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

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

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

Prevalence of cognitive impairment in home health physical therapy

BACKGROUND

The prevalence of cognitive impairment in home health physical therapy (HHPT) is unknown. We sought to identify the prevalence of cognitive impairment, including cognitive impairment no dementia (CIND) and dementia, among older adults who used HHPT, and if cognitive impairment prevalence was higher among those with HHPT-relevant characteristics.

METHODS

For our cross-sectional analysis, we identified 963 fee-for-service Medicare beneficiaries with HHPT claims (>85 years old: 28.8%, women: 63.7%, non-Hispanic White: 82.1%) in the 2014 and 2016 waves of the Health and Retirement Study (HRS) and used a validated algorithm to categorize cognitive status as normal, CIND, or dementia. We estimated the population prevalence and calculated age, gender, race/ethnicity adjusted odds ratio (aOR) of CIND and dementia for characteristics relevant to HHPT service delivery including depression, walking difficulty, fall history, incontinence, moderate-vigorous physical activity (MVPA) ≤1x/week, and community-initiated HHPT using multinomial logistic regression.

RESULTS

The population prevalence of cognitive impairment was 46.4% (CIND: 27.3%, dementia: 19.1%). The prevalence of cognitive impairment was greater among those with depression (46.7% vs. 39.5%), difficulty walking across the room (58.9% vs. 41.8%), fall history (49.1% vs. 42.9%), MVPA ≤1x/week (50.0% vs. 38.0%), and community-initiated HHPT (55.2% vs. 40.2%). Compared to normal cognitive status, the odds of cognitive impairment were greater for those with MVPA≤1x/week (CIND: aOR = 1.57 [95% CI: 1.05-2.33], dementia: aOR = 2.55 [95% CI: 1.54-4.22]), depression (dementia: aOR = 1.99 [95% CI: 1.19-3.30]), difficulty walking across the room (dementia: aOR = 2.54 [95% CI: 1.40-4.60]), fall history (dementia: aOR = 1.85 [95% CI: 1.20-2.83]), and community-initiated HHPT (dementia: aOR = 1.72 (95% CI: 1.13-2.61]).

CONCLUSION

There is a high prevalence of CIND and dementia in HHPT, and no characteristics had a low prevalence of cognitive impairment. Physical therapists should be ready to identify cognitive impairment and adapt home health service delivery for this vulnerable population of older adults.

Variation in Home Healthcare Use by Dementia Status Among a National Cohort of Older Adults

BACKGROUND

Medicare-funded home healthcare (HHC) delivers skilled nursing, therapy, and related services through visits to the patient's home. Nearly one-third (31%) of HHC patients have diagnosed dementia, but little is currently known regarding how HHC utilization and care delivery differ for persons living with dementia (PLwD).

METHODS

We drew on linked 2012-2018 Health and Retirement Study and Medicare claims for a national cohort of 1 940 community-living older adults. We described differences in HHC admission, length of stay, and referral source by patient dementia status and used weighted, multivariable logistic and negative binomial models to estimate the relationship between dementia and HHC visit type and intensity while adjusting for sociodemographic characteristics, health and functional status, and geographic/community factors.

RESULTS

PLwD had twice the odds of using HHC during a 2-year observation period, compared to those without dementia (odds ratio [OR]: 2.03; p < .001). They were more likely to be referred to HHC without a preceding hospitalization (49.4% vs 32.1%; p < .001) and incurred a greater number of HHC episodes (1.4 vs 1.0; p < .001) and a longer median HHC length of stay (55.8 days vs 40.0 days; p < .001). Among post-acute HHC patients, PLwD had twice the odds of receiving social work services (unadjusted odds ratio [aOR]: 2.15; p = .008) and 3 times the odds of receiving speech-language pathology services (aOR: 2.92; p = .002).

CONCLUSIONS

Findings highlight HHC's importance as a care setting for community-living PLwD and indicate the need to identify care delivery patterns associated with positive outcomes for PLwD and design tailored HHC clinical pathways for this patient subpopulation.

Factors Associated With Psychological Wellbeing in Home Care Older Adults With Alzheimer's Disease: A Longitudinal Analysis

The long-term symptoms associated with Alzheimer's disease pose significant challenges to the psychological wellbeing of patients. This longitudinal study aims to analyze the effects of socioeconomic factors and physical health factors on the psychological wellbeing of older patients diagnosed with Alzheimer's disease (AD) receiving home care, as well as the moderating role of aging and care support in influencing their psychological wellbeing. Data from the Health and Retirement Study (N = 628 older Alzheimer's patients) were analyzed using pooled ordinary least squares fixed-effects models. Findings suggest that Alzheimer's patients' psychological wellbeing was significantly affected by factors including cohabitation, gender, assistance frequency, age, education, and daily activity challenges, with assistance and increasing age mitigating some daily difficulties. The findings underline the multifactorial nature of psychological wellbeing among older Alzheimer's patients in home care and the critical role of social and physical health determinants in shaping these outcomes.

Terminally differentiated effector memory T cells associate with cognitive and AD-related biomarkers in an aging-based community cohort

Background and Purpose

The immune response changes during aging and the progression of Alzheimer's disease (AD) and related dementia (ADRD). Terminally differentiated effector memory T cells (called TEMRA) are important during aging and AD due to their cytotoxic phenotype and association with cognitive decline. However, it is not clear if the changes seen in TEMRAs are specific to AD-related cognitive decline specifically or are more generally correlated with cognitive decline. This study aimed to examine whether TEMRAs are associated with cognition and plasma biomarkers of AD, neurodegeneration, and neuroinflammation in a community-based cohort of older adults.

Methods

Study participants from a University of Kentucky Alzheimer's Disease Research Center (UK-ADRC) community-based cohort of aging and dementia were used to test our hypothesis. There were 84 participants, 44 women and 40 men. Participants underwent physical examination, neurological examination, medical history, cognitive testing, and blood collection to determine plasma biomarker levels (Aβ42/Aβ40 ratio, total tau, Neurofilament Light chain (Nf-L), Glial Fibrillary Acidic Protein (GFAP)) and to isolate peripheral blood mononuclear cells (PBMCs). Flow cytometry was used to analyze PBMCs from study participants for effector and memory T cell populations, including CD4+ and CD8+ central memory T cells (TCM), Naïve T cells, effector memory T cells (TEM), and effector memory CD45RA+ T cells (TEMRA) immune cell markers.

Results

CD8+ TEMRAs were positively correlated with Nf-L and GFAP. We found no significant difference in CD8+ TEMRAs based on cognitive scores and no associations between CD8+ TEMRAs and AD-related biomarkers. CD4+ TEMRAs were associated with cognitive impairment on the MMSE. Gender was not associated with TEMRAs, but it did show an association with other T cell populations.

Conclusion

These findings suggest that the accumulation of CD8+ TEMRAs may be a response to neuronal injury (Nf-L) and neuroinflammation (GFAP) during aging or the progression of AD and ADRD. As our findings in a community-based cohort were not clinically-defined AD participants but included all ADRDs, this suggests that TEMRAs may be associated with changes in systemic immune T cell subsets associated with the onset of pathology.

A blunted TH17 cytokine signature in women with mild cognitive impairment: insights from inflammatory profiling of a community-based cohort of older adults

People with dementia have an increase in brain inflammation, caused in part by innate and adaptive immune cells. However, it remains unknown whether dementia-associated diseases alter neuro-immune reflex arcs to impact the systemic immune system. We examined peripheral immune cells from a community-based cohort of older adults to test if systemic inflammatory cytokine signatures associated with early stages of cognitive impairment. Human peripheral blood mononuclear cells were cultured with monocyte or T-cell-targeted stimuli, and multiplex assays quantitated cytokines in the conditioned media. Following T-cell-targeted stimulation, cells from women with cognitive impairment produced lower amounts of TH17 cytokines compared with cells from cognitively healthy women, while myeloid-targeted stimuli elicited similar amounts of cytokines from cells of both groups. This TH17 signature correlated with the proportion of circulating CD4+ and CD8+ T cells and plasma glial fibrillary acidic protein and neurofilament light concentrations. These results suggest that decreases in TH17 cytokines could be an early systemic change in women at risk for developing dementia. Amelioration of TH17s cytokines in early cognitive impairment could, in part, explain the compromised ability of older adults to respond to vaccines or defend against infection.

Prevalence and predictors of incident ADRD diagnosis following a Medicare home health episode

INTRODUCTION

Home health (HH) may be an important source of care for those with early-stage/undiagnosed Alzheimer's Disease and Related Dementias (ADRD), but little is known regarding prevalence or predictors of incident ADRD diagnosis following HH.

METHODS

Using 2010-2012 linked Master Beneficiary Summary File (MBSF) and HH assessment data for 40,596 Medicare HH patients, we model incident ADRD diagnosis within 1 year of HH via multivariable logistic regression.

RESULTS

Among HH patients without diagnosed ADRD, 10% received an incident diagnosis within 1 year. In adjusted models, patients were three times more likely to receive an incident ADRD diagnosis if they had HH clinician-reported impaired overall cognition (compared to patients without reported impairment) and twice as likely if they were community-referred (compared to hospital-referred patients).

DISCUSSION

There is a pressing need to develop tailored HH clinical pathways and protect access to community-referred HH to support community-living older adults with early-stage/undiagnosed ADRD.

A Description of Persons With Alzheimer Disease and Related Dementias Receiving Home Health Care: A National Analysis

The end-of-life period of individuals with Alzheimer disease and related dementias receiving home health care (HHC) is understudied. We sought to describe characteristics of HHC patients with Alzheimer disease and related dementias at risk of death within a year, based on clinician assessment. We conducted a secondary data analysis of a 5% random sample of the Outcome and Assessment Information Set data set for the year 2017. We used Outcome and Assessment Information Set-C item M1034 to identify HHC patients with overall status of progressive condition leading to death within a year. Multivariable logistic regression model was used to examine the association between sociodemographic, functional, clinical, and caregiving factors and likelihood of decline leading to death within a year, as identified by HHC clinicians. Clinician perception of decline leading to death within a year was higher for Whites (vs Blacks or Hispanics) (odds ratio [OR], 0.74 [95% confidence interval (CI), 0.69-0.80], and OR, 0.63 [95% CI, 0.57-0.69], respectively). Factors associated with increased odds of decline leading to death within a year included daily pain (OR, 1.11 [95% CI, 1.06-1.17]), anxiety daily or more often (OR, 1.58 [95% CI, 1.49-1.67]), shortness of breath (OR, 1.45 [95% CI, 1.34-1.57]), use of oxygen (OR, 1.60 [95% CI, 1.52-1.69]), disruptive behavior (OR, 1.26 [95% CI, 1.20-1.31]), and feeding difficulty (OR, 2.25 [95% CI, 2.09-2.43]). High symptom burden exists among HHC patients with Alzheimer disease and related dementias identified to have a status of decline leading to death within a year.

Practitioners' Views on Enabling People With Dementia to Remain in Their Homes During and After Crisis

One way of supporting people living with dementia is assisting them to live in their homes (as opposed to being admitted to hospital or other facility) and providing them with a specialist service that responds to crises. This makes it important to understand how best to organize such crisis response services. This study examines practitioners' actions to reduce inpatient admissions among this population. Through interviews with healthcare practitioners, we find that practitioners negotiate a complex intersection between (1) what constitutes a crisis in relation to the patient and/or the carer, (2) the demands of building a working relationship with both the patient and their family carers, and (3) ensuring effective communications with social services responsible for long-term community support. Findings suggest that policies aimed at reducing admissions should be based on a model of care that more closely maps practitioners' relational and bio-medical work in these services.