A multidimensional home-based care coordination intervention for elders with memory disorders: the maximizing independence at home (MIND) pilot randomized trial

Telehealth Infrastructure, Accountable Care Organization, and Medicare Payment for Patients with Alzheimer's Disease and Related Dementia Living in Socially Vulnerable Areas

Background: Structural social determinants of health have an accumulated negative impact on physical and mental health. Evidence is needed to understand whether emerging health information technology and innovative payment models can help address such structural social determinants for patients with complex health needs, such as Alzheimer's disease and related dementias (ADRD). Objective: This study aimed to test whether telehealth for care coordination and Accountable Care Organization (ACO) enrollment for residents in the most disadvantaged areas, particularly those with ADRD, was associated with reduced Medicare payment. Methods: The study used the merged data set of 2020 Centers for Medicare and Medicaid Services Medicare inpatient claims data, the Medicare Beneficiary Summary File, the Medicare Shared Savings Program ACO, the Center for Medicare and Medicaid Service's Social Vulnerability Index (SVI), and the American Hospital Annual Survey. Our study focused on community-dwelling Medicare fee-for-service beneficiaries aged 65 years and up. Cross-sectional analyses and generalized linear models (GLM) were implemented. Analyses were implemented from November 2023 to February 2024. Results: Medicare fee-for-service beneficiaries residing in SVI Q4 (i.e., the most vulnerable areas) reported significantly higher total Medicare costs and were least likely to be treated in hospitals that provided telehealth post-discharge services or have ACO affiliation. Meanwhile, the proportion of the population with ADRD was the highest in SVI Q4 compared with other SVI levels. The GLM regression results showed that hospital telehealth post-discharge infrastructure, patient ACO affiliation, SVI Q4, and ADRD were significantly associated with higher Medicare payments. However, coefficients of interaction terms among these factors were significantly negative. For example, the average interaction effect of telehealth post-discharge and ACO, SVI Q4, and ADRD on Medicare payment was -$1,766.2 (95% confidence interval: -$2,576.4 to -$976). Conclusions: Our results suggested that the combination of telehealth post-discharge and ACO financial incentives that promote care coordination is promising to reduce the Medicare cost burden among patients with ADRD living in socially vulnerable areas.

[DemStepCare: Risk-stratified support for primary care-based dementia care - evaluation from general practitioner's view]

OBJECTIVE

The innovation fund project DemStepCare aimed to optimize multi-professional care through case management, risk stratification, and crisis outpatient clinic. Here, the evaluation results from the perspective of the general practitioners are presented.

METHODS

A quantitative survey was carried out at three time points regarding acceptance, benefit assessment and sensitivity to dementia of the general practitioners. In addition, qualitative interviews were conducted.

RESULTS

Satisfaction with the overall project was high. Added value and relief factors were perceived and more effective and stable dementia care was achieved through collaboration with case management. Physicians reported increased subjective competence in diagnostics and disease management.

CONCLUSIONS

The results confirm the benefit and effectiveness of DemStepCare from general practitioner's perspective.

Using Natural Language Processing to Identify Home Health Care Patients at Risk for Diagnosis of Alzheimer's Disease and Related Dementias

This study aimed to: (1) validate a natural language processing (NLP) system developed for the home health care setting to identify signs and symptoms of Alzheimer's disease and related dementias (ADRD) documented in clinicians' free-text notes; (2) determine whether signs and symptoms detected via NLP help to identify patients at risk of a new ADRD diagnosis within four years after admission. This study applied NLP to a longitudinal dataset including medical record and Medicare claims data for 56,652 home health care patients and Cox proportional hazard models to the subset of 24,874 patients admitted without an ADRD diagnosis. Selected ADRD signs and symptoms were associated with increased risk of a new ADRD diagnosis during follow-up, including: motor issues; hoarding/cluttering; uncooperative behavior; delusions or hallucinations; mention of ADRD disease names; and caregiver stress. NLP can help to identify patients in need of ADRD-related evaluation and support services.

A psychosocial goal-setting and manualised support intervention for independence in dementia (NIDUS-Family) versus goal setting and routine care: a single-masked, phase 3, superiority, randomised controlled trial

BACKGROUND

Although national guidelines recommend that everyone with dementia receives personalised post-diagnostic support, few do. Unlike previous interventions that improved personalised outcomes in people with dementia, the NIDUS-Family intervention is fully manualised and deliverable by trained and supervised, non-clinical facilitators. We aimed to investigate the effectiveness of home-based goal setting plus NIDUS-Family in supporting the attainment of personalised goals set by people with dementia and their carers.

METHODS

We did a two-arm, single-masked, multi-site, randomised, clinical trial recruiting patient-carer dyads from community settings. We randomly assigned dyads to either home-based goal setting plus NIDUS-Family or goal setting and routine care (control). Randomisation was blocked and stratified by site (2:1; intervention to control), with allocations assigned via a remote web-based system. NIDUS-Family is tailored to goals set by dyads by selecting modules involving behavioural interventions, carer support, psychoeducation, communication and coping skills, enablement, and environmental adaptations. The intervention involved six to eight video-call or telephone sessions (or in person when COVID-19-related restrictions allowed) over 6 months, then telephone follow-ups every 2-3 months for 6 months. The primary outcome was carer-rated goal attainment scaling (GAS) score at 12 months. Analyses were done by intention to treat. This trial is registered with the ISRCTN registry, ISRCTN11425138.

FINDINGS

Between April 30, 2020, and May 9, 2021, we assessed 1083 potential dyads for eligibility, 781 (72·1%) of whom were excluded. Of 302 eligible dyads, we randomly assigned 98 (32·4%) to the control group and 204 (67·5%) to the intervention group. The mean age of participants with dementia was 79·9 years (SD 8·2), 169 (56%) were women, and 133 (44%) were men. 247 (82%) dyads completed the primary outcome, which favoured the intervention (mean GAS score at 12 months 58·7 [SD 13·0; n=163] vs 49·0 [14·1; n=84]; adjusted difference in means 10·23 [95% CI 5·75-14·71]; p<0·001). 31 (15·2%) participants in the intervention group and 14 (14·3%) in the control group experienced serious adverse events.

INTERPRETATION

To our knowledge, NIDUS-Family is the first readily scalable intervention for people with dementia and their family carers that improves attainment of personalised goals. We therefore recommend that it be implemented in health and care services.

FUNDING

UK Alzheimer's Society.

Transitional care model for older adults with multiple chronic conditions: An evaluation of benefits utilising an umbrella review

AIMS

To synthesise and describe the combined evidence from systematic reviews of interventions using elements from the Transitional Care Model, on the content and timeframe of the interventions and the related improvement of outcomes for older patients with multiple chronic conditions.

BACKGROUND

The population of older patients with multiple chronic conditions is increasing worldwide and trajectories are often complicated by risk factors. The Transitional Care Model may contain elements to support transitions between hospital and home.

DESIGN

An umbrella review.

REVIEW METHODS

A comprehensive search in five electronic databases was performed in April 2021 based on the search terms: 'Patients ≥60 years,' 'multi-morbidity,' 'Transitional care model,' 'Transitional care,' and 'Systematic review.' PRISMA guidelines was used.

RESULTS

Five systematic reviews published from 2011 to 2020 comprising 62 intervention studies (59 randomised controlled trials and three quasi-experimental trials) were included in the review. The synthesis predominantly revealed significant improvements in decreasing re-admissions and financial costs and increasing patients' quality of life and satisfaction during discharge.

CONCLUSION

The results of the review indicate that multiple elements from the Transitional Care Model have achieved significant improvements in older patients' transitions from hospital to home. Especially a combination of coordination, communication, collaboration and continuity of care in transitions, organised information and education for patients and pre-arranged structured post-discharge follow-ups.

IMPACT

The transition from hospital to home is a complex process for older patients with multiple chronic conditions. A specific focus on coordination, continuity, and patient education should be implemented in the discharge process. Nurses with specialised knowledge in transitional care are needed to ensure safe transitions.

PATIENT AND PUBLIC CONTRIBUTION

The umbrella review is part of a larger research program which involved a patient expert advisory board, which participated in discussing the relevance of the elements within the umbrella review.

Diagnoses and Treatment of Behavioral and Psychological Symptoms of Dementia Among Racially and Ethnically Diverse Persons Living with Dementia

Background

Behavioral and psychological symptoms of dementia (BPSD) and prescribed central nervous system (CNS) active drugs to treat them are prevalent among persons living with Alzheimer's disease and related dementias (PLWD) and lead to negative outcomes for PLWD and their caregivers. Yet, little is known about racial/ethnic disparities in diagnosis and use of drugs to treat BPSD.

Objective

Quantify racial/ethnic disparities in BPSD diagnoses and CNS-active drug use among community-dwelling PLWD.

Methods

We used a retrospective cohort of community-dwelling Medicare Fee-for-Service beneficiaries with dementia, continuously enrolled in Parts A, B and D, 2017-2019. Multivariate logistic models estimated rates of BPSD diagnosis and, conditional on diagnosis, CNS-active drug use.

Results

Among PLWD, 67.1% had diagnoses of an affective, psychosis or hyperactivity symptom. White (68.3%) and Hispanic (63.9%) PLWD were most likely, Blacks (56.6%) and Asians (52.7%) least likely, to have diagnoses. Among PLWD with BPSD diagnoses, 78.6% took a CNS-active drug. Use was highest among whites (79.3%) and Hispanics (76.2%) and lowest among Blacks (70.8%) and Asians (69.3%). Racial/ethnic differences in affective disorders were pronounced, 56.8% of white PLWD diagnosed; Asians had the lowest rates (37.8%). Similar differences were found in use of antidepressants.

Conclusions

BPSD diagnoses and CNS-active drug use were common in our study. Lower rates of BPSD diagnoses in non-white compared to white populations may indicate underdiagnosis in clinical settings of treatable conditions. Clinicians' review of prescriptions in this population to reduce poor outcomes is important as is informing care partners on the risks/benefits of using CNS-active drugs.

[Can nursing home placement of people with dementia be delayed by case management? A Systematic Review of Randomized Controlled Trials]

BACKGROUND

Dementia is one of the main reasons for care dependency in old age. Demographic changes will lead to decreased formal and informal care potential in Germany. The promotion of structured home care arrangements therefore becomes increasingly significant. The concept of case management (CM) aims at the efficient coordination of health care services based on the needs and resources of patients with chronic health issues and their caregivers. The objective of this review was to evaluate current studies on the effectiveness of outpatient CM approaches on delaying long-term care placement or reducing the risk of long-term care placement in people with dementia.

METHODS

A systematic literature review of randomized controlled trials (RCTs) was conducted. Relevant electronic databases (Pubmed, CINAHL, PsycINFO, Scopus, CENTRAL, Gerolit, ALOIS) were systematically searched. Reporting and study quality was assessed using the CONSORT checklist and Jadad scale.

RESULTS

The search strategies identified 6 RCTs relating to 5 different health care systems (Germany, USA, Netherlands, France, China). Three of the RCTs showed significant delays of long-term care placements and/or significantly reduced rates of long-term care placement in favor of the intervention groups.

CONCLUSION

The outcomes suggest that CM approaches have the potential of promoting the length of time that people with dementia remain in their own domestic environments. Further establishment and evaluation of CM approaches should therefore be strongly encouraged on the part of healthcare decision-makers. When planning and evaluating CM approaches, specific barriers, and resources for the sustainable implementation of CM in existing care chains should be assessed and taken into account.

I want to be seen as myself: needs and perspectives of persons with dementia concerning collaboration and a possible future move to the nursing home in palliative dementia care

Introduction: Interprofessional collaboration (IPC) within and during movements between care settings is crucial for optimal palliative dementia care. The objective of this study was to explore the experiences of persons with dementia regarding collaboration with and between healthcare professionals (HCPs) and their perceptions of a possible future move to the nursing home (NH) in palliative dementia care. Method: We conducted a cross-sectional qualitative study and performed semi-structured interviews with a purposive sample of persons with dementia living at home (N = 18). Data analysis involved content analysis. Results: Our study demonstrated that even though most persons with dementia find it difficult to perceive the collaboration amongst HCPs, they could describe their perceived continuity of care (Theme 1. My perception of collaboration among HCPs). Their core needs in collaboration with HCPs were receiving information, support from informal caregivers, personal attention and tailored care (Theme 2. My needs in IPC). Regarding a possible future move to the NH, persons with dementia cope with their current decline, future decline and a possible future move to the NH (Theme 3. My coping strategies for a possible future move to the NH). They also prefer to choose the NH, and continue social life and activities in their future NH (Theme 4. My preferences when a NH becomes my possible future home). Conclusion: Persons with dementia are collaborative partners who could express their needs and preferences, if they are willing and able to communicate, in the collaboration with HCPs and a possible future move to the NH.

Systematic Review and Meta-Analysis of Effects of Nurse-Led Intervention for People With Dementia

BACKGROUND

Nurses' primary role in clinical settings for persons living with dementia is to lessen the strain of dementia on daily life, monitor comorbidities, and manage medications. However, no comprehensive literature review has investigated the effectiveness of nurse-led interventions for persons living with dementia.

OBJECTIVE

The purpose of this study was to evaluate randomized controlled trials on the efficacy of nurse-led dementia interventions and provide an extended range of outcomes related to cognitive function, depression, and quality of life.

METHODS

A comprehensive literature search of six databases was conducted from database inception to August 10, 2022. Methodologies were evaluated, followed by a pooled analysis using random effects models to explain the effects of nurse-led dementia interventions on patients.

RESULTS

Nurse-led interventions were more effective than standard care in alleviating depression and improving quality of life. However, they did not enhance cognitive performance.

DISCUSSION

Nurse-led interventions for dementia alleviate depression and improve quality of life. However, because of lack of randomized controlled trials, the analysis found less effectiveness in improving cognitive function. Therefore, further trials are needed to corroborate these findings.

Using Chronic Care Management Visits to Reduce the Number of Frequent Emergency Department Visits: A Pilot Study

Background Emergency department (ED) visits are increasing in number and cost and becoming a major way patients are interacting with the healthcare system. Patients who frequently visit the ED are deemed "super-utilizers" who visit for a variety of reasons, including, but not limited to, multiple chronic medical illnesses, homelessness, and substance use disorder, but fail to have an established long-term treatment plan. Methodology We enrolled our hospital's top 50 super-utilizing patients into the Chronic Care Management Program. These patients received monthly telehealth visits to discuss concerns, chronic medical conditions, barriers to care, and support systems unique to each patient's living and social situation (i.e., social determinants of health). Telehealth visits also connected patients to community resources and helped them initiate advanced care services. Results The t-test investigating the frequency of avoidable visits pre- and post-intervention revealed a statistically significant decrease in the number of avoidable visits between the pre-intervention and post-intervention. Results also revealed a non-statistically significant difference in the cost of avoidable visits before and after the intervention. Conclusions The findings revealed a statistically significant decrease in patients' frequency of avoidable visits before and after the intervention.

Cost effectiveness of non-drug interventions that reduce nursing home admissions for people living with dementia

INTRODUCTION

Six million Americans live with Alzheimer's disease and Alzheimer's disease and related dementias (AD/ADRD), a major health-care cost driver. We evaluated the cost effectiveness of non-pharmacologic interventions that reduce nursing home admissions for people living with AD/ADRD.

METHODS

We used a person-level microsimulation to model the hazard ratios (HR) on nursing home admission for four evidence-based interventions compared to usual care: Maximizing Independence at Home (MIND), NYU Caregiver (NYU); Alzheimer's and Dementia Care (ADC); and Adult Day Service Plus (ADS Plus). We evaluated societal costs, quality-adjusted life years and incremental cost-effectiveness ratios.

RESULTS

All four interventions cost less and are more effective (i.e., cost savings) than usual care from a societal perspective. Results did not materially change in 1-way, 2-way, structural, and probabilistic sensitivity analyses.

CONCLUSION

Dementia-care interventions that reduce nursing home admissions save societal costs compared to usual care. Policies should incentivize providers and health systems to implement non-pharmacologic interventions.

Use of Community-Engaged Research Approaches in Clinical Interventions for Neurologic Disorders in the United States: A Scoping Review and Future Directions for Improving Health Equity Research

BACKGROUND AND OBJECTIVES

Evidence suggests a significant prevalence of race and ethnic disparities in the United States among people with neurologic conditions including stroke, Alzheimer disease and related dementia (ADRD), Parkinson disease (PD), epilepsy, spinal cord injury (SCI), and traumatic brain injury (TBI). Recent neurologic research has begun the paradigm shift from observational health disparities research to intervention research in an effort to narrow the disparities gap. There is an evidence base that suggests that community engagement is a necessary component of health equity. While the increase in disparities focused neurologic interventions is encouraging, it remains unclear whether and how community-engaged practices are integrated into intervention design and implementation. The purpose of this scoping review was to identify and synthesize intervention studies that have actively engaged with the community in the design and implementation of interventions to reduce disparities in neurologic conditions and to describe the common community engagement processes used.

METHODS

Two databases, PubMed and CINAHL, were searched to identify eligible empirical studies within the United States whose focus was on neurologic interventions addressing disparities and using community engagement practices.

RESULTS

We identified 392 disparity-focused interventions in stroke, ADRD, PD, epilepsy, SCI, and TBI, of which 53 studies incorporated community engagement practices: 32 stroke studies, 15 ADRD, 2 epilepsy studies, 2 PD studies, 1 SCI study, and 1 TBI study. Most of the interventions were designed as randomized controlled trials and were programmatic in nature. The interventions used a variety of community engagement practices: community partners (42%), culturally tailored materials and mobile health (40%), community health workers (32%), faith-based organizations and local businesses (28%), focus groups/health need assessments (25%), community advisory boards (19%), personnel recruited from the community/champions (19%), and caregiver/social support (15%).

DISCUSSION

Our scoping review reports that the proportion of neurologic intervention studies incorporating community engagement practices is limited and that the practices used within those studies are varied. The major practices used included collaboration with community partners and utilization of culturally tailored materials. We also found inconsistent reporting and dissemination of results from studies that implemented community engagement measures in their interventions. Future directions include involving the community in research early and continuously, building curricula that address challenges to community engagement, prioritizing the inclusion of community engagement reporting in peer-reviewed journals, and prioritizing and incentivizing research of subpopulations that experience disparities in neurologic conditions.

Efficacy of sustained knowledge translation (KT) interventions in chronic disease management in older adults: systematic review and meta-analysis of complex interventions

BACKGROUND

Chronic disease management (CDM) through sustained knowledge translation (KT) interventions ensures long-term, high-quality care. We assessed implementation of KT interventions for supporting CDM and their efficacy when sustained in older adults.

METHODS

Design: Systematic review with meta-analysis engaging 17 knowledge users using integrated KT.

ELIGIBILITY CRITERIA

Randomized controlled trials (RCTs) including adults (> 65 years old) with chronic disease(s), their caregivers, health and/or policy-decision makers receiving a KT intervention to carry out a CDM intervention for at least 12 months (versus other KT interventions or usual care).

INFORMATION SOURCES

We searched MEDLINE, EMBASE, and the Cochrane Central Register of Controlled Trials from each database's inception to March 2020.

OUTCOME MEASURES

Sustainability, fidelity, adherence of KT interventions for CDM practice, quality of life (QOL) and quality of care (QOC). Data extraction, risk of bias (ROB) assessment: We screened, abstracted and appraised articles (Effective Practice and Organisation of Care ROB tool) independently and in duplicate.

DATA SYNTHESIS

We performed both random-effects and fixed-effect meta-analyses and estimated mean differences (MDs) for continuous and odds ratios (ORs) for dichotomous data.

RESULTS

We included 158 RCTs (973,074 participants [961,745 patients, 5540 caregivers, 5789 providers]) and 39 companion reports comprising 329 KT interventions, involving patients (43.2%), healthcare providers (20.7%) or both (10.9%). We identified 16 studies described as assessing sustainability in 8.1% interventions, 67 studies as assessing adherence in 35.6% interventions and 20 studies as assessing fidelity in 8.7% of the interventions. Most meta-analyses suggested that KT interventions improved QOL, but imprecisely (36 item Short-Form mental [SF-36 mental]: MD 1.11, 95% confidence interval [CI] [- 1.25, 3.47], 14 RCTs, 5876 participants, I2 = 96%; European QOL-5 dimensions: MD 0.01, 95% CI [- 0.01, 0.02], 15 RCTs, 6628 participants, I2 = 25%; St George's Respiratory Questionnaire: MD - 2.12, 95% CI [- 3.72, - 0.51] 44 12 RCTs, 2893 participants, I2 = 44%). KT interventions improved QOC (OR 1.55, 95% CI [1.29, 1.85], 12 RCTS, 5271 participants, I2 = 21%).

CONCLUSIONS

KT intervention sustainability was infrequently defined and assessed. Sustained KT interventions have the potential to improve QOL and QOC in older adults with CDM. However, their overall efficacy remains uncertain and it varies by effect modifiers, including intervention type, chronic disease number, comorbidities, and participant age.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42018084810.

Dementia care navigation: Building toward a common definition, key principles, and outcomes

INTRODUCTION

As the complexity of medical treatments and patient care systems have increased, the concept of patient navigation is growing in both popularity and breadth of application. Patient navigators are trained personnel whose role is not to provide clinical care, but to partner with patients to help them identify their needs and goals and then overcome modifiable patient-, provider-, and systems-level barriers. Due to its high incidence, duration, and medical-social complexity, dementia is an ideal candidate for a patient-centric health care delivery model such as care navigation.

METHODS

The Alzheimer's Association formed an expert workgroup of researchers in the field of dementia care navigation to identify evidence-based guidelines.

RESULTS

Recognizing the unique and challenging needs of persons living with dementia and their care partners, several U.S. dementia care navigation programs have been developed and assessed in recent years. Collectively these programs demonstrate that persons living with dementia and their care partners benefit from dementia care navigation. Improved care system outcomes for the person living with dementia include reduced emergency department visits, lower hospital readmissions, fewer days hospitalized, and shorter delays in long-term care placement. Well-being is also increased, as there is decreased depression, illness, strain, embarrassment, and behavioral symptoms and increased self-reported quality of life. For care partners, dementia navigation resulted in decreased depression, burden, and unmet needs.

DISCUSSION

This article presents principles of dementia care navigation to inform existing and emerging dementia care navigation programs.

Highlights

Several U.S. dementia care navigation programs have demonstrated outcomes for persons living with dementia, care partners, and health systems.The Alzheimer's Association formed an expert workgroup of researchers in the field of dementia care navigation to create a shared definition and identify evidence-based guidelines or principles.These outlined principles of dementia care navigation can inform existing and emerging dementia care navigation programs.

An integrative review of measures of transitions and care coordination for persons living with dementia and their caregivers

Introduction

High rates of hospital visits and readmissions are common among persons living with dementia, resulting in frequent transitions in care and care coordination. This paper identifies and evaluates existing measures of transitions and care coordination for persons living with dementia and their caregivers.

Methods

This integrative review builds off a prior review using a systematic search of online databases (PubMed, EBSCO, CINAHL, PsycInfo, and Scopus) to identify records and locate reports (or articles) that use measures of care transitions and care coordination. Identified measures were compared to the Alzheimer's Association's Dementia Care Practice Recommendations to evaluate strengths and weaknesses of the measure in this population, such as if measures were person- and family-centered.

Results

Seventy-one reports using measures of transitions in care and care coordination for persons living with dementia and their caregivers were identified. There were multiple measures identified in some reports. Three main areas of measures were classified into: identification of the population (3 measures, 8 reports), transitional care and care coordination delivery (14 measures, 17 reports), and transitional care and care coordination outcomes (e.g., health-care use, cost, and mortality; 17 measures, 60 reports). A strength of the three main areas of measures was that a portion of the measures were person- and family-centered. Variability in the operational definitions of some measures and time intensiveness of collecting the measure (e.g., number of items, the time it takes to complete the items) were common weaknesses.

Discussion

Transitions and care coordination measures are varied across studies targeted at persons living with dementia and their caregivers. Existing measures focus heavily on outcomes, specifically health-care resource use, and cost, rather than the elements of transitional care or care coordination. Future measure development focused on care transitions and service coordination is needed.

Use of Home-Based Clinical Care and Long-Term Services and Supports Among Homebound Older Adults

OBJECTIVES

Describe use of home-based clinical care and home-based long-term services and supports (LTSS) using a nationally representative sample of homebound older Medicare beneficiaries.

DESIGN

Cross-sectional study.

SETTING AND PARTICIPANTS

Homebound, community-dwelling fee-for-service Medicare beneficiaries participating in the 2015 National Health and Aging Trends Study (n = 974).

METHODS

Use of home-based clinical care [ie, home-based medical care, skilled home health services, other home-based care (eg, podiatry)] was identified using Medicare claims. Use of home-based LTSS (ie, assistive devices, home modification, paid care, ≥40 hours/wk of family caregiving, transportation assistance, senior housing, home-delivered meals) was identified via self or proxy report. Latent class analysis was used to characterize patterns of use of home-based clinical care and LTSS.

RESULTS

Approximately 30% of homebound participants received any home-based clinical care and about 80% received any home-based LTSS. Latent class analysis identified 3 distinct patterns of service use: class 1, High Clinical with LTSS (8.9%); class 2, Home Health Only with LTSS (44.5%); and class 3, Low Care and Services (46.6% homebound). Class 1 received extensive home-based clinical care, but their use of LTSS did not meaningfully differ from class 2. Class 3 received little home-based care of any kind.

CONCLUSIONS AND IMPLICATIONS

Although home-based clinical care and LTSS utilization was common among the homebound, no single group received high levels of all care types. Many who likely need and could benefit from such services do not receive home-based support. Additional work focused on better understanding potential barriers to accessing these services and integrating home-based clinical care services with LTSS is needed.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Dementia Care at the End of Life: A Clinically Focused Review

With the geriatric population in the United States growing rapidly, the prevalence of dementia is expected to rise concomitantly. As dementia is an invariably progressive and terminal illness, planning for and managing end of life care in dementia is an important part of the overall process of dementia care. Unfortunately, this is often neglected outside of formal palliative and hospice medicine training programs and geriatric psychiatrists are left without preparation on how to manage, as well as counsel patients and families on, this important phase of dementia care. This review aims to explore the potential contributors to this historic disparity in geriatric education and care delivery, as well as its impact, while also attempting to shift the field's focus toward a palliative approach to dementia care. To begin to accomplish this, this review explores the natural illness history/disease trajectory of the various dementing illnesses, as well as the topic of prognostication as it pertains to the end of life for patients with dementia and how this information can be used in advanced care planning and symptom management.

Further development needed: models of post-diagnostic support for people with dementia

PURPOSE OF REVIEW

There is increasing recognition of a service gap immediately after diagnosis for people with dementia and carers. This narrative review of models of post-diagnostic support focuses on recent developments and offers suggestions for future development. We present the current evidence for these models and consider the service components they provide against the recommendations of clinical guidelines and principles underpinning ideal post-diagnostic support.

RECENT FINDINGS

Models of post-diagnostic support include a short-term support worker, ongoing support worker, centre-based support, primary care management, and specialist dementia clinics. Of these, specialist dementia clinics that include ongoing support workers provide most components of an ideal and timely post-diagnostic support framework, but may be more costly to implement universally. The greatest research evidence is for the benefits of long-term support models, specifically case management, though this does not necessarily include medical care or nonpharmacological interventions. There is sparce evidence for the benefits of short-term support worker models such as dementia advisers for people with dementia and carers.

SUMMARY

Further development is needed to create whole-system models of dementia support which meet the needs of people with dementia and their carers, are timely, accessible and equitable, and can be implemented universally.

A dyadic advance care planning intervention for people with early-stage dementia and their family caregivers in a community care setting: a feasibility trial

BACKGROUND

Advance care planning (ACP) is highly relevant for people with early-stage dementia to communicate their care preferences for serious illness conditions with their family caregivers before they become mentally incapacitated.

METHODS

A multi-centre, quasi-experimental study was conducted to test the feasibility and acceptability of a theory-guided, dyadic ACP intervention ('Have a Say' programme) among participants with early-stage dementia-family caregiver dyads. The feasibility of the trial design, intervention procedures, subject recruitment and retention, and study instruments were assessed. Study outcomes were measured at baseline (T0), immediately after the intervention (T1), and at 1 month (T2) and 3 months post-intervention (T3). Acceptability of the intervention was determined by the satisfaction score, completion rate and qualitative interviews as process evaluation with a purposive sample of participants and ACP facilitators. Generalised estimating equations were performed to examine differential changes between groups over time, with covariates adjusted.

RESULTS

Subject recruitment from five elderly community centres yielded a recruitment rate of 60% and resulted in 36 client-caregiver dyads. The intervention was acceptable to the dyads, with a mean satisfaction score of 4.4 out of 5 and completion rate of 94.4%. The attrition rates at T1, T2, and T3 were 8.3%, 13.9%, and 19.4%, respectively. The intervention group reported a significantly greater improvement in the readiness for ACP at T1, self-efficacy for ACP at T3, and dyadic concordance on end-of-life care preferences at all time points than the control group, but not on depressive symptoms. Family caregivers in the intervention group reported a significantly higher caregiving burden at T2 than the control group. The qualitative findings revealed that triadic involvement of and trusting relationships among the dyads and ACP facilitators, and documentation of clients' views are the programme strengths, while the structured format and discussion about medical issues posed implementation challenges.

CONCLUSIONS

This ACP intervention and trial design were feasible and acceptable to the dyads. Several refinements were identified, including adding a nurse-led group-based session for information giving, allowing flexibility in arrangement, and adding measure of ACP engagement of family caregivers. A rigorous trial to test the effects of the ACP intervention is warranted.

TRIAL REGISTRATION

Retrospectively registered on 14/08/2020 at clinicaltrials.gov (Identifier: NCT04513106).

Patient navigation programs for people with dementia, their caregivers, and members of the care team: a scoping review

OBJECTIVE

The main objective of this review was to map the literature on the characteristics of patient navigation programs for people with dementia, their caregivers, and members of the care team across all settings. The secondary objective was to map the literature on the barriers and facilitators for implementing and delivering such patient navigation programs.

INTRODUCTION

People with dementia have individualized needs that change according to the stage of their condition. They often face fragmented and uncoordinated care when seeking support to address these needs. Patient navigation may be one way to help people with dementia access better care. Patient navigation is a model of care that aims to guide people through the health care system, matching their unmet needs to appropriate resources, services, and programs. Organizing the available information on this topic will present a clearer picture of how patient navigation programs work.

INCLUSION CRITERIA

This review focused on the characteristics of patient navigation programs for people living with dementia, their caregivers, and the members of the care team. It excluded programs not explicitly focused on dementia. It included patient navigation across all settings, delivered in all formats, and administered by all types of navigators if the programs aligned with this review's definition of patient navigation. This review excluded case management programs.

METHODS

This review was conducted in accordance with JBI methodology for scoping reviews. MEDLINE, CINAHL, APA PsycINFO, Embase, and ProQuest Nursing and Allied Health databases were searched for published full-text articles. A gray literature search was also conducted. Two independent reviewers screened articles for relevance against the inclusion criteria. The results are presented in a Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) flow diagram, and the extracted data are presented narratively and in tabular format.

RESULTS

Thirty-nine articles describing 20 programs were included in this review. The majority of these articles were published between 2015 and 2020, and based out of the United States. The types of sources included randomized controlled trials, quasi-experimental studies, and qualitative exploratory studies, among others. All programs provided some form of referral or linkage to other services or resources. Most dementia navigation programs included an interdisciplinary team, and most programs were community-based. There was no consistent patient navigator title or standard delivery method. Commonly reported barriers to implementing and delivering these programs were navigator burnout and a lack of coordination between stakeholders. Commonly reported facilitators were collaboration, communication, and formal partnerships between key stakeholders, as well as accessible and flexible program delivery models.

CONCLUSIONS

This review demonstrates variety and flexibility in the types of services patient navigation programs provided, as well as in the modes of service delivery and in navigator title. This information may be useful for individuals and organizations looking to implement their own programs in the future. It also provides a framework for future systematic reviews that seek to evaluate the effectiveness or efficacy of dementia navigation programs.

Profiles of Caregiving Arrangements of Community-dwelling People Living with Probable Dementia

People living with dementia receive care from multiple caregivers, but little is known about the structure of their caregiving arrangements. This study used the Health and Retirement Study and latent class analyses to identify subgroups of caregiving arrangements based on caregiving hours received from spouses, children, other family/friends, and paid individuals among married (n = 361) and unmarried (n = 473) community-dwelling people with probable dementia. Three classes in the married sample (class 1 "low hours with shared care," class 2 "spouse-dominant care," and class 3 "children-dominant care") were identified. In class 1, spouses, children, and paid individuals provided 53%, 22%, and 26% of the caregiving hours, respectively. Three classes in the unmarried sample (class 1 "low hours with shared care," class 2 "children-dominant care," and class 3 "paid-dominant care") were identified. In unmarried class 1, children, other family/friends, and paid individuals provided 35%, 41% and 24% of the caregiving hours, respectively.

An HIT-Supported Care Coordination Framework for Reducing Structural Racism and Discrimination for Patients With ADRD

Black and Latinx Americans are disproportionately at greater risk for having Alzheimer's disease and related dementias (ADRD) than White Americans. Such differences in risk for ADRD are arguably explained through health disparities, social inequities, and historical policies. Structural racism and discrimination (SRD), defined as "macro-level conditions that limit opportunities, resources, and well-being of less privileged groups," have been linked with common comorbidities of ADRD, including hypertension, obesity, diabetes, depression. Given the historical impact of SRD-including discriminatory housing policies resulting in racial residential segregation that has been shown to limit access to education, employment, and healthcare-Black and Latinx populations with ADRD are directly or indirectly negatively affected by SRD in terms of access, quality and cost for healthcare. Emerging studies have brought to light the value of structural-level hospital and public health collaboration on care coordination for improving healthcare quality and access, and thus could serve as a macro-level mechanism for addressing disparities for minoritized racial and ethnic populations with ADRD. This paper presents a conceptual framework delineating how care coordination can successfully be achieved through health information technology (HIT) systems and ultimately address SRD. To address health inequities, it is therefore critical that policy initiatives invest in HIT capacities and infrastructures to promote care coordination, identify patient needs and preferences, and promote engagement of patients with ADRD and their caregivers.

Reasons for Hospitalization while Receiving Dementia Care Coordination through Maximizing Independence at Home

OBJECTIVES

Persons living with dementia (PLWD), particularly those with higher levels of functional impairment, are at increased risk of hospitalization and higher hospital-associated health care costs. Our objective was to provide a nuanced description of reasons for hospitalizations over a 12-month period among community-living persons with dementia taking part in a dementia care coordination study using caregiver-reported data and to describe how reasons varied by disease stage.

DESIGN

Retrospective descriptive analysis of pooled data from 2 concurrent studies of PLWD receiving the MIND at Home dementia care coordination program.

SETTING AND PARTICIPANTS

Four hundred ninety-four community-dwelling PLWD with a family caregiver in the Greater Baltimore and Central Maryland region, 2015‒2019.

METHODS

PLWD sociodemographic, clinical, functional, cognitive, and behavioral characteristics were assessed during an in-home baseline visit. Caregiver-reported hospitalizations and primary reasons for events were recorded every 4.5 months by research staff and by memory care coordinators during program delivery for a 12-month period. Hospitalization event data were subsequently reviewed, reconciled, and coded by a trained investigator.

RESULTS

One hundred seventy PLWD (34.4%) had at least 1 hospitalization within 12 months of enrollment, with 316 separate events. The most common primary reason for hospitalization according to caregivers was infection (22.4%), falls (16.5%), and cardiovascular/pulmonary (12.4%). Top reasons for hospitalization were falls among persons with mild and moderate functional impairment (17.7% and 21.9% respectively) and infection among PLWD with severe impairment (30.3%).

CONCLUSIONS AND IMPLICATIONS

Infections and falls were the most common caregiver-reported reasons for hospitalization in PLWD receiving dementia care coordination. Reasons for hospitalization varied based on severity of functional impairment. Greater understanding of reasons for hospitalization among PLWD receiving dementia care management interventions, from multiple important perspectives, may help programs more effectively address and prevent hospitalization.

A Systematic Review and Meta-Analysis of Dyadic Psychological Interventions for BPSD, Quality of Life and/or Caregiver Burden in Dementia or MCI

Objectives: This systematic review and meta-analysis assesses the effectiveness of psychological interventions that involve people with dementia or mild cognitive impairment (MCI) and their informal caregivers, and target improvements in the management of the behavioral and psychological symptoms of dementia (BPSD); quality of life; and/or burden reduction for people with either dementia or MCI and their informal caregivers.Methods: Studies were identified through database searches (Cochrane Library, CENTRAL, CINAHL, EMBASE, MEDLINE and PsychINFO) and clinical trials registers (ClinicalTrials.gov and http://apps.who.int/trialsearch/). Data were pooled for meta-analysis.Results: Database and reference list searches identified 1,878 references, of which fourteen studies were included. Positive effects were found on the anxiety symptoms of people with dementia on the RAID scale; on the quality of life of people with dementia on the self-rated QoL-AD scale; and on informal caregiver burden on the Zarit Burden Interview.Conclusions: Psychological interventions involving whole dyads have some promise for both people with dementia and informal caregivers, but are still far from uniformly effective across BPSD, quality of life, and caregiver burden. Further research directions are discussed.Clinical Implications: The results suggest that clinicians should routinely involve both halves of the dyad when delivering psychological interventions targeting anxiety or quality of life for people with dementia, or burden for informal caregivers.

Case management for people with dementia living at home and their informal caregivers: A scoping review

Case management is a complex intervention aimed at addressing a variety of health needs of people in their social environment. Case management for people with dementia is often poorly defined and insufficiently described. The crucial process steps are often not well understood. We aim to map and compare the key components, processes and contextual factors of case management programmes for dementia and to explore aspects of the interventions' generalisability. Our search covered the databases PubMed, CINAHL, Cochrane and GeroLit, as well as policy papers from international organisations. We included qualitative, quantitative and mixed-methods studies in the English or German language that was published between 1999 and 2020. The programmes were analysed according to programme characteristics, case management intervention and the structural and processing conditions. We identified 67 studies dealing with 25 programmes. Approximately half of the programmes were investigated in randomised controlled trials, two programmes used a mixed-methods design and the remaining were the subject of pre-post cohort studies. Participants in the studies were predominantly dyads of people with dementia and their informal caregivers. About half of the programmes reported a theoretical framework. All the programmes were derived from case management approaches or referred to such approaches. Despite huge differences in implementation, all the programmes covered the case management steps. In 14 out of 25 programmes, case management was carried out without additional intervention, the other programmes provided mainly education and training for informal caregivers. Costs of the case management interventions were stated in more than half of the programmes.The effectiveness and generalisability of dementia-specific case management interventions could be enhanced if the framework introduced in the review was used in the future by policy, practice and research.

Cognitive impairment associated with greater care intensity during home health care

BACKGROUND

In Medicare-funded home health care (HHC), one in three patients has cognitive impairment (CI), but little is known about the care intensity they receive in this setting. Recent HHC reimbursement changes fail to adjust for patient CI, potentially creating a financial disincentive to caring for these individuals.

METHODS

This cohort study included a nationally representative sample of 1214 Medicare HHC patients between 2011 and 2016. Multivariable logistic and negative binomial regressions modelled the relationship between patient CI and care intensity-measured as the number and type of visits received during HHC and likelihood of receiving multiple successive HHC episodes.

RESULTS

Patients with CI had 45% (P < .05) greater odds of receiving multiple successive HHC episodes and received an additional 2.82 total (P < .001), 1.39 nursing (P = .003), 0.72 physical therapy (P = .03), and 0.60 occupational therapy visits (P = .01) during the index HHC episode.

DISCUSSION

Recent HHC reimbursement changes do not reflect the more intensive care needs of patients with CI.

Clinical and Demographic Profiles of Home Care Patients With Alzheimer's Disease and Related Dementias: Implications for Information Transfer Across Care Settings

Home health care (HHC) clinicians serving individuals with Alzheimer's disease and related dementias (ADRD) do not always have information about the person's ADRD diagnosis, which may be used to improve the HHC plan of care. This retrospective cohort study examined characteristics of 56,652 HHC patients with varied documentation of ADRD diagnoses. Data included clinical assessments and Medicare claims for a 6-month look-back period and 4-year follow-up. Nearly half the sample had an ADRD diagnosis observed in the claims either prior to or following the HHC admission. Among those with a prior diagnosis, 63% did not have it documented on the HHC assessment; the diagnosis may not have been known to the HHC team or incorporated into the care plan. Patients with ADRD had heightened risk for adverse outcomes (e.g., urinary tract infection and aspiration pneumonia). Interoperable data across health care settings should include ADRD-specific elements about diagnoses, symptoms, and risk factors.

Developing Treatments for Alzheimer's and Related Disorders with Precision Medicine: A Vision

Precision medicine, also known as personalized medicine, is concerned with finding the right treatment for the right patient at the right time. It is a way of thinking focused on parsing heterogeneity ultimately down to the level of the individual. Its main mission is to identify characteristics of heterogeneous clinical conditions so as to target tailored therapies to individuals. Precision Medicine however is not an agnostic collection of all manner of clinical, genetic and other biologic data in select cohorts. This is an important point. Simply collecting as much information as possible on individuals without applying this way of thinking should not be considered Precision Medicine.

Characteristics associated with neuropsychiatric symptoms in persons living with dementia and caregiver distress and diminished well-being

BACKGROUND

The population of persons living with dementia (PLWDs) is increasing, although mainstream dementia care quality is suboptimal.

PURPOSE

To identify characteristics associated with: (1) PLWDs' neuropsychiatric symptoms and quality of life; and (2) distress from neuropsychiatric symptoms and well-being among their family caregivers (N = 49).

METHODOLOGY

Cross-sectional single-group examination of PLWD and caregivers when they enrolled into a nurse-led dementia-centered primary care clinic. Pearson correlations were run between characteristics of PLWD and caregiver and variables representing PLWD's neuropsychiatric symptoms and quality of life and their caregivers' well-being. Statistically significant correlations were reported via Cohen d statistics.

RESULTS

Caregivers' characteristics associated with higher distress from neuropsychiatric symptoms and diminished well-being included Black race, female gender, younger age, caring for a parent with dementia, and being employed. Characteristics of PLWD associated with caregivers' higher distress and diminished well-being included longer time since dementia onset, higher Charlson Comorbidity Index, and non-Alzheimer dementia. Caregivers' characteristics associated with higher neuropsychiatric symptom burden included Black race, female gender, younger age, caring for parent PLWD, and being employed. Characteristics of PLWDs associated with higher neuropsychiatric symptom burden included non-Alzheimer dementia, longer time since dementia onset, more comorbidities, and higher Charlson Comorbidity Index. Finally, a longer time since dementia onset was associated with PLWDs' lower quality of life.

CONCLUSIONS

Black race, caring for caring for a parent with dementia, younger age, and being employed were characteristics linked to PLWDs' higher neuropsychiatric symptom burden and caregivers' diminished well-being.

IMPLICATIONS

Clinicians must assess and intervene with unpaid caregivers who may not appear obviously distressed.

The Impact of Ambulatory Dementia Care Models on Hospitalization of Persons Living With Dementia: A Systematic Review

This systematic review presents an overview of the existing dementia care models in various ambulatory care settings under three categories (i.e., home- and community-based care models, partnership between health systems and community-based resources, and consultation models) and their impact on hospitalization among Persons Living with Dementia (PLWD). PRISMA guidelines were applied, and our search resulted in a total of 13 studies focusing on 11 care models. Seven studies reported that utilization of dementia care models was associated with a modest reduction in hospitalization among community-residing PLWD. Only two studies reported statistically significant results. Dementia care models that were utilized in specialty ambulatory care settings such as memory care showed more promising results than traditional primary care. To develop a better understanding of how dementia care models can be improved, future studies should explore how confounders (e.g., stage of dementia) influence hospitalization.

Clinical and cost-effectiveness of a New psychosocial intervention to support Independence in Dementia (NIDUS-family) for family carers and people living with dementia in their own homes: a randomised controlled trial

BACKGROUND

Most people living with dementia want to remain living in their own homes and are supported to do so by family carers. No interventions have consistently demonstrated improvements to people with dementia's life quality, functioning, or other indices of living as well as possible with dementia. We have co-produced, with health and social care professionals and family carers of people with dementia, a new intervention (NIDUS-family). To our knowledge, NIDUS-family is the first manualised intervention that can be tailored to personal goals of people living with dementia and their families and is delivered by facilitators without clinical training. The intervention utilizes components of behavioural management, carer support, psychoeducation, communication and coping skills training, enablement, and environmental adaptations, with modules selected to address dyads' selected goals. We will evaluate the effect of NIDUS-family and usual care on goal attainment, as measured by Goal Attainment Scaling (GAS) rated by family carers, compared to usual care alone at 12-month follow-up. We will also determine whether NIDUS-family and usual care is more cost-effective than usual care alone over 12 months.

METHODS

A randomised, two-arm, single-masked, multi-site clinical trial involving 297 people living with dementia-family carer dyads. Dyads will be randomised 2:1 to receive the NIDUS-family intervention with usual care (n = 199) or usual care alone (n = 98). The intervention group will be offered, over 1 year, via 6-8 video call or telephone sessions (or face to face if COVID-19 restrictions allow in the recruitment period) in the initial 6 months, followed by telephone follow-ups every 1-2 months to support implementation, with a trained facilitator.

DISCUSSION

Increasing the time lived at home by people living with dementia is likely to benefit lives now and in the future. Our intervention, which we adapted to include remote delivery prior to trial commencement due to the COVID-19 pandemic, aims to address barriers to living as well and as independently as possible that distress people living with dementia, exacerbate family carer(s) stress, negatively affect relationships, lead to safety risks, and frequently precipitate avoidable moves to a care home.

TRIAL REGISTRATION

International Standard Randomised Controlled Trials Number ISRCTN11425138 . Registered on 7 October 2019.

Sustainable nurse-led care for people with dementia including mild cognitive impairment and their family in an ambulatory care setting: A scoping review

AIMS

This review aimed to determine the characteristics of a nurse-led intervention for people with dementia including mild cognitive impairment and their family in an ambulatory care setting.

BACKGROUND

Enhancing the role of nurses in a multidisciplinary team of ambulatory care follow-up after a diagnosis of dementia is thought to lead to successful dementia care.

DESIGN

This is a scoping review.

DATA SOURCES

MEDLINE, CINAHL, EMBASE, Cochrane, JBI, Japan Medical Abstracts Society, PsycINFO and Web of Science were searched on 14 March 2019.

REVIEW METHODS

This scoping review was conducted using the Joanna Briggs Institute methodology, followed the PRISMA-ScR checklist and considered studies that included interventions conducted by nurses and included outcomes regarding dementia symptoms or family care burden.

RESULTS

Eleven studies were included. Of these, all interventions were multifactorial and reported effective results. Educational interventions were most common, and the content of education included the characteristics of dementia and how to interact with patients with dementia. The roles of nurses included caregiver education, assessment, care plan creation for continuous monitoring and team building.

CONCLUSION

This scoping review suggested that effective nurse-led interventions in the ambulatory care of people with dementia are continuous patient and family supports, primarily caregiver education within multidisciplinary teams.

Components, impacts and costs of dementia home support: a research programme including the DESCANT RCT

Background

Over half of people with dementia live at home. We know little about what home support could be clinically effective or cost-effective in enabling them to live well.

Objectives

We aimed to (1) review evidence for components of home support, identify their presence in the literature and in services in England, and develop an appropriate economic model; (2) develop and test a practical memory support package in early-stage dementia, test the clinical effectiveness and cost-effectiveness of routine home support in later-stage dementia and design a toolkit based on this evidence; and (3) elicit the preferences of staff, carers and people with dementia for home support inputs and packages, and evaluate the cost-effectiveness of these approaches in early- and later-stage dementia.

Design

We undertook (1) an evidence synthesis, national surveys on the NHS and social care and an economic review; (2) a multicentre pragmatic randomised trial [Dementia Early Stage Cognitive Aids New Trial (DESCANT)] to estimate the clinical effectiveness and cost-effectiveness of providing memory aids and guidance to people with early-stage dementia (the DESCANT intervention), alongside process evaluation and qualitative analysis, an observational study of existing care packages in later-stage dementia along with qualitative analysis, and toolkit development to summarise this evidence; and (3) consultation with experts, staff and carers to explore the balance between informal and paid home support using case vignettes, discrete choice experiments to explore the preferences of people with dementia and carers between home support packages in early- and later-stage dementia, and cost–utility analysis building on trial and observational study.

Setting

The national surveys described Community Mental Health Teams, memory clinics and social care services across England. Recruitment to the trial was through memory services in nine NHS trusts in England and one health board in Wales. Recruitment to the observational study was through social services in 17 local authorities in England. Recruitment for the vignette and preference studies was through memory services, community centres and carers’ organisations.

Participants

People aged > 50 years with dementia within 1 year of first attendance at a memory clinic were eligible for the trial. People aged > 60 years with later-stage dementia within 3 months of a review of care needs were eligible for the observational study. We recruited staff, carers and people with dementia for the vignette and preference studies. All participants had to give written informed consent.

Main outcome measures

The trial and observational study used the Bristol Activities of Daily Living Scale as the primary outcome and also measured quality of life, capability, cognition, general psychological health and carers’ sense of competence.

Methods

Owing to the heterogeneity of interventions, methods and outcome measures, our evidence and economic reviews both used narrative synthesis. The main source of economic studies was the NHS Economic Evaluation Database. We analysed the trial and observational study by linear mixed models. We analysed the trial by ‘treatment allocated’ and used propensity scores to minimise confounding in the observational study.

Results

Our reviews and surveys identified several home support approaches of potential benefit. In early-stage dementia, the DESCANT trial had 468 randomised participants (234 intervention participants and 234 control participants), with 347 participants analysed. We found no significant effect at the primary end point of 6 months of the DESCANT intervention on any of several participant outcome measures. The primary outcome was the Bristol Activities of Daily Living Scale, for which scores range from 0 to 60, with higher scores showing greater dependence. After adjustment for differences at baseline, the mean difference was 0.38, slightly but not significantly favouring the comparator group receiving treatment as usual. The 95% confidence interval ran from –0.89 to 1.65 (p = 0.56). There was no evidence that more intensive care packages in later-stage dementia were more effective than basic care. However, formal home care appeared to help keep people at home. Staff recommended informal care that cost 88% of formal care, but for informal carers this ratio was only 62%. People with dementia preferred social and recreational activities, and carers preferred respite care and regular home care. The DESCANT intervention is probably not cost-effective in early-stage dementia, and intensive care packages are probably not cost-effective in later-stage dementia. From the perspective of the third sector, intermediate intensity packages were cheaper but less effective. Certain elements may be driving these results, notably reduced use of carers’ groups.

Limitations

Our chosen outcome measures may not reflect subtle outcomes valued by people with dementia.

Conclusions

Several approaches preferred by people with dementia and their carers have potential. However, memory aids aiming to affect daily living activities in early-stage dementia or intensive packages compared with basic care in later-stage dementia were not clinically effective or cost-effective.

Future work

Further work needs to identify what people with dementia and their carers prefer and develop more sensitive outcome measures.

Study registration

Current Controlled Trials ISRCTN12591717. The evidence synthesis is registered as PROSPERO CRD42014008890.

Funding

This project was funded by the National Institute for Health Research (NIHR) Programme Grants for Applied Research programme and will be published in full in Programme Grants for Applied Research; Vol. 9, No. 6. See the NIHR Journals Library website for further project information.

Integrating the Financing and Delivery of Medical and Supportive Services for People Living With Dementia

The number of people living with dementia (PLWD) is expected to grow considerably in the coming years. PLWD often have substantial medical and supportive service needs and face fragmentation of services across payers and across health and social service systems; recently, efforts have been made to achieve greater integration of care and financing. This article considers issues related to integrating long-term services and supports (LTSS), medical care, and financing for PLWD; reviews the policy context and key clinical and delivery system challenges to these efforts; and describes key lessons regarding integration learned from examples in the field. Recommendations are provided and include the following: (1) assess carefully whether integration of medical and LTSS is required to achieve the intended outcomes of an intervention or program targeted at PLWD; if integration is needed, select carefully the types of medical and LTSS to integrate and the mode of integration; (2) use measures that evaluate quality across LTSS settings in which PLWD receive care; (3) assess whether and how eligibility and payment policies pose barriers to PLWD from receiving services they need, and evaluate ways in which policies might be reformed to meet beneficiaries' needs; and (4) conduct research examining the potential of value-based payment efforts to improve the quality and efficiency of care received by PLWD, including their potential impact on out-of-pocket expenses and caregiving burden for PLWD and their families.

Discerning rural Appalachian stakeholder attitudes toward memory screening

OBJECTIVE

The aim of this descriptive study was to examine Appalachian stakeholder attitudes toward routine memory screening, and to compare and contrast results from a similar study conducted in an ethnically diverse rural Florida cohort. Determining perceptions about memory screening is essential prior to developing culturally relevant programs for increasing early dementia detection and management among rural underserved older adults at risk of cognitive impairment. Benefits of early detection include ruling out other causes of illness and treating accordingly, delaying onset of dementia symptoms through behavior management and medications, and improving long-term care planning (Dubois, Padovani, Scheltens, Rossi, & Dell'Agnello, 2016). These interventions can potentially help to maintain independence, decrease dementia care costs, and reduce family burdens (Frisoni, et al., 2017).

METHOD

Researchers applied a parallel mixed method design (Tashakkori & Newman, 2010) of semi-structured interviews, measurements of health literacy (REALM-SF) (Arozullah, et al., 2007), sociodemographics, and cognitive screening perceptions (PRISM-PC) (Boustani, et al., 2008), to examine beliefs and attitudes about memory screening among 22 FL and 21 WV rural stakeholders (residents, health providers, and administrators).

RESULTS

Findings included that > 90% participants across both cohorts were highly supportive of earlier dementia detection through routine screening regardless of sample characteristics. However, half of those interviewed were doubtful that provider care or assistance would be adequate for this terminal illness. Despite previous concerns of stigma associated with an Alzheimer's disease diagnosis, rural providers are encouraged to educate patients and community members regarding Alzheimer's disease and offer routine cognitive screening and follow-through.

Medical care needs for patients receiving home healthcare in Taiwan: Do gender and income matter?

Studies about medical care needs for home healthcare (HHC) previously focused on disease patterns but not gender and income differences. We used the Taiwan National Health Research Insurance Database from 1997 to 2013 to examine trends in medical care needs for patients who received HHC, and the gender and income gaps in medical care needs, which were represented by resource utilization groups (RUG). We aimed to clarify three questions: 1. Are women at a higher level of medical care needs for HHC than men, 2. Does income relate to medical care needs? 3. Is the interaction term (gender and income) related to the likelihood of medical care needs? Results showed that the highest level of medical care need in HHC was reducing whereas the basic levels of medical care need for HHC are climbing over time in Taiwan during 1998 and 2013. The percentages of women with income-dependent status in RUG1 to RUG4 are 26.43%, 26.24%, 30.68%, and 32.07%, respectively. Women were more likely to have higher medical care needs than men (RUG 3: odds ratio, OR = 1.17, 95% confidence interval, CI = 1.10-1.25; RUG4: OR = 1.13, 95% CI = 1.06-1.22) in multivariates regression test. Compared to the patients with the high-income status, patients with the income-dependent status were more likely to receive RUG3 (OR = 2.34, 95% CI = 1.77-3.09) and RUG4 (OR = 1.98, 95% CI = 1.44-2.71). The results are consistent with the perspectives of fundamental causes of disease and feminization of poverty theory, implying gender and income inequalities in medical care needs. Policymakers should increase public spending for delivering home-based integrated care resources, especially for women with lower income, to reduce the double burden of female poverty at the higher levels of medical care needs for HHC.

Effectiveness of Resilience Interventions on Psychosocial Outcomes for Persons With Neurocognitive Disorders: A Systematic Review and Meta-Analysis

Background: Neurocognitive disorders, such as mild cognitive impairment (MCI), dementia, and Alzheimer's disease, not only harm people's cognitive function but also lead to negative emotions, poor quality of life (QOL), and unsatisfactory level of well-being. Resilience can be defined as a dynamic and amendable process, which maintains or improves life satisfaction and quick recovery from own dilemma. However, no meta-analysis of randomized controlled trials (RCTs) has thus far examined the effectiveness of resilience interventions among persons with neurocognitive disorders, and the results of RCTs were inconsistent. This systematic review aimed to assess the effectiveness of resilience interventions on psychosocial outcomes among persons with neurocognitive disorders. Methods: Nine electronic Chinese and English databases (the Cochrane Library, PsycINFO, Web of Science, PubMed, Medline, Eric, JSTOR, CNKI, and WANGFANG) were searched through April 2021. Only RCTs were included, and the quality of the included studies was assessed by the Cochrane "Risk of Bias" tool. Meta-analysis was carried out on psychosocial outcomes, and heterogeneity was investigated by subgroup and sensitivity analysis. RevMan 5.4 was used for meta-analysis. Results: Fourteen RCT studies were identified, representing a total of 2,442 participants with neurocognitive disorders. The risk of bias was high or unclear for most included studies in the domains of allocation concealment, blinding participants, and interventionists. Meta-analysis showed that heterogeneity was low or moderate. There were significant differences in favor of resilience interventions compared with control on the outcome of QOL, using the Quality of Life-Alzheimer Disease scale (QOL-AD) [I ² = 36%, standardized mean difference (SMD) = 0.14, 95% CI (0.02, 0.26), p = 0.02], and no significant differences on depression, using the Cornell Scale for Depression in Dementia (CSDD) [I ² = 41%, SMD = -0.14, 95% CI (-0.34, 0.05), p = 0.16], and neuropsychiatric symptoms using the Neuropsychiatric Inventory Questionnaire (NPI-Q) [I ² = 62%, SMD = -0.10, 95% CI (-0.37, -0.16), p ≤ 0.46]. Conclusions: Resilience interventions had a significant benefit on QOL but no significant benefit on depression and neuropsychiatric behavioral symptoms. More evidence is needed to answer questions about how to implement resilience interventions and how to evaluate their effectiveness.

Free-Text Documentation of Dementia Symptoms in Home Healthcare: A Natural Language Processing Study

Background

Little is known about symptom documentation related to Alzheimer's disease and related dementias (ADRD) by home healthcare (HHC) clinicians.

Objective

This study: (1) developed a natural language processing (NLP) algorithm that identifies common neuropsychiatric symptoms of ADRD in HHC free-text clinical notes; (2) described symptom clusters and hospitalization or emergency department (ED) visit rates for patients with and without these symptoms.

Method

We examined a corpus of -2.6 million free-text notes for 112,237 HHC episodes among 89,459 patients admitted to a non-profit HHC agency for post-acute care with any diagnosis. We used NLP software (NimbleMiner) to construct indicators of six neuropsychiatric symptoms. Structured HHC assessment data were used to identify known ADRD diagnoses and construct measures of hospitalization/ED use during HHC.

Results

Neuropsychiatric symptoms were documented for 40% of episodes. Common clusters included impaired memory, anxiety and/or depressed mood. One in three episodes without an ADRD diagnosis had documented symptoms. Hospitalization/ED rates increased with one or more symptoms present.

Conclusion

HHC providers should examine episodes with neuropsychiatric symptoms but no ADRD diagnoses to determine whether ADRD diagnosis was missed or to recommend ADRD evaluation. NLP-generated symptom indicators can help to identify high-risk patients for targeted interventions.

A systematic review on implementation of person-centered care interventions for older people in out-of-hospital settings

THE PURPOSE

of this study was to explore the content and essential components of implemented person-centered care in the out-of-hospital context for older people (65+).

METHOD

A systematic review was conducted, searching for published research in electronic databases: PubMed, CINAHL, Scopus, PsycInfo, Web of Science and Embase between 2017 and 2019. Original studies with both qualitative and quantitative methods were included and assessed according to the quality assessment tools EPHPP and CASP. The review was limited to studies published in English, Swedish, Danish, Norwegian and Spanish.

RESULTS

In total, 63 original articles were included from 1772 hits. The results of the final synthesis revealed the following four interrelated themes, which are crucial for implementing person-centered care: (1) Knowing and confirming the patient as a whole person; (2) Co-creating a tailored personal health plan; (3) Inter-professional teamwork and collaboration with and for the older person and his/her relatives; and (4) Building a person-centered foundation.

CONCLUSION

Approaching an interpersonal and inter-professional teamwork and consultation with focus on preventive and health promoting actions is a crucial prerequisite to co-create optimal health care practice with and for older people and their relatives in their unique context.

Advance care planning in different settings for people with dementia: A systematic review and narrative synthesis

BACKGROUND

Advance care planning (ACP) is identified as being an important process for people with dementia. However, its efficacy for improving outcomes relevant for the individual, carers and the health system has yet to be established.

AIM

We conducted a systematic review with the aims of testing the efficacy of ACP for people with dementia and describing the settings and population in which it has been evaluated.

METHODS

A search was completed of electronic databases in August 2016. Articles were included if they described interventions aimed at increasing planning for future care of people with dementia, delivered to the person with dementia, their carers and/or health professionals.

RESULTS

Of 4,772 articles returned by searches, 30 met the inclusion criteria, testing interventions in nursing home (n= 16) community (n = 10) and acute care (n = 4) settings. Only 18 interventions directly involved the person with dementia, with the remainder focusing on surrogate decision-makers. In all settings, interventions were found effective in increasing ACP practice. In nursing homes, ACP was found to influence care and increase the concordance between end of life wishes and care provided. Interventions in the community were found to improve patient quality of life but were not shown to influence concordance.

CONCLUSION

Future research should focus on ways to involve people with dementia in decision-making through supported means.

LIVE@Home.Path-innovating the clinical pathway for home-dwelling people with dementia and their caregivers: study protocol for a mixed-method, stepped-wedge, randomized controlled trial

BACKGROUND

The global health challenge of dementia is exceptional in size, cost and impact. It is the only top ten cause of death that cannot be prevented, cured or substantially slowed, leaving disease management, caregiver support and service innovation as the main targets for reduction of disease burden. Institutionalization of persons with dementia is common in western countries, despite patients preferring to live longer at home, supported by caregivers. Such complex health challenges warrant multicomponent interventions thoroughly implemented in daily clinical practice. This article describes the rationale, development, feasibility testing and implementation process of the LIVE@Home.Path trial.

METHODS

The LIVE@Home.Path trial is a 2-year, multicenter, mixed-method, stepped-wedge randomized controlled trial, aiming to include 315 dyads of home-dwelling people with dementia and their caregivers, recruited from 3 municipalities in Norway. The stepped-wedge randomization implies that all dyads receive the intervention, but the timing is determined by randomization. The control group constitutes the dyads waiting for the intervention. The multicomponent intervention was developed in collaboration with user-representatives, researchers and stakeholders to meet the requirements from the national Dementia Plan 2020. During the 6-month intervention period, the participants will be allocated to a municipal coordinator, the core feature of the intervention, responsible for regular contact with the dyads to facilitate L: Learning, I: Innovation, V: Volunteering and E: Empowerment (LIVE). The primary outcome is resource utilization. This is measured by the Resource Utilization in Dementia (RUD) instrument and the Relative Stress Scale (RSS), reflecting that resource utilization is more than the actual time required for caring but also how burdensome the task is experienced by the caregiver.

DISCUSSION

We expect the implementation of LIVE to lead to a pathway for dementia treatment and care which is cost-effective, compared to treatment as usual, and will support high-quality independent living, at home.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT04043364. Registered on 15 March 2019.

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.

Clinical trial testing in-home multidisciplinary care management for older adults with cognitive vulnerability: Rationale and study design

Care management approaches are being widely tested in the Medicare-eligible population to manage chronic conditions, but few have focused on cognitive vulnerability as the pathway to optimizing independence in the community-dwelling older population. Cognitive vulnerability refers to living with dementia, depression, and/or a history of delirium. Many studies have shown that cognitive vulnerability is associated with poor health-related outcomes in community-dwelling older adults, raising the health policy importance of finding evidence-based approaches to improve outcomes for this target population. Moreover, very little is known about effects of care management approaches in the rapidly growing Medicare Advantage population. In response to these knowledge gaps, we are testing the efficacy of an in-home, nurse practitioner-led care management team for adults age ≥ 65 with cognitive vulnerability in a Medicare Advantage population. Older adults and family caregivers randomized either to this multidisciplinary care management team, or to a telephonic care management program routinely offered by our Medicare Advantage partner. The intervention period is 12 months and the primary outcome is any emergency department visit or hospitalization over the 12-month period. In this paper, we report on the rationale for testing a multidisciplinary care management intervention for this target population, and explain how a university-based research team collaborated with a Medicare Advantage insurer to conceptualize and implement the clinical trial. We also provide details on study design, and on components of the in-home and telephonic care management interventions. We conclude with a synopsis of recruitment progress along with selected baseline characteristics of the study cohort.

Quantifying the diagnostic pathway for patients with cognitive impairment: real-world data from Australia

OBJECTIVES

Rapid diagnosis of dementia is essential to ensure optimum patient care. This study used real-world data to quantify the dementia diagnostic pathway in Australia.

DESIGN

A real-world, cross-sectional survey of physicians and patients.

SETTING

Clinical practice.

PARTICIPANTS

Primary care or specialist physicians managing patients with cognitive impairment (CI).

MEASUREMENTS

Descriptive analyses focused on key events in the diagnostic pathway. Regression modeling compared the duration between first consultation and formal diagnosis with various factors.

RESULTS

Data for 600 patients were provided by 60 physicians. Mean time from initial symptoms to first consultation was 6.1 ± 4.4 months; 20% of patients had moderate or severe CI at first consultation. Mean time from first consultation to formal diagnosis was 4.0 ± 7.4 months (1.2 ± 3.6 months if not referred to a secondary physician, and 5.3 ± 8.3 months if referred). Time from first consultation to diagnosis was significantly associated with CI severity at first consultation; time was shorter with more severe CI. There was no association of disease severity and referral to a secondary physician; 69.5% of patients were referred, the majority (57.1%) to a geriatrician. The highest proportion of patients were diagnosed by geriatricians (47.4%). Some form of test or scale was used to aid diagnosis in 98.8% of patients.

CONCLUSIONS

A substantial number of Australians experience cognitive decline and behavioral changes some time before consulting a physician or being diagnosed with dementia. Increasing public awareness of the importance of early diagnosis is essential to improve the proportion of patients receiving comprehensive support prior to disease progression.