a narrative review of services and models of care

Objective There is an impetus for the timely diagnosis of dementia to enable optimal management of patients, carers and government resources. This is of growing importance in the setting of a rising prevalence of dementia in an aging population. The Australian Clinical Practice Guidelines and Principles of Care for People with Dementia advocate referral to comprehensive memory services for dementia diagnosis, but in practice many patients may be diagnosed in other settings. The aim of the present study was to obtain evidence of the roles, effectiveness, limitations and accessibility of current settings and services available for dementia diagnosis in Australia. Methods A literature review was performed by searching Ovid MEDLINE using the terms 'dementia' AND 'diagnosis OR detection'. In addition, articles from pertinent sources, such as Australian government reports and relevant websites (e.g. Dementia Australia) were included in the review. Results Literature was found for dementia diagnosis across general practice, hospitals, memory clinics, specialists, community, care institutions and new models. General practitioners are patients' preferred health professionals when dealing with dementia, but gaps in symptom recognition and initiation of cognitive testing lead to underdiagnosis. Hospitals are opportunistic places for dementia screening, but time constraints and acute medical issues hinder efficient dementia diagnosis. Memory clinics offer access to multidisciplinary skills, demonstrate earlier dementia diagnosis and potential cost-effectiveness, but are disadvantaged by organisational complexities. Specialists have increased confidence in diagnosing dementia than generalists, but drawbacks include long wait lists. Aged care assessment teams (ACAT) are a potential service for dementia diagnosis in the community. A multidisciplinary model for dementia diagnosis in care institutions is potentially beneficial, but is time and cost intensive. New models with technology allow dementia diagnosis in rural regions. Conclusion Memory clinics are most effective for formal dementia diagnosis, but healthcare professionals in other settings play vital roles in recognising patients with dementia and initiating investigations and referrals to appropriate services. What is known about this topic? Delays in dementia diagnosis are common, and it is unclear where majority of patients receive a diagnosis of dementia in Australia. While the Australian Clinical Practice Guidelines and Principles of Care for People with Dementia advocate referrals to services such as memory clinics for comprehensive assessment and diagnosis of dementia, such services may have limited capacity and may not be readily accessible to all. What does this paper add? This paper presents an overview of the various settings and services available for dementia diagnosis in Australia including evidence of the roles, accessibility, effectiveness and limitations of each setting. What are the implications for practitioners? This concerns a disease that is highly prevalent and escalating, and highlights the roles for practitioners in various settings including general practices, acute hospitals, specialist clinics, community and nursing homes. In particular, it discusses the potential roles, advantages and challenges of dementia diagnosis in each setting.

Systematic Dementia Screening by Multidisciplinary Team Meetings in Nursing Homes for Reducing Emergency Department Transfers: The IDEM Cluster Randomized Clinical Trial

IMPORTANCE

Dementia is often underdiagnosed in nursing homes (NHs). This potentially results in inappropriate care, and high rates of emergency department (ED) transfers in particular.

OBJECTIVE

To assess whether systematic dementia screening of NH residents combined with multidisciplinary team meetings resulted in a lower rate of ED transfer at 12 months compared with usual care.

DESIGN, SETTING, AND PARTICIPANTS

Multicenter, cluster randomized trial with NHs as the unit of randomization. The IDEM (Impact of Systematic Tracking of Dementia Cases on the Rate of Hospitalization in Emergency Care Units) trial took place at 64 public and private NHs in France. Recruitment started on May 1, 2010, and was completed on March 31, 2012. Residents who were aged 60 years or older, had no diagnosed or documented dementia, were not bedridden, had lived in the NH for at least 1 month at inclusion, and had a life expectancy greater than 12 months were included. The residents were followed up for 18 months. The main study analyses were completed on October 14, 2016.

INTERVENTION

Two parallel groups were compared: an intervention group consisting of NHs that set up 2 multidisciplinary team meetings to identify residents with dementia and to discuss an appropriate care plan, and a control group consisting of NHs that continued their usual practice. During the inclusion period of 23 months, all residents of participating NHs who met eligibility criteria were included in the study.

MAIN OUTCOMES AND MEASURES

The primary end point (ED transfer) was analyzed at 12 months, but the residents included were followed up for 18 months.

RESULTS

A total of 64 NHs participated in the study and enrolled 1428 residents (mean [SD] age, 84.7 [8.1] years; 1019 [71.3%] female): 599 in the intervention group (32 NHs) and 829 in the control group (32 NHs). The final study visit was completed by 1042 residents (73.0%). The main reason for early discontinuation was death (318 residents [22.7%]). The intervention did not reduce the risk of ED transfers during the 12-month follow-up: the proportion of residents transferred at least once to an ED during the 12-month follow-up was 16.2% in the intervention group vs 12.8% in the control group (odds ratio, 1.32; 95% CI, 0.83-2.09; P = .24).

CONCLUSIONS AND RELEVANCE

This study failed to demonstrate that systematic screening for dementia in NHs resulted in fewer ED transfers. The findings do not support implementation of multidisciplinary team meetings for systematic dementia screening of all NH residents, beyond the national recommendations for dementia diagnosis, to reduce ED transfers.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT01569997.

End of life care practice and symptom management outcomes of nursing home residents with dementia: secondary analyses of IQUARE trial

PURPOSE

End-of-life care is a central issue in nursing homes. Poor care outcomes have been reported, especially among residents with dementia. Our aim was two-fold: to assess whether the diagnosis of dementia was associated with specific patterns of care and symptom management for residents with dementia during the last 6 months of life, and to compare these patterns of care between residents with dementia who died within 6 months and those who survived longer.

METHODS

Secondary prospective analyses of the IQUARE trial (trial registration number NCT01703689). 175 nursing homes in South West France. Residents with and without dementia at baseline (May-June 2011), stratified according to their vital status at 6-month follow-up.

RESULTS

Of 6275 residents enrolled in IQUARE study (including 2688 with dementia), 494 (7.9%) died within 6 months. Compared to residents without dementia (n = 254), those with dementia (n = 240) were less likely to be self-sufficient (OR = 0.08, 95% CI 0.01-0.64). They were more likely to have physical restraints (OR = 1.65, 95% CI 1.08-2.51) and less likely to be prescribed benzodiazepines (OR = 0.58, 95% CI 0.38-0.88). Among residents with dementia, those who died during the first 6 months of follow-up were more likely to be identified with a formal "end-of-life" status (OR = 5.71, 95% CI 3.48-9.37) although such identification remains low with only 15% of them. They were more likely to experience pain (OR = 1.43, 95% CI 1.04-1.97) and to be physically restrained (OR = 1.46, 95% CI 1.08-1.98). However, pain relief and psychological distress management were not improved.

CONCLUSIONS

Poor quality indicators such as physical restraints are associated with end-of-life care for residents with dementia. Among symptom management outcomes, pain medication remains low even if pain complaint increased at life end.

Most appropriate placement for people with dementia: individual experts' vs. expert groups' decisions in eight European countries

AIMS

To investigate the extent of variability in individuals' and multidisciplinary groups' decisions about the most appropriate setting in which to support people with dementia in different European countries.

BACKGROUND

Professionals' views of appropriate care depend on care systems, cultural background and professional discipline. It is not known to what extent decisions made by individual experts and multidisciplinary groups coincide.

DESIGN

A modified nominal group approach was employed in eight countries (Estonia, Finland, France, Germany, the Netherlands, Spain, Sweden and the UK) as part of the RightTimePlaceCare Project.

METHODS

Detailed vignettes about 14 typical case types of people with dementia were presented to experts in dementia care (n = 161) during November and December 2012. First, experts recorded their personal judgements about the most appropriate settings (home care, assisted living, care home, nursing home) in which to support each of the depicted individuals. Second, participants worked in small groups to reach joint decisions for the same vignettes.

RESULTS

Considerable variation was seen in individuals' recommendations for more than half the case types. Cognitive impairment, functional dependency, living situation and caregiver burden did not differentiate between case types generating high and low degrees of consensus. Group-based decisions were more consistent, but country-specific patterns remained.

CONCLUSIONS

A multidisciplinary approach would standardize the decisions made about the care needed by people with dementia on the cusp of care home admission. The results suggest that certain individuals could be appropriately diverted from care home entry if suitable community services were available.

Indicators of influenza and pneumococcal vaccination in French nursing home residents in 2011

INTRODUCTION

Older adults living in nursing homes (NH) are at high risk of developing influenza and pneumococcal infections. The objectives of this study were to describe vaccination coverage for influenza and pneumococcal among French NH residents and to investigate which NH structure- and organisation-related aspects could impact on vaccination in this population.

METHODS

This study is based on cross-sectional data from 175 French NHs (N=6275 residents), collected in May-July 2011. Residents' vaccination status (yes vs. no) against pneumococcal infection and seasonal influenza was recorded by the NH staff (on the basis of the resident's medical chart). Residents' health-related variables (e.g., co-morbidities) and information on NH structure and internal organisation were recorded by the NH staff. Mixed-effects logistic regressions were performed on influenza and pneumococcal vaccination separately.

RESULTS

Influenza vaccination coverage was high (n=5071, i.e., 80.8% of residents) and relatively well-distributed across NHs, whereas pneumococcal vaccination was low (n=1758, i.e., 28%) and highly variable across facilities. Mixed-effects logistic regressions confirmed that structural and organisational aspects related to the NH functioning impacted vaccination coverage. More precisely, living in a private for profit NH, living in NHs located in low-urban areas, and coordinating physician training increased the odds of receiving pneumococcal vaccine, whereas living in NHs located at high-urban areas decreased this odds. Moreover, the time spent by the coordinating physician in the NH increased the odds of receiving influenza vaccine. Prescriptions re-examination since resident's admission at the NH and the presence of an individualised health care project increased the odds of receiving both influenza and pneumococcal vaccines.

CONCLUSIONS

Our findings suggest that a more standardised approach is needed to improve vaccination coverage against pneumococcal infection in French NH residents.