Effectiveness of dementia follow-up care by memory clinics or general practitioners: randomised controlled trial

Self-Assessment Instruments for Supporting Family Caregivers: An Integrative Review

Family caregivers take on a variety of tasks when caring for relatives in need of care. Depending on the situation and the intensity of care, they may experience multidimensional burdens, such as physical, psychological, social, or financial stress. The aim of the present study was to identify and appraise self-assessment instruments (SAIs) that capture the dimensions of family caregivers' burdens and that support family caregivers in easily identifying their caregiving role, activities, burden, and needs. We performed an integrative review with a broad-based strategy. A literature search was conducted on PubMed, Google Scholar, Google, and mobile app stores in March 2020. After screening the records based on the eligibility criteria, we appraised the tools we found for their usefulness for family care and nursing practice. From a total of 2654 hits, 45 suitable SAIs from 274 records were identified and analyzed in this way. Finally, nine SAIs were identified and analyzed in detail based on further criteria such as their psychometric properties, advantages, and disadvantages. They are presented in multi-page vignettes with additional information for healthcare professionals. These SAIs have proven useful in assessing the dimensions of caregiver burden and can be recommended for application in family care and nursing practice.

Rural general practitioner confidence in diagnosing and managing dementia: A two-stage, mixed methods study of dementia-specific training

INTRODUCTION

Dementias a prevalent chronic healthcare condition affecting 46 million people worldwide and projected to grow in the coming years. Australians living in rural and regional areas often lack access to specialist dementia care, despite greater prevalence relative to metropolitan areas.

OBJECTIVE

This study aimed to explore general practitioners (GP) understanding, confidence and attitudes towards dementia management in the rural context, and design and pilot a dementia-specific training program.

DESIGN

A two-stage, mixed methods design, using qualitative and quantitative methods. Sixteen regional GPs from across Victoria participated in scoping semi-structured interviews. Fourteen separate GPs in the St Anthony Family Medical Practice group in the regional Loddon-Mallee area of Victoria completed the pilot training intervention. Pre- and post-training surveys (n = 10), as well as post-training interviews (n = 10), assessed attitude and knowledge changes.

FINDINGS

Analysis of semi-structured scoping interviews indicated three themes regarding experience of dementia management, including: (1) attitudes to and experiences of dementia; (2) supporting people living with dementia; and (3) knowledge, education and training of dementia. The pilot dementia-specific training was found to improve attitudes (agreement across 24 best-practice indicators improved from 30% to 79%), knowledge (median increase of 2.5/10) and confidence in managing dementia and disclosing dementia diagnoses (median increase 3/10 and 2.75/10, respectively).

DISCUSSION

General practitioners in this study lacked initial confidence in detecting and managing dementia in a rural primary care setting. A targeted training program showed improvements in these areas.

CONCLUSION

Accessible, locally delivered, dementia education has the potential to improve confidence in early detection and management of people with dementia and thereby may address gaps in access to care for people living with dementia in rural settings.

Characteristics of Changes in Caregiver Burden during Follow-up at a Memory Clinic: A Retrospective Cohort Study

Background

Because dementia is a long-term condition, the appropriate involvement of health-care professionals is considered important. However, little is known about the factors associated with changes in family caregiver burden.

Objective

To clarify changes in family caregiver burden and associated factors during follow-up at a memory clinic.

Methods

A retrospective cohort study was conducted, enrolling 495 pairs of patients with dementia or mild cognitive impairment and their family caregivers. A total of 120 pairs completed the second evaluation. The caregiver burden was assessed using the Zarit Burden Interview (ZBI). Data at the initial visit and after an average follow-up of about 2 years were compared and analyzed.

Results

At initial visit, the patients' mean age, Mini-Mental State Examination (MMSE) and ZBI scores were 78.6±5.6 years, 23.3±3.5, and 22.6±16.7, respectively. At follow-up, MMSE scores decreased (21.4±4.5, p < 0.001), but ZBI scores remained similar (22.5±13.6). When the difference in ZBI scores between the two time points was defined as ΔZBI, and the related factors were analyzed by multiple regression analysis, ZBI scores at the initial visit, start of psychotropic drug, and decrease of neuropsychiatric symptoms were identified as significant factors (p < 0.001, p = 0.003, p < 0.001, respectively). A significant negative correlation was found between ZBI scores at the initial visit and ΔZBI (r = -0.588, p < 0.001).

Conclusions

These findings suggest the importance of assessing changes in the burden experienced by family caregivers during the disease follow-up.

Application of a Novel Endpoint Staging Framework: Proof of Concept in the AMBAR Study

Background

A theoretical endpoint staging framework was previously developed and published, aligning outcomes (i.e., memory) to the stage of Alzheimer's disease (AD) in which a given outcome is most relevant (i.e., has the greatest risk of degradation). The framework guides the selection of endpoints measuring outcomes relevant within a target AD population. Here, a proof of concept is presented via post-hoc analyses of the Alzheimer Management by Albumin Replacement (AMBAR) Phase 2b clinical trial in patients with AD (NCT01561053, 2012).

Objective

To evaluate whether aligning endpoints measuring cognition, function, and quality of life to hypothesized 'target' stages of AD yields magnitudes of treatment efficacy greater than those reported in the AMBAR full analysis set (FAS).

Methods

Three endpoints were tested: ADAS-Cog 12, ADCS-ADL, and QoL-AD. The magnitude of treatment efficacy was hypothesized to be maximized in the target stages of mild, mild-to-moderate, and very mild AD, respectively, compared to the full analysis set (FAS) and non-target stages.

Results

For ADAS-Cog 12, the magnitude of treatment efficacy was largest in the non-target stage (-4.0, p = 0.0760) compared to target stage and FAS. For ADCS-ADL and QoL-AD, the magnitude of treatment efficacy was largest in the target stage (14.2, p = 0.0003; 2.4, p < 0.0001, respectively) compared to non-target stage and FAS.

Conclusions

Findings indicated that evaluating endpoints in the most relevant AD stage can increase the magnitude of the observed treatment efficacy. Evidence provides preliminary proof of concept for the endpoint staging framework.

Effects of DementiaNet's Community Care Network Approach on Admission Rates and Healthcare Costs: A Longitudinal Cohort Analysis

BACKGROUND

People with dementia are increasingly living at home, relying on primary care providers for most healthcare needs. Suboptimal collaboration and communication between providers could cause inefficiencies and worse patient outcomes. Innovative strategies are needed to address this growing disease burden and rising healthcare costs. The DementiaNet programme, a community care network approach targeted at patients with dementia in the Netherlands, has been shown to improve patient's quality of care. However, very little is known about the impact of DementiaNet on admission risks and healthcare costs. This study addresses this knowledge gap.

METHODS

A longitudinal cohort analysis was performed, using medical and long-term care claims data from 38 525 patients between 2015-2019. The primary outcomes were risk of hospital admission and annual total healthcare costs. Mixed-model regression analyses were used to identify changes in outcomes.

RESULTS

Patients who received care from a DementiaNet community care network showed a general trend in lower risk of admission for all types of admissions studied (ie, hospital, emergency ward, intensive care, crisis, and nursing home). Also, the intervention group showed a significant reduction of 12% in nursing days (relative risk [RR] 0.88; 95% CI: 0.77- 0.96). No significant differences were found for total healthcare costs. However, we found effects in two sub-elements of total healthcare costs, being a decrease of 19.7% (95% CI: 7.7%-30.2%) in annual hospital costs and an increase of 10.2% (95% CI: 2.3%-18.6%) in annual primary care costs.

CONCLUSION

Our study indicates that DementiaNet's community care network approach may reduce admission risks for patients with dementia over a long-term period of five years. This is accompanied by a decrease in nursing days and savings in hospital care that exceed increased primary care costs. This improvement in integrated dementia care supports wider scale implementation and evaluation of these networks.

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.

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.

Identifying Primary Care Models of Dementia Care that Improve Quality of Life for People Living with Dementia and their Care Partners: An Environmental Scan

Dementia is a growing concern in Canada, affecting peoples' health and raising the cost of care. Between June and October 2019, we conducted an environmental scan to identify primary care models, strategies, and resources for dementia care from 11 pre-selected countries and assess their impact on quality-of-life measures. Search strategies included a rapid scoping review, grey literature search, and discussions with stakeholders. Eighteen primary care-based models of dementia care were identified. Common factors include team-based care, centralized care/case coordination, individual treatment plans, a stepped-care approach, and support for care partners. Five provinces had released a dementia strategy. Evidence of positive outcomes supported primary care-based models for dementia care, although only one model demonstrated evidence of impact on quality of life. Although these findings are encouraging, further research is needed to identify primary care-based models of dementia care that demonstrably improve quality of life for people living with dementia and their care partners.

A new model for general practice-led, regional, community-based, memory clinics

Background

Dementia is a major international health issue with high impact on the patient, relatives, and broader society. Routine screening for dementia is limited, despite known benefit of early detection and intervention on quality of care and patient outcomes. Screening is particularly limited in rural and regional areas, despite high burden and projected growth of dementia in these populations. The current study aimed to implement a new general practitioner (GP) led, multidisciplinary, model of care providing dementia detection and referral pathway to a community-based specialist clinic across six regional general practices.

Methods

Cross-sectional analysis of dementia screening and referral characteristics in the St Anthony Family Medical Practices group based in the regional area of Loddon-Mallee, Victoria. Data were collected on demographics and relevant medical history. Cognitive state was assessed using the Mini-Mental State Examination (MMSE), GP Assessment of Cognition (GPCog), and Geriatric Depression Scale (GDS). Referrals and referral outcomes were recorded for geriatrician, psycho-geriatrician, or both.

Results

Eight hundred and eighteenth patients over 65 years were screened, accounting for approximately 24.2% of 65 and over presentations for the practice network. Of those screened, 68.9% were indicated for referral and 30.3% of these were successfully referred. Of the indicated patients who received referrals, 34.2% declined. Many who declined referral had intermediate scores on the cognitive assessments utilized.

Conclusion

Standardised models of care, integrated within community services, are necessary to improve access to early detection, referral and quality management of dementia. The St Anthony Memory Service model will be invaluable in informing future service development, and in particular the development of services for people living with dementia in rural and regional communities.

Evaluation of a community-based memory clinic in collaboration with local hospitals to support patients with memory decline

Objective

This study evaluates the role of a specialised and multidisciplinary healthcare team, including a pharmacist, in providing medication management for patients with mild cognitive impairment (MCI) and dementia, in a memory clinic.

Methods

The study analysed the dataset of 102 patients of a geriatric and memory clinic in a rural area of Ontario, Canada. The case histories of the patients were reviewed a week before the clinic day and a pharmacist performed medication reconciliations. During the clinic day, cognitive tests were conducted and outcomes were discussed with the team, to create a care plan and schedule a follow-up within 3, 6 or 12 months.

Results

Most patients had an average of 5 prescriptions and 2 non-prescription medications deprescribed, and 57% of patients were started on memory-related medications. A total of 712 medications (p-value 0.001) were deprescribed, with 510 prescriptions and 202 non-prescription items. Out of the 712 deprescribed drugs, 374 were discontinued with no therapeutic substitutions, 202 were reduced in dosage and 136 were switched to a safer alternative. A total of 43 patients showed improved Activities of Daily Living (ADL) performance after 3 and 6 months and 68 patients showed improvement after 12 months.

Conclusion

This study highlights the importance of a multidisciplinary approach in addressing drug-therapy problems, medication optimisation, and deprescription in patients with dementia. The presence of a pharmacist in the multidisciplinary team enables impactful medication optimisation and leads to improved patient outcomes. This demonstrates the value of specialised expertise in medication management for patients with dementia.

Short Term Economic Evaluation of the Digital Platform "Support, Monitoring and Reminder Technology for Mild Dementia" (SMART4MD) for People with Mild Cognitive Impairment and their Informal Caregivers

BACKGROUND

A randomized controlled trial of the SMART4MD tablet application was conducted for persons with mild cognitive impairment (PwMCI) and their informal caregivers to improve or maintain quality of life.

OBJECTIVE

The objective was to conduct economic evaluation of SMART4MD compared to standard care in Sweden from a healthcare provider perspective based on a 6-month follow-up period.

METHODS

Three hundred forty-five dyads were enrolled: 173 dyads in the intervention group and 172 in standard care. The primary outcome measures for PwMCI and informal caregivers were quality-adjusted life years (QALY). The results are presented as incremental cost-effectiveness ratios, and confidence intervals are calculated using non-parametric bootstrap procedure.

RESULTS

For PwMCI, the mean difference in total costs between intervention and standard care was € 12 (95% CI: -2090 to 2115) (US$ = € 1.19) and the mean QALY change was -0.004 (95% CI: -0.009 to 0.002). For informal caregivers, the cost difference was - € 539 (95% CI: -2624 to 1545) and 0.003 (95% CI: -0.002 to 0.008) for QALY. The difference in cost and QALY for PwMCI and informal caregivers combined was -€ 527 (95% CI: -3621 to 2568) and -0.001 (95% CI: -0.008 to 0.006). Although generally insignificant differences, this indicates that SMART4MD, compared to standard care was: 1) more costly and less effective for PwMCI, 2) less costly and more effective for informal caregivers, and 3) less costly and less effective for PwMCI and informal caregivers combined.

CONCLUSION

The cost-effectiveness of SMART4MD over 6 months is inconclusive, although the intervention might be more beneficial for informal caregivers than PwMCI.

Evaluating a Memory Clinic Using the RE-AIM Model. The Experience of the "Memory and Neuropsychiatry Clinic" in Hospital Del Salvador, Chile

The development of healthcare services for dementia is key to improving access to care and post-diagnostic support for people living with dementia. Memory Units have emerged as a new healthcare service composed of multidisciplinary teams with the goal of improving diagnosis and/or management of dementia patients. The main objective of this study was to describe and evaluate the Reach and Effectiveness of a Memory Unit in a public hospital in Chile, using the RE-AIM model, a multi-component model that allows for the evaluation of the implementation of ongoing healthcare programs. Regarding “R” (Reach): from March 2018 up to June 2019, a total of 510 patients were referred and assessed. Most patients came from primary care (51.9%) and from outpatient services at the Hospital Salvador (39.2%), particularly from the Neurology (63.3%) and Psychiatry (16.0%) departments. We estimated that our Memory Unit assessed 5.39% of all of the dementia patients living in the area of referral. With respect to “E” (Effectiveness): 419 patients are still being followed up at the Memory Unit. Ninety-one patients (18%) were discharged. Of these, 55 (66%) were referred to primary healthcare, 28 (31%) to other outpatient services, 9 (10%) to a specialized mental healthcare center, and 9 (10%) to a daycare center. Due to the short period of time that the Memory Unit has been operating, no other RE-AIM dimensions could be evaluated at this juncture. To our knowledge, this is the first implementation study of a Memory Unit in Latin America, and the first using the RE-AIM model. Although cultural differences worldwide might play a role in the lack of international guidelines, the publication of the experience of the first year of this unit in Chile could inform new countries about this process. Ongoing challenges include continuing to collect data to complement the RE-AIM evaluation and developing a protocol that can be adopted elsewhere in Chile and Latin America. Further studies are needed to assess the benefits of a Memory Unit in comparison to regular care and to develop a model that assures continuity and coordination of care for people with dementia.

Characteristics and Real-Life Outcomes of Dementia and Cognitive Impairment at a Geriatric Clinic

BACKGROUND

Various patterns of dementia care have been developed in different settings, depending on the availability of healthcare resources and facilities. The purpose of this study was to examine the epidemiology and characteristics of dementia care at a geriatric clinic, a field that has been subject to little prior evaluation.

METHODS

A retrospective chart review was undertaken of cohort patients with cognitive impairment who had received a diagnosis and were still on active follow-up at a geriatric clinic. A total of 892 patients were included. In addition, 203 geriatric patients with no cognitive impairment who attended the clinic during the study period were sampled as a control.

RESULTS

The main diagnoses of dementia were Alzheimer's disease (AD) (40.1%), vascular dementia (16.9%), unspecified dementia (16.3%), mixed dementia (9.0%), AD with cerebrovascular disease (8.7%), and Parkinson's disease dementia (6.1%). Atypical dementia was presented in 3.0% of cases. There were 178 patients with mild cognitive impairment, 20 with vascular cognitive impairment, and 18 with subjective cognitive decline. Other comorbidities were found in 97% of the subjects. Patients with cognitive impairment had a higher total number of other geriatric syndromes and higher percentages for delirium, falls, immobility, loss of appetite, and incontinence. Potentially reversible causes of dementia were found in 11.3% of the cases. Acetylcholinesterase inhibitors were administered to 61%, whereas 23.5% received an NMDA receptor antagonist. The need for a change in the antidementia medication was identified for 10.7% of the subjects; the major cause was adverse drug side effects. Nonpharmacological therapy only was administered to 52.4% of the people with dementia who had behavioral and psychological symptoms.

CONCLUSIONS

Mixed brain pathologies, comorbidities, and the coexistence of other geriatric syndromes are common at geriatric clinics. Holistic, integrated, and continuous care are needed to improve the outcomes of patients with more complicated comorbidities.

Comparative efficacy of interventions for reducing symptoms of depression in people with dementia: systematic review and network meta-analysis

OBJECTIVE

To describe the comparative efficacy of drug and non-drug interventions for reducing symptoms of depression in people with dementia who experience depression as a neuropsychiatric symptom of dementia or have a diagnosis of a major depressive disorder.

DESIGN

Systematic review and meta-analysis.

DATA SOURCES

Medline, Embase, the Cochrane Library, CINAHL, PsycINFO, and grey literature between inception and 15 October 2020.

ELIGIBILITY CRITERIA FOR STUDY SELECTION

Randomised trials comparing drug or non-drug interventions with usual care or any other intervention targeting symptoms of depression in people with dementia.

MAIN OUTCOME MEASURES

Pairs of reviewers screened studies, abstracted aggregate level data, and appraised risk of bias with the Cochrane risk of bias tool, which facilitated the derivation of standardised mean differences and back transformed mean differences (on the Cornell scale for depression in dementia) from bayesian random effects network meta-analyses and pairwise meta-analyses.

RESULTS

Of 22 138 citations screened, 256 studies (28 483 people with dementia) were included. Missing data posed the greatest risk to review findings. In the network meta-analysis of studies including people with dementia without a diagnosis of a major depressive disorder who were experiencing symptoms of depression (213 studies; 25 177 people with dementia; between study variance 0.23), seven interventions were associated with a greater reduction in symptoms of depression compared with usual care: cognitive stimulation (mean difference -2.93, 95% credible interval -4.35 to -1.52), cognitive stimulation combined with a cholinesterase inhibitor (-11.39, -18.38 to -3.93), massage and touch therapy (-9.03, -12.28 to -5.88), multidisciplinary care (-1.98, -3.80 to -0.16), occupational therapy (-2.59, -4.70 to -0.40), exercise combined with social interaction and cognitive stimulation (-12.37, -19.01 to -5.36), and reminiscence therapy (-2.30, -3.68 to -0.93). Except for massage and touch therapy, cognitive stimulation combined with a cholinesterase inhibitor, and cognitive stimulation combined with exercise and social interaction, which were more efficacious than some drug interventions, no statistically significant difference was found in the comparative efficacy of drug and non-drug interventions for reducing symptoms of depression in people with dementia without a diagnosis of a major depressive disorder. Clinical and methodological heterogeneity precluded network meta-analysis of studies comparing the efficacy of interventions specifically for reducing symptoms of depression in people with dementia and a major depressive disorder (22 studies; 1829 patients).

CONCLUSIONS

In this systematic review, non-drug interventions were found to be more efficacious than drug interventions for reducing symptoms of depression in people with dementia without a major depressive disorder.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42017050130.

Obtaining EQ-5D-5L utilities from the disease specific quality of life Alzheimer's disease scale: development and results from a mapping study

PURPOSE

The Quality of Life Alzheimer's Disease Scale (QoL-AD) is commonly used to assess disease specific health-related quality of life (HRQoL) as rated by patients and their carers. For cost-effectiveness analyses, utilities based on the EQ-5D are often required. We report a new mapping algorithm to obtain EQ-5D indices when only QoL-AD data are available.

METHODS

Different statistical models to estimate utility directly, or responses to individual EQ-5D questions (response mapping) from QoL-AD, were trialled for patient-rated and proxy-rated questionnaires. Model performance was assessed by root mean square error and mean absolute error.

RESULTS

The response model using multinomial regression including age and sex, performed best in both the estimation dataset and an independent dataset.

CONCLUSIONS

The recommended mapping algorithm allows researchers for the first time to estimate EQ-5D values from QoL-AD data, enabling cost-utility analyses using datasets where the QoL-AD but no utility measures were collected.

Randomized crossover trial of a modified ketogenic diet in Alzheimer's disease

BACKGROUND

Brain energy metabolism is impaired in Alzheimer's disease (AD), which may be mitigated by a ketogenic diet. We conducted a randomized crossover trial to determine whether a 12-week modified ketogenic diet improved cognition, daily function, or quality of life in a hospital clinic of AD patients.

METHODS

We randomly assigned patients with clinically confirmed diagnoses of AD to a modified ketogenic diet or usual diet supplemented with low-fat healthy-eating guidelines and enrolled them in a single-phase, assessor-blinded, two-period crossover trial (two 12-week treatment periods, separated by a 10-week washout period). Primary outcomes were mean within-individual changes in the Addenbrookes Cognitive Examination - III (ACE-III) scale, AD Cooperative Study - Activities of Daily Living (ADCS-ADL) inventory, and Quality of Life in AD (QOL-AD) questionnaire over 12 weeks. Secondary outcomes considered changes in cardiovascular risk factors and adverse effects.

RESULTS

We randomized 26 patients, of whom 21 (81%) completed the ketogenic diet; only one withdrawal was attributed to the ketogenic diet. While on the ketogenic diet, patients achieved sustained physiological ketosis (12-week mean beta-hydroxybutyrate level: 0.95 ± 0.34 mmol/L). Compared with usual diet, patients on the ketogenic diet increased their mean within-individual ADCS-ADL (+ 3.13 ± 5.01 points, P = 0.0067) and QOL-AD (+ 3.37 ± 6.86 points, P = 0.023) scores; the ACE-III also increased, but not significantly (+ 2.12 ± 8.70 points, P = 0.24). Changes in cardiovascular risk factors were mostly favourable, and adverse effects were mild.

CONCLUSIONS

This is the first randomized trial to investigate the impact of a ketogenic diet in patients with uniform diagnoses of AD. High rates of retention, adherence, and safety appear to be achievable in applying a 12-week modified ketogenic diet to AD patients. Compared with a usual diet supplemented with low-fat healthy-eating guidelines, patients on the ketogenic diet improved in daily function and quality of life, two factors of great importance to people living with dementia.

TRIAL REGISTRATION

This trial is registered on the Australia New Zealand Clinical Trials Registry, number ACTRN12618001450202 . The trial was registered on August 28, 2018.

Organisational aspects and assessment practices of Australian memory clinics: an Australian Dementia Network (ADNeT) Survey

OBJECTIVES

Conducting a national survey of clinicians and administrators from specialised dementia assessment services (memory clinics) in Australia to examine their current organisational aspects and assessment procedures and inform clinical tool harmonisation as part of the Australian Dementia Network-memory clinics project.

DESIGN

A cross-sectional survey.

SETTING

Public and private memory clinics across Australia.

PARTICIPANTS

150 individual clinicians completed the survey between May and August 2019. Responses could be given anonymously. Most clinics were publicly funded services (83.2%) and in metropolitan regions (70.9%).

OUTCOME MEASURES

Descriptive data on organisational aspects of memory clinics (eg, waiting times, staffing); the three most commonly used assessment tools per assessment type (eg, self-report) and cognitive domain (eg, attention).

RESULTS

Since the last national survey in 2009, the number of memory clinics across Australia has increased substantially but considerable variability has remained with respect to funding structure, staffing and assessment procedures. The average clinic employed 2.4 effective full-time staff (range 0.14-14.0). The reported waiting time for an initial assessment ranged from 1 week to 12 months with a median of 7 weeks. While most clinics (97%) offered follow-up assessments for their clients, only a few (31%) offered any form of cognitive intervention. We identified over 100 different cognitive assessment tools that were used at least 'sometimes', with widespread use of well-established core screening tools and a subset of common neuropsychological tests.

CONCLUSION

This paper presents a current snapshot of Australian memory clinics, showing considerable heterogeneity with some common core elements. These results will inform the development of national memory clinic guidelines. Furthermore, our data make a valuable contribution to the international comparison of clinical practice standards and advocate for greater harmonisation to ensure high-quality dementia care.

Le Plan Alzheimer québécois, un plan basé sur les soins primaires

Many countries have answered the call from the World Health Organization, and developed or implemented Alzheimer Plans. Some plans anchored the majority of the care for persons living with dementia in specialized care settings, while others anchored it in primary care. In this article we present the Quebec Alzheimer Plan, which is being implemented in Family Medicine Groups, primary care interdisciplinary clinics, across the Canadian province. The Quebec Alzheimer Plan aims to enable primary healthcare teams of physicians, nurses and/or social workers to provide access to personalized, coordinated assessment and treatment services for people living with dementia and their caregivers. The Quebec Alzheimer Plan enables and empowers primary care clinicians to detect, diagnose, treat and follow-up the vast majority of patients/caregivers. A major strength of the Quebec Alzheimer Plan strategy is the embedded evaluation to inform implementation and its flexibility to allow local adaptations. We are discussing that it is feasible and advantageous to anchor dementia care in an interprofessional primary care setting.

Effectiveness of different post-diagnostic dementia care models delivered by primary care: a systematic review

BACKGROUND

Global policy recommendations suggest a task-shifted model of post-diagnostic dementia care, moving towards primary and community-based care. It is unclear how this may best be delivered.

AIM

To assess the effectiveness and cost-effectiveness of primary care-based models of post-diagnostic dementia care.

DESIGN AND SETTING

A systematic review of trials and economic evaluations of post-diagnostic dementia care interventions where primary care was substantially involved in care plan decision making.

METHOD

Searches were undertaken of MEDLINE, PsychINFO, EMBASE, Web of Science, and CINAHL (from inception to March 2019). Two authors independently critically appraised studies and inductively classified interventions into types of care models. Random effects meta-analysis or narrative synthesis was conducted for each model where appropriate.

RESULTS

From 4506 unique references and 357 full texts, 23 papers were included from 10 trials of nine interventions, delivered in four countries. Four types of care models were identified. Primary care provider (PCP)-led care (n = 1) led to better caregiver mental health and reduced hospital and memory clinic costs compared with memory clinics. PCP-led care with specialist consulting support (n = 2) did not have additional effects on clinical outcomes or costs over usual primary care. PCP-case management partnership models (n = 6) offered the most promise, with impact on neuropsychiatric symptoms, caregiver burden, distress and mastery, and healthcare costs. Integrated primary care memory clinics (n = 1) had limited evidence for improved quality of life and cost-effectiveness compared with memory clinics.

CONCLUSION

Partnership models may impact on some clinical outcomes and healthcare costs. More rigorous evaluation of promising primary care-led care models is needed.

Validation of a Questionnaire for Family Physicians: Knowledge, Attitude, Practice on Dementia Care

Our study objective was to develop and validate a questionnaire assessing the knowledge, attitude, and practice (KAP) of family physicians regarding dementia care and dementia strategies in Canada. Using a multistage process with a panel of experts, we developed and distributed an 83-item questionnaire to 542 eligible family physicians in 42 interdisciplinary primary care teams participating in the Quebec Alzheimer Plan implementation. Altogether, 369 physicians (68%) returned questionnaires. Median item-specific non-response rate was 0.8 per cent (0.3%-8.1%). Exploratory factor analyses and scale correlation supported the questionnaire validity. The final questionnaire contained five factors and 31 items. The KAP questionnaire has proved to be a reliable instrument for assessing the KAP of family physicians regarding dementia care and dementia strategies. This questionnaire provides researchers, clinicians, managers, and decision-makers with a tool to assess an intervention, a program, or a policy change implemented in primary health care for patients with dementia.

Screening for Cognitive Impairment in Older Adults: Updated Evidence Report and Systematic Review for the US Preventive Services Task Force

IMPORTANCE

Early identification of cognitive impairment may improve patient and caregiver health outcomes.

OBJECTIVE

To systematically review the test accuracy of cognitive screening instruments and benefits and harms of interventions to treat cognitive impairment in older adults (≥65 years) to inform the US Preventive Services Task Force.

DATA SOURCES

MEDLINE, PubMed, PsycINFO, and Cochrane Central Register of Controlled Trials through January 2019, with literature surveillance through November 22, 2019.

STUDY SELECTION

Fair- to good-quality English-language studies of cognitive impairment screening instruments, and pharmacologic and nonpharmacologic treatments aimed at persons with mild cognitive impairment (MCI), mild to moderate dementia, or their caregivers.

DATA EXTRACTION AND SYNTHESIS

Independent critical appraisal and data abstraction; random-effects meta-analyses and qualitative synthesis.

MAIN OUTCOMES AND MEASURES

Sensitivity, specificity; patient, caregiver, and clinician decision-making; patient function, quality of life, and neuropsychiatric symptoms; caregiver burden and well-being.

RESULTS

The review included 287 studies with more than 280 000 older adults. One randomized clinical trial (RCT) (n = 4005) examined the direct effect of screening for cognitive impairment on patient outcomes, including potential harms, finding no significant differences in health-related quality of life at 12 months (effect size, 0.009 [95% CI, -0.063 to 0.080]). Fifty-nine studies (n = 38 531) addressed the accuracy of 49 screening instruments to detect cognitive impairment. The Mini-Mental State Examination was the most-studied instrument, with a pooled sensitivity of 0.89 (95% CI, 0.85 to 0.92) and specificity of 0.89 (95% CI, 0.85 to 0.93) to detect dementia using a cutoff of 23 or less or 24 or less (15 studies, n = 12 796). Two hundred twenty-four RCTs and 3 observational studies including more than 240 000 patients or caregivers addressed the treatment of MCI or mild to moderate dementia. None of the treatment trials were linked with a screening program; in all cases, participants were persons with known cognitive impairment. Medications approved to treat Alzheimer disease (donepezil, galantamine, rivastigmine, and memantine) improved scores on the ADAS-Cog 11 by 1 to 2.5 points over 3 months to 3 years. Psychoeducation interventions for caregivers resulted in a small benefit for caregiver burden (standardized mean difference, -0.24 [95% CI, -0.36 to -0.13) over 3 to 12 months. Intervention benefits were small and of uncertain clinical importance.

CONCLUSIONS AND RELEVANCE

Screening instruments can adequately detect cognitive impairment. There is no empirical evidence, however, that screening for cognitive impairment improves patient or caregiver outcomes or causes harm. It remains unclear whether interventions for patients or caregivers provide clinically important benefits for older adults with earlier detected cognitive impairment or their caregivers.

Educating Dutch General Practitioners in Dementia Advance Care Planning: A Cluster Randomized Controlled Trial

OBJECTIVES

Advance care planning (ACP) is seldom initiated with people with dementia (PWD) and mainly focuses on medical end-of-life decisions. We studied the effects of an educational intervention for general practitioners (GPs) aimed at initiating and optimizing ACP, with a focus on discussing medical and nonmedical preferences of future care.

DESIGN

A single-blinded cluster randomized controlled trial.

SETTING AND PARTICIPANTS

In 2016, 38 Dutch GPs (all from different practices) completed the study. They recruited 140 PWD, aged ≥65 years at any stage and with any type of dementia, from their practice.

METHODS

Intervention group GPs were trained in ACP, including shared decision-making and role-playing exercises. Control group GPs provided usual care. The primary outcome was ACP initiation: the proportion of PWD that had at least 1 ACP conversation documented in their medical file. Key secondary outcomes were the number of medical (ie, resuscitation, hospital admission) and nonmedical (ie, activities, social contacts) preferences discussed. At the 6-month follow-up, subjects' medical records were analyzed using random effect logistics and linear models with correction for GP clustering.

RESULTS

38 GP clusters (19 intervention; 19 control) included 140 PWD (intervention 73; control 67). Four PWD (2.9%) dropped out on the primary and key secondary outcomes. After 6 months, intervention group GPs initiated ACP with 35 PWD (49.3%), and control group GPs initiated ACP with 9 PWD (13.9%) [odds ratio (OR) 1.99; P = .002]. Intervention group GPs discussed 0.8 more medical [95% confidence interval (CI) 0.3, 1.3; P = .003] and 1.5 more nonmedical (95% CI 0.8, 2.3; P < .001) preferences per person with dementia than control group GPs.

CONCLUSIONS AND IMPLICATIONS

Our educational intervention increased ACP initiation, and the number of nonmedical and medical preferences discussed. This intervention has the potential to better align future care of PWD with their preferences but because of the short follow-up, the GPs' long-term adoption remains unknown.

Can non-pharmacological interventions reduce hospital admissions in people with dementia? A systematic review

Background

People with dementia who are admitted to hospital have worse outcomes than those without dementia. Identifying interventions that could reduce the risk of hospitalisation in people with dementia has the potential to positively impact on lives of people with dementia. This review aimed to investigate whether there are non-pharmacological interventions that successfully reduce hospitalisation risk, length of stay and mortality in people with dementia.

Methods

7 electronic databases and trial registries were searched from inception to October 2018. We included randomised controlled trials that evaluated non-pharmacological interventions in out of hospital settings and targeted people with any type of dementia. All stages of the review process were performed by two reviewers. Risk of bias was assessed using the Cochrane Risk of Bias tool. We grouped studies based on intervention: care management, counselling/self-help, enhanced GP services or memory clinics, and physiotherapy or occupational therapy. Data were pooled within intervention categories using random effects meta-analysis.

Results

There was no evidence that any of the intervention categories were associated with reduced hospital admission or mortality. There was very weak evidence to suggest that care management interventions (mean difference, MD, -0.16, 95% CI -0.32, 0.01), physiotherapy/occupational therapy (MD -0.16, 95% CI -0.36, 0.03) and enhanced GP/memory clinics (MD -0.14, 95% CI -0.31, 0.03) were associated with small reductions in hospital stay. There was no evidence for an effect of counselling/self-help interventions on length of hospital stay.

Conclusions

Current evidence from randomised trials suggests no clear benefit or harm associated with any of interventions on risks of hospitalisation, duration of hospitalisation or death. Further research with the primary aim to reduce hospitalisation in people with dementia is required.

Impact of health service interventions on acute hospital use in community-dwelling persons with dementia: A systematic literature review and meta-analysis

Background

Persons with dementia have twice the acute hospital use as older persons without dementia. In addition to straining overburdened healthcare systems, acute hospital use impacts patient and caregiver quality of life and is associated with increased risk of adverse outcomes including death. Reducing avoidable acute hospital use in persons with dementia is thus a global healthcare priority. However, evidence regarding the impact of health service interventions as defined by the Effective Practice and Organization of Care Cochrane Group on acute hospital use is scant and inconclusive. The aim of this systematic review and meta-analysis was to synthesize available evidence on the impact of health service interventions on acute hospital use in community-dwelling persons with dementia compared to usual care.

Methods

Data Sources: MEDLINE, EMBASE, CINAHL and Cochrane CENTRAL (from 01/1995 to 08/2017). Study eligibility criteria: Randomised controlled trials measuring the impact of health service interventions on acute hospital use (proportion and mean number of emergency department visits and hospitalisations, mean number of hospital days, measured at 12 months, and at longest follow-up) in community-dwelling persons with dementia, compared to usual care. Study selection, appraisal and synthesis methods: Reviewers independently identified studies, extracted data, and assessed the risk of bias, with the Cochrane risk of bias tool. Authors of relevant trials were queried about unpublished data. Random effects model was used for meta-analyses. Effect heterogeneity was assessed through prediction intervals, and explored using sub-group analyses.

Findings

Seventeen trials provided data on 4,549 persons. Unpublished data were obtained for 13 trials, representing 65% of synthesized data. Most interventions included a case management or a self-management component. None of the outcome comparisons provided conclusive evidence supporting the hypothesis that these interventions would lead to a decrease in acute hospital use. Furthermore, prediction intervals indicated possible and important increased service use associated with these interventions, such as emergency department visits, hospital admissions, and hospital days. Subgroup analyses did not favour any type of intervention. A limitation of this study is the inclusion of any type of health service intervention, which may have increased the observed heterogeneity.

Conclusion

Despite a comprehensive systematic review and meta-analysis, including predominantly unpublished data, no health service intervention beyond usual care was found to reduce acute hospital use in community-dwelling persons with dementia. An important increase in service use may be associated with these interventions. Further research is urgently needed to identify effective interventions for this vulnerable population to limit rising acute hospital use, associated costs and adverse outcomes. Systematic review registration PROSPERO CRD42016046444.

Caregiver burden and quality of life 2 years after attendance at a memory clinic

OBJECTIVES

We aimed to describe (1) the burden and health-related quality of life (HRQL) of informal caregivers of new patients attending a memory assessment service (MAS), (2) changes in these outcomes over 2 years, and (3) satisfaction with services.

METHODS

Informal caregivers of patients attending one of 73 MASs throughout England completed questionnaires at the patient's first appointment, and 6 and 12 months later. Participants from 30 of these MASs were also followed up at 24 months. Questionnaires covered caregivers' sociodemographic characteristics, Zarit Burden Interview, EQ-5D-3L, and satisfaction with services. We used multivariable linear regression to assess relationships between burden, HRQL, and caregiver and patient characteristics.

RESULTS

Of 1020 caregivers at baseline, 569 were followed up at 6 months, 452 at 12 months, and 187 at 24 months. There was a small increase in caregiver burden over 2 years (effect size 0.30 SD). These changes were not associated with most caregiver or patient characteristics, except socio-economic deprivation, which was associated with larger increases in burden at 2 years. Caregivers' HRQL was weakly associated with burden and showed a small reduction over time (0.2 SD). Most caregivers were satisfied with services, but caregivers who were not satisfied with the services they received reported greater increases in burden.

CONCLUSIONS

Increases in caregiver burden and reductions in HRQL appear to be small over the first 2 years after attending a MAS. However, the longer term impact on caregivers and those they care for needs investigating, as do strategies to reduce their burden.

Cognitive Impairment and Glycemic Control in Elderly Patients Under Health-Care Case Management

We aim to test whether the association between glucose control and cognitive function still holds true in elderly patients with diabetes mellitus (DM) and Alzheimer disease (AD) under health-care case management. We enrolled 100 patients with DM (mean age: 74.6 years; male: 49%) and 102 patients with AD (mean age: 77.9 years; male: 41.2%) consecutively from the Diabetes Shared Care Program and the memory clinic. These patients were followed up every 3 months with scheduled examinations. Most patients with AD were at early stage and DM was a common comorbidity (n = 42). In the DM group, there were 76 patients with subjective cognitive decline and 19 patients with mild cognitive impairment, but none sought further consultation. After adjusting for age, sex, education, and comorbidity, higher levels of glycated hemoglobin (HbA_1C) were not associated with lower Mini-Mental State Examination (MMSE) scores in the DM group (coefficient: 0.03; 95% confidence interval [CI]: -0.44 to 0.50) and lower MMSE scores were not associated with higher HbA_1C in the AD group either (coefficient: -0.05; 95% CI: -0.11 to 0.01). When additionally accounting for the variability of HbA_1C in the DM group, higher standard deviation of HbA_1C was associated with poor clock drawing test scores, but not MMSE. The coexistence of AD-DM was common, but the association between hyperglycemia and cognitive impairment was not seen in patients under regular health monitoring.

Effectiveness of a peer-mediated educational intervention in improving general practitioner diagnostic assessment and management of dementia: a cluster randomised controlled trial

OBJECTIVE

Test effectiveness of an educational intervention for general practitioners (GPs) on quality of life and depression outcomes for patients.

DESIGN

Double-blind, cluster randomised controlled trial.

SETTING

General practices in Australia between 2007 and 2010.

PARTICIPANTS

General practices were randomly allocated to the waitlist (n=37) or intervention (n=66) group, in a ratio of 1:2. A total of 2030 (1478 intervention; 552 waitlist) community-dwelling participants aged 75 years or older were recruited via 168 GPs (113 intervention; 55 waitlist).

INTERVENTIONS

A practice-based academic detailing intervention led by a peer educator that included: (1) training in use of the GP assessment of cognition dementia screening instrument; (2) training in diagnosis and management based on Royal Australian College of General Practitioners Dementia Guidelines; (3) addressing GPs' barriers to dementia diagnosis; and (4) a business case outlining a cost-effective dementia assessment approach.

OUTCOME MEASURES

Primary outcome measures were patient quality of life and depression; secondary outcome measures were: (1) sensitivity and specificity of GP identification of dementia; (2) referral to medical specialists and/or support services; (3) patient satisfaction with care; and (4) carer quality of life, depression and satisfaction with care.

RESULTS

The educational intervention had no significant effect on patient quality of life or depression scores after 12 months. There were however improvements in secondary outcome measures including sensitivity of GP judgement of dementia (p=0.002; OR 6.0, 95% CI 1.92 to 18.73), satisfaction with GP communication for all patients (p=0.024; mean difference 2.1, 95% CI 0.27 to 3.93) and for patients with dementia (p=0.007; mean difference 7.44, 95% CI 2.02 to 12.86) and enablement of carers (p=0.0185; mean difference 24.77, 95% CI 4.15 to 45.40).

CONCLUSION

Practice-based academic detailing did not improve patient quality of life or depression scores but did improve detection of dementia in primary care and patient satisfaction with GP communication.

TRIAL REGISTRATION NUMBER

ACTRN12607000117415; Pre-results.

A retrospective analysis of care in patients with dementia hospitalized at a tertiary medical center

BACKGROUND

Hospitalization is an opportunity to address various aspects related to management of dementia, including the goals of care to avoid futile care. We studied the prevalence of these factors when patients with dementia are hospitalized.

DESIGN

One hundred and thirty-one charts of patients with dementia admitted to a single university-based hospital were retrospectively reviewed. Data were collected and analyzed for age, gender, the severity of dementia, co-morbidities, co-existing vascular dementia, reversible causes of dementia, mental status scores, medications, consultations, procedures, complications, availability of advance directives, decision-maker, code status, and goals of care discussion.

RESULTS

In patients with dementia, co-morbidities and vascular disease burden were frequent. When these patients were hospitalized, use of psychotropic medications, invasive procedures, and multi-specialty consultations was common. Tests of mental status, screening for reversible causes, and use of FDA-approved medications for dementia is less common. Despite the lack of advance directives, goals of care were infrequently discussed. When goals of care were discussed, proxy decision-maker preferred palliative care and long-term institutionalization on discharge.

CONCLUSION

Goals of care and other aspects of management are not fully addressed in hospitalized patients with dementia.

Supporting carers of people with dementia: What is effective?

Carer stress is well documented, especially in those caring for individuals with dementia. A recommendation of all national dementia strategies is to provide excellent support and information to informal carers of people with dementia. NICE guidance suggests that a range of tailored interventions, including psychological input, psychoeducation and training courses, should be offered to reduce caregiver burden and stress, although good-quality outcome-based evidence is lacking. On the basis of a narrative review of the literature, we describe individual and multicomponent carer support packages and discuss their evidence base, reflecting on outcomes for carers. Multicomponent interventions have the best evidence for effectiveness.

Learning Objectives

• Consider the risks of both physical and psychological harm experienced by carers of people with dementia (often referred to as carer burden or caregiver burden)

• Be aware of the interventions available for the support of carers of people with dementia

• Consider the evidence for the effectiveness of these interventions and be aware of the limitations of the evidence

The cost of diagnosis and early support in patients with cognitive decline

OBJECTIVE

Recent research indicates considerable heterogeneity in the provision of memory assessment services (MAS). However, little is known on the extent of variation in the costs of the services MAS provide. We investigated the costs of supporting patients with suspected dementia, including assessment and support over the following 6 months.

METHODS

Clinic costs were estimated on the basis of an organisational survey reporting staff roll, grade and activities. Costs of primary health and social care were estimated from questionnaire data reported by carers of patients at baseline, 3 and 6 months after referral.

RESULTS

Mean monthly staff costs at MAS were £73 000. Imaging at assessment costs an additional £3500 per month. Monthly clinic cost per new patient assessed varied from £320 to £5400 across clinics. Additional primary health and social care costs of £130-220 a month between baseline and 6 months were reported by carers. Costs of pharmacological and non-pharmacological treatments reported by carers were small. Informal care costs dwarfed health and social care costs when valued at a modest unit cost. The overall mean cost of supporting a patient for 6 months varied from £1600 to £2500 dependent on assumptions regarding the proportion of MAS intervention and review costs accrued at 6 months.

CONCLUSIONS

There is considerable variation in the intensity and associated costs of services provided by MAS. Further research should ascertain to what extent such variation is associated with differences in patient outcomes. Copyright © 2016 John Wiley & Sons, Ltd.

Evaluation of an integrated primary care-led dementia shared care program in Singapore: An effectiveness and cost-effectiveness study

AIM

With an aging Singapore population, there is an increasing demand for dementia care. The present study aimed to evaluate the effectiveness and cost-effectiveness of the Primary Care Dementia Clinic (PCDC) in comparison with the Memory Clinic (MC; hospital-based) and other polyclinics.

METHODS

A quasi-experimental design was implemented. Effectiveness of PCDC was assessed through caregiver satisfaction, quality of life (caregiver-rated) and adverse events rates. Quality-of-Life measures using the EuroQol 5 Dimension Questionnaire (EQ-5D) at baseline, 6 months and 12 months was assessed. Costs were calculated from a societal perspective. The incremental cost-effectiveness of the PCDC was compared with MC and other polyclinics.

RESULTS

The present study showed that quality of life and the rate of adverse events at 12 months were similar between the three groups. Caregiver satisfaction at 12 months was higher in the PCDC group when compared with other polyclinics. There were no observed differences in societal cost between the three groups. At 6-month follow up, direct medical costs for PCDC were significantly lower that of other polyclinics. At 12-month follow up, PCDC patients had higher Quality Adjusted Life Years (QALYs) compared with the MC group.

CONCLUSION

PCDC provided effective care, similar to care at MC and better than care at other polyclinics. Caregiver satisfaction was higher for the PCDC group, and PCDC patients had lower direct medical costs at 6-month follow up. Given these findings, adopting a PCDC model in other polyclinics in Singapore can be beneficial for optimal right siting of patients. Geriatr Gerontol Int 2018; 18: 479-486.

Direct and indirect risk associated with the use of dietary supplements among persons with dementia in a Norwegian memory clinic

BACKGROUND

The use of dietary supplements (DS) is common among persons with dementia. Direct risks associated with DS use include adverse events and DS-drug interactions. A direct risk is a risk caused by the treatment itself. Indirect risks are related to the treatment setting, such as the conditions of use, and not to the treatment itself. Because dementia symptoms may reduce a person's ability to cope with the administration of DS, the use of DS may pose a threat to safety as an indirect risk. The aim of this study was to describe the extent of DS use among persons with dementia in ambulatory care and to identify some relevant direct and indirect risks related to DS use.

METHODS

We conducted a survey among 151 persons with dementia attending an outpatient memory clinic in Northern Norway. Study measurements included: the participants' characteristics, cognitive functioning, functioning in the activities of daily living (ADL), and the use of DS and prescription drugs (PD). We assessed direct risks by evaluating potential DS-drug interactions and indirect risks by evaluating the conditions under which it was used.

RESULTS

Forty-six percent (n = 70) of the persons with dementia used DS. Ninety-seven percent (n = 147) used PD. We found potentially clinically relevant DS-drug interactions representing a direct risk in eight persons with dementia (11% of users). While only 36% (n = 26) of the participants received assistance with the administration of DS, 73% (n = 106) received assistance with the administration of PD. Persons with dementia living alone were at risk of not receiving assistance, as home care service seldom was involved in DS administration. Data indicated that assistance with DS administration was not provided for all persons with dementia in need, representing an indirect risk to these persons. Only one-third of the persons with dementia and half of the caregivers were aware of the general risks of adverse events and interactions associated with the use of DS.

CONCLUSIONS

Persons with dementia use DS frequently, yet DS use may be associated with direct and indirect risks to patient safety as potentially clinically relevant interactions were discovered and DS intake often was unsupervised.

Navigating Without a Roadmap: Challenges of Early Alzheimer's Caregivers With Their Health Care Team

Caregivers of individuals with Alzheimer's disease are willing to make large sacrifices to attend to the everyday demands of their loved one's health. Many still lack the necessary skills, information, and resources from medical professionals needed to fully execute this role. The aim of this study is to explore the challenges that first-time Alzheimer's caregivers encountered with members of their health care team around a loved one's diagnosis. Four focus groups (N = 13) were conducted in a primary care clinic and academic setting, using a semi-structured interview format facilitated by a mental health professional. The authors used thematic analysis to generate three overarching themes regarding lack of information given about the diagnosis, complications with medication management, and level of confidence in their medical team. Medical professionals should consider educating Alzheimer's disease caregivers during the initial stage of this role, providing greater continuity of care with the family throughout treatment.

Diagnostic Care Pathways in Dementia

OBJECTIVES

Increasing diagnostic rates of dementia is a national health priority; to meet this priority, improvement needs to be made to diagnostic services. It has been increasingly recognized that primary can play a significant role in the diagnostic journey for people with dementia, with some diagnostic services entirely located in primary care. This article reviews the extent of the involvement of primary care in diagnostic care pathways for people presenting with memory complaints within England, and presents examples of innovative approaches, which may be of interest to practitioners.

METHOD

A rapid review was undertaken to identify articles outlining diagnostic care pathways for dementia involving primary care in England.

RESULTS

Six articles relating to pathway evaluations and innovative approaches involving primary care were deemed suitable for inclusion in the review.

CONCLUSIONS

The review found examples of diagnostic pathways and innovative practices being implemented in in primary care. These practices aligned to the strategic ambitions of the National Dementia Strategy. However, it was widely acknowledged that there is a need to improve postdiagnostic pathways; in particular, access to postdiagnostic support. This issue is being reflected in contemporary policy initiatives such as the Department of Health's 2016 Joint Declaration on postdiagnostic dementia care and support.

Psychiatry and the geriatric syndromes - creating constructive interfaces

Integrating mental and physical healthcare is difficult to achieve because of professional and organisational barriers. Psychiatrists recognise the problems resulting from fragmentation of services and want continuity of care for patients, but commissioning and service structures perpetuate these problems. One way forward may be to follow the syndromic model employed by geriatricians as a means of avoiding over-emphasis on diagnosis above the pragmatics of implementing multi-component, coordinated care. Commissioners need to be made aware of the overlap and complementarity of skills possessed by old age psychiatry and geriatric medicine to create joint services for people vulnerable to dementia and delirium. A re-forged alliance between the two specialties will be necessary to turn integrated care for frail, elderly people from rhetoric into reality.

Triple aim improvement for individuals, services and society in dementia care : The DementiaNet collaborative care approach

Background

A redesigning of primary care is required to meet dementia patients’ needs. In the Netherlands, current dementia care still falls short in areas including ad hoc collaboration, lack of feedback on quality to professionals involved, and insufficient implementation of established multidisciplinary guidelines.

Objective

DementiaNet is a collaborative care approach, which aims to reduce the burden of the disease on individuals, healthcare services and society via network-based care that encourages collaboration, enhances knowledge and skills and stimulates quality improvement cycles.

Material and methods

DementiaNet was developed to support primary care networks through implementation of five core processes: network-based care, clinical leadership, quality improvement cycles, interprofessional practice-based training and communication support tools, following a stepwise tailor-made approach. Alongside this, a mixed method study was designed to evaluate innovation and effectiveness.

Results

Currently, 18 networks have been formed. These vary in quality of care and strength of collaboration due to local circumstances. Initial activities and goals of each network also vary, ranging from acquaintance to shared care plans. Ongoing research will identify barriers, facilitators and merits of the approach in increasing quality of care and ultimately improving outcomes for patient, carer, health service and society.

Conclusion

Initial results show that clinical practice varies and the DementiaNet approach can lead to quality improvement. Complexity and variety of local care requires complex interventions and evaluation methods that account for this in order to safeguard the value for practice. Strict methodology lessens external validity.

Clinical practice with anti-dementia drugs: A revised (third) consensus statement from the British Association for Psychopharmacology

The British Association for Psychopharmacology coordinated a meeting of experts to review and revise its previous 2011 guidelines for clinical practice with anti-dementia drugs. As before, levels of evidence were rated using accepted standards which were then translated into grades of recommendation A-D, with A having the strongest evidence base (from randomised controlled trials) and D the weakest (case studies or expert opinion). Current clinical diagnostic criteria for dementia have sufficient accuracy to be applied in clinical practice (B) and both structural (computed tomography and magnetic resonance imaging) and functional (positron emission tomography and single photon emission computerised tomography) brain imaging can improve diagnostic accuracy in particular situations (B). Cholinesterase inhibitors (donepezil, rivastigmine, and galantamine) are effective for cognition in mild to moderate Alzheimer's disease (A), memantine for moderate to severe Alzheimer's disease (A) and combination therapy (cholinesterase inhibitors and memantine) may be beneficial (B). Drugs should not be stopped just because dementia severity increases (A). Until further evidence is available other drugs, including statins, anti-inflammatory drugs, vitamin E, nutritional supplements and Ginkgo biloba, cannot be recommended either for the treatment or prevention of Alzheimer's disease (A). Neither cholinesterase inhibitors nor memantine are effective in those with mild cognitive impairment (A). Cholinesterase inhibitors are not effective in frontotemporal dementia and may cause agitation (A), though selective serotonin reuptake inhibitors may help behavioural (but not cognitive) features (B). Cholinesterase inhibitors should be used for the treatment of people with Lewy body dementias (both Parkinson's disease dementia and dementia with Lewy bodies), and memantine may be helpful (A). No drugs are clearly effective in vascular dementia, though cholinesterase inhibitors are beneficial in mixed dementia (B). Early evidence suggests multifactorial interventions may have potential to prevent or delay the onset of dementia (B). Though the consensus statement focuses on medication, psychological interventions can be effective in addition to pharmacotherapy, both for cognitive and non-cognitive symptoms. Many novel pharmacological approaches involving strategies to reduce amyloid and/or tau deposition in those with or at high risk of Alzheimer's disease are in progress. Though results of pivotal studies in early (prodromal/mild) Alzheimer's disease are awaited, results to date in more established (mild to moderate) Alzheimer's disease have been equivocal and no disease modifying agents are either licensed or can be currently recommended for clinical use.

Assessing quality of life in Alzheimer's disease: Implications for clinical trials

Introduction

Characterization of the quality of life (QOL) in Alzheimer's disease (AD) scale within the context of a clinical trial may inform its applicability in future trials.

Methods

Using data from 1322 patients enrolled in two phase-III studies (EXPEDITION 1 [NCT00905372] and 2 [NCT00904683]) of intravenous solanezumab in outpatients with mild AD dementia, correlations between patient- and caregiver-assessed QOL and between QOL and clinical outcome measures were examined. Longitudinal effects of solanezumab over 80 weeks were explored, controlling for patient and caregiver baseline characteristics.

Results

Caregivers rated patients' QOL worse than did patients themselves. Patients' QOL was correlated, albeit modestly, with clinical/health measures. Patients' QOL changed minimally over 80 weeks, although a treatment effect of solanezumab on QOL was detected.

Discussion

Further investigations are needed to determine the optimal measures with which to quantify and qualify QOL of patients with mild AD.

Reducing sample size by combining superiority and non-inferiority for two primary endpoints in the Social Fitness study

OBJECTIVES

In randomized controlled trials, two endpoints may be necessary to capture the multidimensional concept of the intervention and the objectives of the study adequately. We show how to calculate sample size when defining success of a trial by combinations of superiority and/or non-inferiority aims for the endpoints.

STUDY DESIGN AND SETTING

The randomized controlled trial design of the Social Fitness study uses two primary endpoints, which can be combined into five different scenarios for defining success of the trial. We show how to calculate power and sample size for each scenario and compare these for different settings of power of each endpoint and correlation between them.

RESULTS

Compared to a single primary endpoint, using two primary endpoints often gives more power when success is defined as: improvement in one of the two endpoints and no deterioration in the other. This also gives better power than when success is defined as: improvement in one prespecified endpoint and no deterioration in the remaining endpoint.

CONCLUSION

When two primary endpoints are equally important, but a positive effect in both simultaneously is not per se required, the objective of having one superior and the other (at least) non-inferior could make sense and reduce sample size.

Psychosocial interventions for people with dementia: An overview and commentary on recent developments

An influential review in 2010 concluded that non-pharmacological multi-component interventions have positive effects on cognitive functioning, activities of daily living, behaviour and mood of people with dementia. Our aim here is to provide an up-to-date overview of research into psychosocial interventions and their impact on psychosocial outcomes. We focused on randomised controlled trials, controlled studies and reviews published between October 2008 and August 2015, since the earlier review. The search of PsychInfo, Medline and the Cochrane database of systematic reviews yielded 61 relevant articles, organised into four themes echoing key phases of the care pathway: Living at home with dementia (five reviews, eight studies), carer interventions (three reviews, four studies), interventions in residential care (16 reviews, 12 studies) and end-of-life care (three reviews, two studies), along with an additional group spanning community and institutional settings (six reviews, two studies). Community findings suggested that appointment of dementia specialists and attention to case management can produce positive outcomes; physical therapies, cognitive training and modified cognitive behaviour therapy also had a range of benefits. There was more limited evidence of positive benefits for people with dementia through interventions with family carers. Thirty-two articles focused on the management of 'behavioural symptoms' through a range of interventions all of which had some evidence of benefit. Also a range of multi-component and specific interventions had benefits for cognitive, emotional and behavioural well-being of people with dementia in residential settings, as well as for quality of life. Overall, interventions tended to be short term with impact only measured in the short term. We recommend further research on interventions to promote living well in the community post-diagnosis and to address end-of-life care. Development of psychosocial interventions would benefit from moving beyond the focus on control of behaviours to focus on wider aspects of life for people with dementia.

Examination of level of knowledge in Italian general practitioners attending an education session on diagnosis and management of the early stage of Alzheimer's disease: pass or fail?

BACKGROUND

We detected the general level of knowledge about the early diagnosis of Alzheimer's disease (AD) and subsequent care in general practitioners (GPs) from Southern Italy. We explored also the GP perception about their knowledge and training on diagnosis and management of AD.

METHODS

On a sample of 131 GPs, we administered two questionnaires: the GP-Knowledge, evaluating GPs' expertise about AD epidemiology, differential diagnosis, and available treatments, and the GP-QUestionnaire on Awareness of Dementia (GP-QUAD), assessing the GPs' attitudes, awareness, and practice regarding early diagnosis of dementia.

RESULTS

Specific screening tests or protocols to diagnose and manage dementia were not used by 53% of our GPs. The training on the recognition of early AD signs and symptoms was considered inadequate by 55% of the participants. Females were more likely to consider their training insufficient (58%) compared to males (53%). Female GPs were less likely to prescribe antipsychotic drugs to control neuropsychiatric symptoms (NPS) and suggest specialist advice in late stage of cognitive impairment. Multiple Correspondence Analysis (MCA) performed only on GP-QUAD suggested two dimensions explaining 26.1% ("GP attitude") and 20.1% ("GP knowledge") of the inertia for a total of 46.2%,

CONCLUSION

In our survey on GP clinical practice, several problems in properly recognizing early AD symptoms and subsequently screening patients to be referred to secondary/tertiary care centers for diagnosis confirmation have emerged. In the future, specific training programs and educational projects for GPs should be implemented also in Italy to improve detection rates and management of dementia in primary care.

Outpatient services and primary care: scoping review, substudies and international comparisons

Aim

This study updates a previous scoping review published by the National Institute for Health Research (NIHR) in 2006 (Roland M, McDonald R, Sibbald B.Outpatient Services and Primary Care: A Scoping Review of Research Into Strategies For Improving Outpatient Effectiveness and Efficiency. Southampton: NIHR Trials and Studies Coordinating Centre; 2006) and focuses on strategies to improve the effectiveness and efficiency of outpatient services.

Findings from the scoping review

Evidence from the scoping review suggests that, with appropriate safeguards, training and support, substantial parts of care given in outpatient clinics can be transferred to primary care. This includes additional evidence since our 2006 review which supports general practitioner (GP) follow-up as an alternative to outpatient follow-up appointments, primary medical care of chronic conditions and minor surgery in primary care. Relocating specialists to primary care settings is popular with patients, and increased joint working between specialists and GPs, as suggested in the NHS Five Year Forward View, can be of substantial educational value. However, for these approaches there is very limited information on cost-effectiveness; we do not know whether they increase or reduce overall demand and whether the new models cost more or less than traditional approaches. One promising development is the increasing use of e-mail between GPs and specialists, with some studies suggesting that better communication (including the transmission of results and images) could substantially reduce the need for some referrals.

Findings from the substudies

Because of the limited literature on some areas, we conducted a number of substudies in England. The first was of referral management centres, which have been established to triage and, potentially, divert referrals away from hospitals. These centres encounter practical and administrative challenges and have difficulty getting buy-in from local clinicians. Their effectiveness is uncertain, as is the effect of schemes which provide systematic review of referrals within GP practices. However, the latter appear to have more positive educational value, as shown in our second substudy. We also studied consultants who held contracts with community-based organisations rather than with hospital trusts. Although these posts offer opportunities in terms of breaking down artificial and unhelpful primary–secondary care barriers, they may be constrained by their idiosyncratic nature, a lack of clarity around roles, challenges to professional identity and a lack of opportunities for professional development. Finally, we examined the work done by other countries to reform activity at the primary–secondary care interface. Common approaches included the use of financial mechanisms and incentives, the transfer of work to primary care, the relocation of specialists and the use of guidelines and protocols. With the possible exception of financial incentives, the lack of robust evidence on the effect of these approaches and the contexts in which they were introduced limits the lessons that can be drawn for the English NHS.

Conclusions

For many conditions, high-quality care in the community can be provided and is popular with patients. There is little conclusive evidence on the cost-effectiveness of the provision of more care in the community. In developing new models of care for the NHS, it should not be assumed that community-based care will be cheaper than conventional hospital-based care. Possible reasons care in the community may be more expensive include supply-induced demand and addressing unmet need through new forms of care and through loss of efficiency gained from concentrating services in hospitals. Evidence from this study suggests that further shifts of care into the community can be justified only if (a) high value is given to patient convenience in relation to NHS costs or (b) community care can be provided in a way that reduces overall health-care costs. However, reconfigurations of services are often introduced without adequate evaluation and it is important that new NHS initiatives should collect data to show whether or not they have added value, and improved quality and patient and staff experience.

Funding

The NIHR Health Services and Delivery Research programme.

A Simple and Practical Index to Measure Dementia-Related Quality of Life

BACKGROUND

Research on new treatments for dementia is gaining pace worldwide in an effort to alleviate this growing health care problem. The optimal evaluation of such interventions, however, calls for a practical and credible patient-reported outcome measure.

OBJECTIVES

To describe the refinement of the Dementia Quality-of-life Instrument (DQI) and present its revised version.

METHODS

A prototype of the DQI was adapted to cover a broader range of health-related quality of life (HRQOL) and to improve consistency in the descriptions of its domains. A valuation study was then conducted to assign meaningful numbers to all DQI health states. Pairs of DQI states were presented to a sample of professionals working with people with dementia and a representative sample of the Dutch population. They had to repeatedly select the best DQI state, and their responses were statistically modeled to obtain values for each health state.

RESULTS

In total, 207 professionals working with people with dementia and 631 members of the general population completed the paired comparison tasks. Statistically significant differences between the two samples were found for the domains of social functioning, mood, and memory. Severe problems with physical health and severe memory problems were deemed most important by the general population. In contrast, severe mood problems were considered most important by professionals working with people with dementia.

DISCUSSION

The DQI is a simple and feasible measurement instrument that expresses the overall HRQOL of people suffering from dementia in a single meaningful number. Current results suggest that revisiting the discussion of using values from the general population might be warranted in the dementia context.