Canadian Outcomes Study in Dementia: study methods and patient characteristics

Converting Functional Autonomy Measurement System Scores of Patients Post-Stroke to FIM Scores

Purpose: The Functional Independence Measure (FIM) is widely used to assess persons post-stroke. The Quebec government has selected the Functional Autonomy Measurement System (SMAF) for use in all care settings. In this article, we propose simple equations to convert SMAF scores to FIM scores for persons undergoing post-stroke rehabilitation. Method: Persons post-stroke (n=143) from three rehabilitation centres were assessed at admission and discharge using the FIM and SMAF. The sample was randomly split into derivation and validation data sets. Regression analysis was performed on the first data set to derive a conversion equation at each time point. The validity of the equations was measured using correlation coefficients, and differences between the observed and predicted FIM scores were computed from the second data set. Results: The relationship between the SMAF and FIM scores was linear at admission but quadratic at discharge. The proposed equations are, at admission, FIM=139-1.5×SMAF and, at discharge, FIM=118-0.018×SMAF². The observed and predicted FIM scores were highly correlated in the validation data set (rs=0.92 and 0.93 at admission and discharge, respectively). Furthermore, the equations performed well in classifying stroke severity compared with a classification based on the observed FIM scores. Conclusions: SMAF scores can be reliably converted to FIM scores using the proposed equations, thus facilitating international trials in stroke rehabilitation.

Trends, Predictors, and Outcomes of Healthcare Resources Used in Patients Hospitalized with Alzheimer's Disease with at Least One Procedure: The Nationwide Inpatient Sample

We assessed trends, predictors and outcomes of resource utilization in hospital inpatient discharges with a principal diagnosis of Alzheimer's disease (AD) with at least one procedure. Using Nationwide Inpatient Sample data (NIS, 2002-2012), discharges primarily diagnosed with AD, aged ≥60 y and with ≥1 procedure, were selected (Weighted N = 92,300). Hospital resource utilization were assessed using ICD-9-CM codes, while hospitalization outcomes included total charges (TC, 2012$), length of stay (LOS, days), and mortality risk (MR, %). Brain and respiratory/gastrointestinal procedure utilization both dropped annually by 3-7%, while cardiovascular procedures/evaluations, blood evaluations, blood transfusion, and resuscitation ("CVD/Blood") as well as neurophysiological and psychological evaluation and treatment ("Neuro") procedures increased by 5-8%. Total charges, length of stay, and mortality risk were all markedly higher with use of respiratory/gastrointestinal procedures as opposed to being reduced with use of "Brain" procedures. Procedure count was positively associated with all three hospitalization outcomes. In sum, patterns of hospital resources that were used among AD inpatients changed over-time, and were associated with hospitalization outcomes such as total charges, length of stay, and mortality risk.

Risk Factors for Progression of Alzheimer Disease in a Canadian Population: The Canadian Outcomes Study in Dementia (COSID)

OBJECTIVE

To determine risk factors for clinically significant progression during 12 months in patients with mild-to-moderate Alzheimer disease.

METHOD

Community-dwelling patients with mild-to-moderate Alzheimer disease were enrolled in a 3-year prospective study, the Canadian Outcomes Study in Dementia (commonly referred to as COSID), at 32 Canadian sites. Assessments included the Global Deterioration Scale (GDS) for disease severity, the Mini-Mental State Examination (MMSE) for cognition, the Functional Autonomy Measurement System (SMAF) for daily functioning, and the NeuroPsychiatric Inventory (NPI) for behaviour, measured at baseline and at 12 months. Logistic regression identified factors associated with GDS decline, and subsequent stepwise regression identified key independent predictors. Area under the curve (AUC) was then calculated for the model.

RESULTS

Among 488 patients (mean age 76.5 years [SD 6.4], MMSE 22.1 [SD4.6], 44.1% male), 225 (46%) showed GDS decline. After adjusting for age, baseline risk factors for deterioration included the following: poorer cognition (lower MMSE score, OR 0.55; 95% CI 0.4 to 0.72 per 5 points, P ≤ 0.001), greater dependence (lower SMAF, OR 0.72; 95% CI 0.63 to 0.83 per 5 points, P ≤ 0.001), and more neuropsychiatric symptoms (higher NPI, OR 1.11; 95% CI 1.02 to 1.2 per 5 points, P = 0.02), with a protective effect of male sex (OR 0.59; 95% CI 0.39 to 0.9, P = 0.02), and higher (worse) GDS score (very mild, compared with mild OR 0.25; 95% CI 0.09 to 0.70, P ≤ 0.01; compared with moderate, OR 0.08; 95% CI 0.03 to 0.23, P < 0.001; compared with moderately severe, OR 0.03; 95% CI 0.01 to 0.11, P < 0.001). The AUC was 73% (P < 0.001) (sensitivity 90% and specificity 33%).

CONCLUSION

The progression of Alzheimer disease in Canada can be predicted using readily available clinical information.

Disease Staging and Milestones

This new section to the guidelines was added due to the recognition that clinical milestones are useful indices of the progression of dementia in patients with Alzheimer's disease and could help in the development of stage-specific targeted therapy. This review specifically looks at clinical milestones that could be used in clinical trials, such as global function, function, behaviour, caregiver burden, and quality of life milestones. It also addresses the possible use of biological and surrogate markers for use as milestones - which may eventually replace clinical milestones. It concludes that current definitions of dementia must be broadened beyond cognition alone to include some of the domains listed.

The prevalence and incidence of dementia with Lewy bodies: a systematic review of population and clinical studies

BACKGROUND

Dementia with Lewy bodies (DLB) is increasingly recognized as a common cause of dementia in older people. However, its true frequency remains unclear, with previous studies reporting a prevalence range from zero to 22.8% of all dementia cases. This review aimed to establish the population prevalence and incidence for DLB and to compare this to its prevalence in secondary care settings.

METHOD

A literature review of all relevant population and clinical studies was conducted using PubMed. Additional references from papers found during that process were added to this.

RESULTS

DLB accounted for 4.2% of all diagnosed dementias in the community. In secondary care this increased to 7.5%. The incidence of DLB was 3.8% of new dementia cases. There was a significant increase in DLB diagnoses when using the revised (2005) International Consensus Criteria (ICC) for DLB compared to the original (1996) criteria.

CONCLUSIONS

DLB currently accounts for around one in 25 dementia cases diagnosed in the community and one in 13 cases in secondary care. The significantly higher rates of DLB in secondary care may reflect enhanced diagnostic accuracy in specialist settings and/or the increased morbidity and carer burden of the DLB syndrome compared to other dementias. However, the true prevalence is likely to be much higher because DLB diagnoses are often missed, although there is evidence that new criteria aid case identification.

Prevalence and correlates of potentially undetected dementia among residents of institutional care facilities in Ontario, Canada, 2009-2011

OBJECTIVES

This study aims to determine the prevalence of potentially undetected dementia among institutional care facility residents in Ontario, Canada, and to identify factors associated with undetection.

METHODS

We utilized a population-based secondary data analysis approach, pertaining to data from the Canadian Institute for Health Information's Continuing Care Reporting System, 2009-2011. Potentially undetected dementia was defined as having severely impaired cognitive function and requiring extensive assistance on activity of daily living (ADL) but no records of dementia diagnoses. Cognitive function was measured by the Cognitive Performance Scale (CPS), 0 (intact) to 6 (very severe impairment), and ADL by a hierarchy scale, 0 (independent) to 6 (total dependence).

RESULTS

Of the 242,957 residents who had no records of dementia diagnoses, 11.6% (n = 28,078) had a CPS score ≥4 (severe impairment or higher) and ADL score ≥3 (required extensive assistance or more). Data from 11,614 demented residents with corresponding CPS and ADL scores were used for comparison. Residents without dementia diagnosis were younger (77 vs. 84 years), more likely to have never married (20% vs. 6%), and have longer admission (4 vs. 2.8 years). The most significant factors for no diagnoses were never married (adjusted odds ratio = 2.1, 95% confidence interval [CI] = 1.91-2.29), admitted to hospital-based facilities (adjusted odds ratio = 1.58, 95% CI = 1.48-1.69), presence of schizophrenia (adjusted odds ratio = 1.43, 95% CI = 1.22-1.69), depression (adjusted odds ratio = 1.23, 95% CI = 1.16-1.29), and diabetes mellitus (adjusted odds ratio = 1.32, 95% CI = 1.26-1.40).

CONCLUSIONS

A large number of residents who had poor cognitive function and inadequate ADL ability did not have dementia diagnoses on record. Social and comorbid conditions were contributing factors to potentially undetected dementia.

Patients in Australian Memory Clinics: baseline characteristics and predictors of decline at six months

BACKGROUND

The Prospective Research In MEmory clinics (PRIME) is a three-year non-prescriptive, observational study identifying and measuring relationships among predictor and outcome variables.

METHODS

Patients from nine memory clinics, diagnosed with dementia or mild cognitive impairment (MCI), living in the community with <40 hours/week nursing care were divided into diagnostic groups defined at baseline as Alzheimer's disease (AD) early or late onset, frontotemporal dementia (FTD), vascular dementia (VaD), mixed (AD and VaD) and other dementia. To achieve outcome measures, baseline and change over six months in all measures by diagnostic group, and predictors of change at six months were examined.

RESULTS

Of the 970 patients enrolled, 967 were eligible for analysis. The most common disorder was AD (late onset) accounting for 46.5% of this population. Patients had an overall slight worsening on all assessment scales over the six-month period. Patients with FTD had a more marked change (decline) in cognition, function and behavior over six months compared to other diagnostic groups. However, in the regression analysis the difference was not significant between groups. Predictors of decline in Mini-Mental State Examination (MMSE) scores were not robust at six months, and longer follow-up is required. Patients with FTD were more likely to be prescribed psychotropics.

CONCLUSION

The PRIME study is continuing and will provide important data on predictors of decline along with differences between diagnosis groups on the rate of change.

Quality-of-life outcomes among Alzheimer's disease family caregivers following community-based intervention

This study sought to determine how community-based interventions such as adult day programs and caregiver support groups affected the quality of life (QOL) of caregivers of Alzheimer's disease clients. The authors hypothesized that using community-based interventions would increase the QOL of caregivers of Alzheimer's disease clients. They conducted a pilot study employing a cross-sectional comparative design involving 62 caregivers in the Durham region, Ontario, Canada. Individuals were recruited at five adult day programs and at six caregiver support groups, involving primary data collection consisting of a self-report questionnaire and a 13-item QOL scale. The authors' findings show that caregivers of Alzheimer's disease clients who used community-based interventions enjoyed similar levels of QOL as caregivers of non-Alzheimer's disease clients. These findings suggest that community-based interventions may be beneficial and should target the multiple needs of caregivers, including their knowledge of community resources and coping strategies.

The relation between disease severity and cost of caring for patients with Alzheimer disease in Canada

OBJECTIVES

to characterize the cost of caring for an outpatient in Canada with Alzheimer disease (AD) based on disease severity, and to describe how costs change with increases in disease severity.

METHOD

community-dwelling patients with mild-to-moderate AD were enrolled in a 3-year, naturalistic, observational study. Assessments included cognition (Mini Mental Status Examination), global ratings (Global Deterioration Scale [GDS]), and daily function (Functional Autonomy Measurement System) as part of the Canadian Outcomes Study in Dementia. Direct (medical and nonmedical) and indirect costs were collected using resource use questionnaires. Costs at baseline were compared with costs at follow-up and correlated with disease severity.

RESULTS

total costs associated with treating AD were significantly higher with greater disease severity. The mean total cost to treat patients with very mild AD (GDS = 2) was $367 per month, compared with $4063 per month for patients with severe or very severe AD (GDS = 6). From baseline to follow-up, the greatest changes in cost were observed in the group of patients with the most severe AD as measured by all scales. The largest component of total cost was indirect costs at most severity levels, though medication costs contributed the most in patients with very mild AD. Significant independent contributors to cost were being female, having more impaired activities of daily living, and exhibiting more neuropsychiatric symptoms.

CONCLUSIONS

costs for treating a patient with AD were strongly associated with disease severity, even though none of the patients were institutionalized. Delaying the progression of AD may reduce indirect costs and burden to caregivers.

Priorities for research consortia on Alzheimer's disease

Coordination and harmonization of efforts between five major research consortia on Alzheimer's disease may increase our understanding of this condition and improve our therapeutic approaches. Specific opportunities include a registry for families with early onset dementia, a study registry, minimal data sets, validation of assessment tools and outcomes, update on ethical issues, resolution of methodological issues, new investigators training, longitudinal observation studies, prevention studies, and liaison with stakeholders such as Alzheimer Disease International.

The effect on caregiver burden of a problem-based home visiting programme for frail older people

OBJECTIVE

caregiver effects of geriatric care models focusing primarily at the patient have not been consistently studied. We studied caregiver effects of a nurse-led comprehensive geriatric evaluation and management (GEM) programme for community-dwelling frail older people that showed-in a randomised comparison with usual care--health-related quality of life benefits for the care receivers.

METHODS

this randomised trial included 110 caregiver/patient dyads who were followed up for 6 months. Primary analyses were intention-to-treat analyses of caregiver burden assessed with Zarit Burden Interview (ZBI; 0-88; higher means more burden). Preplanned subgroup analyses were conducted for cognition, living arrangement and patient/caregiver co-residence.

RESULTS

overall, perceived caregiver burden showed no significant differences between study groups in changes over time. However, perceived burden was at baseline more than eight points higher in caregivers sharing a household with patients (n = 23) compared to caregivers living separately (n = 87). The intervention performed better in caregivers living together with the patient than in caregivers living separately (P for interaction = 0.04). Co-resident caregivers experienced six-Zarit point improvement compared with four-point deterioration in the non-co-resident caregivers.

CONCLUSIONS

GEM at home benefited patients, but maybe not caregivers. Caregiver effects are related to whether caregivers live with the patient or not.

First Link: Strengthening Primary Care Partnerships for Dementia Support

While primary care faces many challenges, including an increasing prevalence of older individuals, emerging knowledge about the potential benefits of collaborative partnerships has encouraged the development of new means of providing and supporting primary care. First Link™ is an innovative program involving collaborations among primary care providers, Alzheimer Societies, and other health professionals. The program aims to support persons with Alzheimer's and related diseases after the diagnosis is made and to link them with support services earlier in the disease course. This paper describes the First Link program, provides an overview of a study currently underway to evaluate it, and identifies some of the benefits and challenges associated with this partnership.

The ICTUS Study: A Prospective Longitudinal Observational Study of 1,380 AD Patients in Europe

The long-term objective of the ICTUS study is to identify milestones in Alzheimer's disease (AD) progression and to develop a model to predict disease course in individual AD patients in Europe. The secondary objectives are to describe the patterns of prescribing, and the socioeconomic impact of AD in Europe. Between 2003 and 2005 1,380 patients with probable AD were recruited in specialised (secondary care) clinics in 12 European countries. Their mean age was 76 years and they had a mean of 8.0 +/- (SD) 4.6 years of education. Thirty-five percent were male. The mean MMSE score was 20.4 +/- (SD) 4.0. Forty-three percent had very mild dementia (CDR 0.5) and 44% had mild dementia (CDR 1). All patients completed baseline evaluation and biannual follow-up is ongoing. The goals of the current study are to describe the specific methods for recruitment in this crosscultural setting and the characteristics of the inception ICTUS cohort, including clinical features, co-morbidity, neuropsychological performance, neuropsychiatric symptoms, functional impairment and social burden.

The eSMAF: a software for the assessment and follow-up of functional autonomy in geriatrics

Background

Functional status or disability forms the core of most assessment instruments used to identify mix and level of resources and services needed by older adults who possess common characteristics. The Functional Autonomy Measurement System (SMAF) is a 29-item scale measuring functional ability in five different areas. It has been recommended for use for home care, for allocation of chronic beds, for developing care plans in institutional settings and for epidemiological and evaluative studies. The SMAF can also be used with a case-mix classification system (Iso-SMAF) to allocate resources based on patients' functional autonomy characteristics. The objective of this project was to develop a software version of the SMAF to facilitate the evaluation of the functional status of older adults in health services research and to optimize the clinical decision-making process.

Results

The eSMAF was developed over an 24-month period using a modified waterfall software engineering process. Requirements and functional specifications were determined using focus groups of stakeholders. Different versions of the software were iteratively field-tested in clinical and research environments and software adaptations made accordingly. User documentation and online help were created to assist the deployment of the software. The software is available in French or English versions under a 30-day unregistered demonstration license or a free restricted registered academic license. It can be used locally on a Windows-based PC or over a network to input SMAF data into a database, search and aggregate client data according to clinical and/or administrative criteria, and generate summary or detailed reports of selected data sets for print or export to another database.

Conclusion

In the last year, the software has been successfully deployed in the clinical workflow of different institutions in research and clinical applications. The software performed relatively well in terms of stability and performance. Barriers to implementation included antiquated computer hardware, low computer literacy and access to IT support. Key factors for the deployment of the software included standardization of the workflow, user training and support.

Predictors of driving cessation in mild-to-moderate dementia

BACKGROUND

Although physicians in most provinces are mandated to report patients whose driving ability is impaired by illness, little is known about dementia-related factors associated with driving cessation. The purpose of our study was to explore factors that may affect the likelihood of driving cessation in a sample of elderly, community-dwelling patients with dementia.

METHODS

A 3-year prospective study, the Canadian Outcomes Study in Dementia (COSID) has enrolled 883 patients with mild-to-moderate dementia at 32 centres across Canada. Assessment tools included the Mini-Mental State Examination (MMSE) for cognition, the Global Deterioration Scale (GDS) for staging (severity), the Functional Autonomy Measurement System (SMAF) for function, and the Neuropsychiatric Inventory (NPI) for behaviour. Factors associated with the decision to quit driving after the baseline assessment were tested with Cox survival analysis.

RESULTS

Of 719 subjects who were or had been drivers, 203 (28.2%) were still driving at baseline. Over an observation period that averaged 23 months, 97 (48.5%) of 200 patients quit driving. Factors predictive of driving cessation included GDS (hazard ratio [HR] 1.68, 95% confidence interval [CI] 1.15-2.45), MMSE score (HR 0.90, 95% CI 0.83-0.97) and NPI findings (HR 1.63 for presence of > or = 3 behaviours, 95% CI 1.01-2.62). Among the NPI behaviours, when they were analyzed separately, agitation led to a decreased likelihood of driving cessation (p = 0.019), whereas apathy (p = 0.031) and hallucinations (p = 0.050) led to an increased likelihood.

INTERPRETATION

Cognitive impairment and behaviours such as agitation, apathy and hallucinations were significant predictors of driving cessation in patients with a mild to moderate degree of dementia. These findings should be considered when one counsels patients and their families.

The contribution of neuropsychiatric symptoms to the cost of dementia care

OBJECTIVE

To estimate the contribution of behavioral and psychological symptoms of dementia (BPSD) to the costs of care.

METHOD

A one-year prospective study of resource utilization recorded monthly by 500 caregivers of community dwelling patients with dementia. The effect of behavior on total, direct and indirect costs of care was examined.

RESULTS

The total cost of care was $1,298 per month and there was a significant independent relationship between costs and BPSD. The incremental cost of a one point increase in Neuropsychiatric Inventory score was $30 per month (95% CI: $19-$41).

CONCLUSION

BPSD contribute significantly to the overall costs of dementia care. Interventions targeted at BPSD may help to reduce the staggering societal costs of this illness.