Health care utilisation amongst older adults with sensory and cognitive impairments in Europe

Impact of allied health student placements for older clients' health and wellbeing in primary healthcare settings: a systematic integrative review

PURPOSE

Allied health student placements in healthcare settings are complex, constantly evolving, and tailored to real-life environments. The value of student placements in acute and primary healthcare settings is reflected in enhanced student learning, improved service delivery, and positive patient outcomes. This review aims to synthesise the effects of allied health student placements in primary healthcare settings, particularly focusing on older clients' health outcomes and satisfaction with care.

MATERIALS AND METHODS

A systematic integrative review was conducted. The five-step integrative review approach, established by Whittemore and Knafl was used to allow the inclusion of diverse research methodologies. Five major databases, i.e., Medline-EBSCO, PubMed, PROQUEST, CINAHL, and SCOPUS were searched. The CLUSTER model was used to track additional references. Data were extracted as suggested by Whittemore and Knafl and then thematically synthesised.

RESULTS

Eleven papers were reviewed. Despite a lack of rigorous methodologies, five mixed-methods studies, four quantitative studies, one qualitative study, and one cost-benefit analysis were identified exploring the possible effects of allied health student placements for older clients. From these papers, four main themes were identified: student integration in service delivery, older clients' health outcomes, satisfaction with care, and insights into mechanisms to achieving health and well-being outcomes.

CONCLUSION

This review suggests that integration of allied health students into service delivery can provide additional healthcare support for older clients, but further high-quality research is needed to confirm.

Examining the magnitude of inequality and inequity in use of healthcare resources among older Australians with cognitive decline

BACKGROUND

This study investigates whether healthcare utilisation among older Australians is equitable, particularly focusing on people with cognitive decline from age 50. It investigates the economic concept of horizontal inequity in various types of healthcare use among older Australians and compares inequity among three groups: a representative sample of all individuals aged 50 and above, those with cognitive impairment, and individuals with a disability. Additionally, we examine changes in these patterns over time.

METHODS AND DATA

This study utilizes cross-sectional data for 2013 and 2017 from the Household, Income and Labour Dynamics in Australia (HILDA) survey to investigate four types of healthcare utilisation-general practitioner (GP), specialist, dental, and hospital admissions. We calculate the concentration index to measure the inequality and inequity in use. To quantify inequity, we correct for differences in needs and health status, following the indirect standardisation approach.

RESULTS

Our findings suggest that among the three samples, the inequity faced by older Australians with cognitive impairment is the most pronounced. Individuals with higher socioeconomic status used dental care more, while GP visits were concentrated among the lower socioeconomic groups in 2013. By 2017, all types of healthcare except GP visits favour the better-off people (pro-rich). Among those with disabilities, we find a pro-rich distribution of dental care in both 2013 and 2017, and pro-rich inequity in the usage of specialist visits, even after adjusting for needs.

CONCLUSION

Pronounced disparities are observed among older people with cognitive impairment. Further targeting of policies to improve access to healthcare for older vulnerable Australians is recommended, to help achieve equitable and universal coverage in Australia.

A Meta-analysis of Loneliness and Risk of Dementia using Longitudinal Data from >600,000 Individuals

Loneliness is one critical risk factor for cognitive health. Combining data from ongoing aging studies and the published literature, we provided the largest meta-analysis on the association between loneliness and dementia (k = 21 samples, N = 608,561) and cognitive impairment (k = 16, N = 103,387). Loneliness increased risk for all-cause dementia (HR = 1.306, 95% CI [1.197,1.426]), Alzheimer's disease (HR = 1.393, 95% CI [1.290,1.504]; k = 5), vascular dementia (HR = 1.735, 95% CI [1.483,2.029]; k = 3), and cognitive impairment (HR = 1.150, 95% CI [1.113,1.189]). The associations persisted when models controlled for depression, social isolation, and/or other modifiable risk factors for dementia. The large heterogeneity across studies was partly due to differences in loneliness measures and ascertainment of cognitive status. Results underscored the importance to further examine type/sources of loneliness and cognitive symptoms to develop effective interventions that reduce the risk of dementia.

Effects of physical and psychological multimorbidity on the risk of dementia: multinational prospective cohorts and a meta-analysis

BACKGROUND

Previous studies only considered the impact of a single physical or psychological disorder on dementia. Our study investigated the association of physical and psychological multimorbidity with dementia among older adults using two multinational prospective cohorts to supplement the limited joint evidence.

METHODS

We utilized the Health and Retirement Study (HRS 2012 to 2018) in the United States (US) and the Survey of Health, Ageing and Retirement in Europe (SHARE 2012 to 2018). Physical disorder was defined as any one of seven self-reported physician-diagnosed conditions. Psychological disorder was assessed using the 8-item Center for Epidemiologic Research Depression (CES-D) scale or the EURO-D. Dementia was determined through a combination of self-reported physician diagnosis of dementia or Alzheimer's disease, or the 27-point HRS cognitive scale. Competing risk models were utilized to estimate the hazard ratios (HRs) and 95% confidence intervals (95% CI). DerSimonian-Laird random-effects meta-analyses were conducted to obtain pooled estimates.

RESULTS

The prevalence of physical and psychological multimorbidity was 17.29% (1027/5939) in continental Europe and 15.52% (1326/8543) in the US. The incidence of dementia was 6.21 per 1000 person-years in continental Europe and 8.27 per 1000 person-years in the US, respectively. It was highest among participants with physical and psychological multimorbidity in continental Europe (10.46 per 1000 person-years) and the US (14.82 per 1000 person-years), compared with the other three groups. In the univariate model, participants who reported physical and psychological multimorbidity had a higher risk of dementia compared with those who reported no physical and psychological disorders in continental Europe (HR = 2.59; 95% CI: 1.55, 4.33) and the US (HR = 4.11; 95% CI: 2.44, 6.94). After adjusting all covariates, the risk of dementia among participants who reported physical and psychological multimorbidity increased by 86% in continental Europe (aHR = 1.86; 95% CI: 1.08, 3.21) and by 176% in the US (aHR = 2.76; 95% CI: 1.61, 4.72), respectively. After pooling the outcomes, the risk of dementia among participants who reported physical and psychological multimorbidity increased by 115% (aHR = 2.15; 95% CI: 1.27, 3.03).

CONCLUSIONS

Physical and psychological multimorbidity was prevalent among older adults in the US and continental Europe. Given the consistent associations with dementia, it is imperative to increase awareness of the links and recognize the limitations of single-disorder care. Specific attention should be given to providing care coordination.

Association Between Dementia, Change in Home-Care Use, and Depressive Symptoms During the COVID-19 Pandemic: A Longitudinal Study Using Data from Three Cohort Studies

Background

The emotional impact of the coronavirus disease 2019 (COVID-19) pandemic on people with dementia has been quantified. However, little is known about the impact of change in home-care use owing to the pandemic.

Objective

To determine the longitudinal association between dementia, change in home-care use, and depressive symptoms during the pandemic.

Methods

We included data of 43,782 home-dwelling older adults from the English Longitudinal Study of Ageing (ELSA), Study of Health, Ageing and Retirement in Europe (SHARE), and National Health and Aging Trends Study (NHATS). This study considered the latest main wave survey prior to the pandemic as the baseline, and the COVID-19 survey as follow-up. In a series of coordinated analyses, multilevel binomial logistic regression model was used to examine the association between baseline dementia, change in home-care use at follow-up, and presence of depressive symptoms.

Results

Dementia, using the ELSA, SHARE, and NHATS datasets, was identified in 2.9%, 2.3%, and 6.5% of older adults, and home-care use reduced in 1.7%, 2.8%, and 1.1% of individuals with dementia, respectively. Dementia was significantly associated with the increased risk of depressive symptoms in all three cohorts. However, the interaction between dementia and period (follow-up) was non-significant in SHARE and NHATS. Across all three cohorts, home-care use during the pandemic, regardless of change in amount, was significantly associated with increased depressive symptoms, compared to the non-use of home care.

Conclusions

These results highlight the need for tailoring dementia care at home to promote independence and provide sustainable emotional support.

Handgrip strength, physical activity and incident mild cognitive impairment and dementia

OBJECTIVE

We analyzed the mediating role of handgrip strength in the association between moderate to vigorous physical activity and incident mild cognitive impairment and dementia.

METHODS

We used prospective data from 14 European countries participating in the Survey of Health, Ageing, and Retirement in Europe. 19,686 participants free of dementia and mild cognitive impairment (64.9 ± 8.7 years) were followed up for a mean of 10.2 years. Moderate to vigorous physical activity was self-reported, and handgrip strength was assessed with a dynamometer. Mild cognitive impairment was defined as 1.5 standard deviations below the mean of the standardized global cognition score, while dementia was determined by physician diagnosis. Gender, age, country, education, presence of chronic diseases, depressive symptoms, limitations in activities of daily living, body mass index, and baseline cognitive levels were used as covariates. Cox proportional hazards as well as mediation models were used.

RESULTS

Moderate to vigorous physical activity for at least 1 day per week was independently associated with lower incident mild cognitive impairment (HR: 0.85; 95%CI: 0.74-0.98). A 10 % increase in handgrip strength was associated a 6 % lower hazard for incident mild cognitive impairment (0.94; 0.92-0.97) and 5 % lower hazard for incident dementia (0.95; 0.93-0.98). Handgrip strength partly mediated the association of moderate to vigorous physical activity with mild cognitive impairment (Coefficient: 0.03; 95%CI: 0.01-0.05; 17.9 %).

CONCLUSIONS

Physical activity is independently associated with a lower incidence of mild cognitive impairment.

The Longitudinal Association between Co-Residential Care Provision and Healthcare Use among the Portuguese Population Aged 50 and Over: A SHARE Study

Co-residential care is associated with poor caregiver health and a high burden. Although Portugal relies heavily on co-residential care by individuals aged 50 and over, studies on the impact of co-residential care provision on Portuguese caregivers' healthcare use are lacking. This study aims to analyze the impact of co-residential care (spousal and non-spousal care) on healthcare use of the Portuguese population aged 50 plus. Data from waves 4 (n = 1697) and 6 (n = 1460) of the Survey of Health, Ageing and Retirement in Europe (SHARE) were used. Negative Binomial Generalized Linear Mixed Models with random (individual level) and fixed (covariates) effects were performed. The results show that the number of visits to the doctor decrease significantly over time for the co-residential spousal caregivers as compared to the non-co-residential caregivers. This result highlights the fact that the Portuguese co-residential spousal caregiver group is at a higher risk of not using healthcare, thus jeopardizing their own health and continuity of care. Promoting more accessible healthcare services and implementing public policies adjusted to the needs of informal caregivers are important to improve the health and healthcare use of Portuguese spousal co-residential caregivers.

Association Between Neuroticism and Dementia on Healthcare Use: A Multi-Level Analysis Across 27 Countries from The Survey of Health, Ageing and Retirement in Europe (SHARE)

BACKGROUND

People with high levels of neuroticism are greater users of health services. Similarly, people with dementia have a higher risk of hospitalization and medical visits. As a result, dementia and a high level of neuroticism increase healthcare use (HCU). However, how these joint factors impact the HCU at the population level is unknown. Similarly, no previous study has assessed the degree of generalization of such impacts, considering relevant variables including age, gender, socioeconomic, and country-level variability.

OBJECTIVE

To examine how neuroticism and dementia interact in the HCU.

METHODS

A cross-sectional study was performed on a sample of 76,561 people (2.4% with dementia) from 27 European countries and Israel. Data were analyzed with six steps multilevel non-binomial regression modeling, a statistical method that accounts for correlation in the data taken within the same participant.

RESULTS

Both dementia (Incidence Rate Ratio (IRR): 1.537; α= 0.000) and neuroticism (IRR: 1.122; α= 0.000) increased the HCU. The effect of having dementia and the level of neuroticism increased the HCU: around 53.67% for the case of having dementia, and 12.05% for each increment in the level of neuroticism. Conversely, high levels of neuroticism in dementia decreased HCU (IRR: 0.962; α= 0.073). These results remained robust when controlling for age, gender, socioeconomic, and country-levels effects.

CONCLUSION

Contrary to previous findings, neuroticism trait in people with dementia decreases the HCU across sociodemographic, socioeconomic, and country heterogeneity. These results, which take into account this personality trait among people with dementia, are relevant for the planning of health and social services.

Trend and effects of high-deductible health insurance plans in the health care system: financial access problems in management of cognitive impairment

BACKGROUND: High-deductible health plans (HDHPs) are characterized by higher deductibles and lower monthly premiums compared with a typical health plan. HDHPs may reduce, or delay, needed care, which will ultimately lead to poorer access to care for chronically affected participants. OBJECTIVES: To (1) investigate the HDHP enrollment trend and (2) determine the effects of HDHPs on financial access problems for individuals with self-reported cognitive impairment. METHODS: Data between 2010 and 2018 were obtained from the National Health Interview Survey (NHIS). Individuals with cognitive impairment were identified if they were limited by memory difficulties. Problems regarding financial access to health care were assessed based on 6 survey questions from the Centers for Disease Control and Prevention. Multivariable logistic regressions were implemented to evaluate the effects of HDHPs. RESULTS: This study identified 1,148 individuals with cognitive impairment, representing 3.9 million individuals in the United States from 2010 to 2018. A nearly 2-fold increase in HDHP enrollment with cognitive impairment was observed from 2010 (20.9%) to 2018 (41.9%). This increase is similar to that reported for noncognitively impaired individuals. After controlling for possible confounding variables, cognitively impaired individuals with HDPHs were more likely to have overall financial access difficulties compared with those without HDHPs (OR = 1.17, 95% CI = 0.88-1.56, P = 0.271), but this likelihood was not statistically significant. CONCLUSIONS: HDHPs are intended to support effective care options and reduce health care costs. However, our research found that among individuals with cognitive impairment, those with HDHPs experienced some financial access problems, such as affording medical care, follow-up care, and specialists, than those without HDHPs, indicating that HDHPs might have unintended consequences for health care usage. DISCLOSURES: No outside funding supported this study. The authors have no conflicts of interest or financial interests to disclose.

Family-Centered Primary Care for Older Adults with Cognitive Impairment

Cognitive impairment (e.g. dementia) presents challenges for individuals, their families, and healthcare professionals alike. The primary care setting presents a unique opportunity to care for older adults living with cognitive impairment, who present with complex care needs that may benefit from a family-centered approach. This indepth systematic review was completed to address three aims: (a) identify the ways in which families of older-adult patients with cognitive impairment are engaged in primary care settings, (b) examine the outcomes of family engagement practices, and (c) organize and discuss the findings using CJ Peek's Three World View. Researchers searched PubMed, Embase, and PsycINFO databases through July 2019. The results included 22 articles out of 6743 identified in the initial search. Researchers provided a description of the emerging themes for each of the three aims. It revealed that family-centered care and family engagement yields promising results including improved health outcomes, quality care, patient experience, and caregiver satisfaction. Furthermore, it promotes and advances the core values of medical family therapy: agency and communion. This review also exposed the inconsistent application of family-centered practices and the need for improved interprofessional education of primary care providers to prepare multidisciplinary teams to deliver family-centered care. Utilizing the vision of Patient- and Family-Centered Care and the lens of the Three World View, this systematic review provides Medical Family Therapists, healthcare administrators, policy makers, educators, and clinicians with information related to family engagement and how it can be implemented and enhanced in the care of patients with cognitive impairment.

A dynamic microeconomic analysis of the impact of physical activity on cognition among older people

This microeconomic study explores the dynamic relationship between physical activity and cognition, using longitudinal data from 6 waves of the Survey of Health, Ageing and Retirement in Europe (SHARE) between 2004 and 2017. Physical activity has drawn significant attention as a potentially successful action for protecting brain health and cognition in the aging population, but the empirical evidence in observational studies is inconclusive to date. We add to the literature by estimating the effect of physical activity on cognition, tackling many sources of bias, which have previously not been addressed consistently. The challenge in estimating the effect of physical activity on cognition is the dynamics of cognition and the endogeneity of physical activity caused by unobserved heterogeneity, reverse causality and measurement error. To address this endogeneity and at the same time control for lagged cognition, we propose a system - generalized method of moments (GMM) estimator, using lagged levels and differences of the endogenous explanatory variables as instruments, while transforming out the fixed effects. We find that being moderately & vigorously physically active at least once a week increases memory status by 0.282 and 0.552 standard deviations for men and women respectively. We find different effects for varying physical activity intensity.

Loneliness is associated with risk of cognitive impairment in the Survey of Health, Ageing and Retirement in Europe

OBJECTIVES

To test whether loneliness is associated with the risk of cognitive impairment up to 11 years later in a European sample of middle-aged and older adults. The study examines whether this association is independent of measures of social isolation, depression, and other risk factors for cognitive impairment and dementia.

METHODS

Participants (N = 14 114) from the Survey of Health, Ageing and Retirement in Europe (SHARE) answered a single item on loneliness at baseline and were assessed for cognitive impairment every 2-to-3 years for 11 years. Participants who scored at least 1.5 standard deviations below the age-graded mean on both a memory recall task and verbal fluency task were classified as impaired. A three-item measure of loneliness was available for a sample of respondents followed up to 4 years.

RESULTS

Feeling lonely was associated with increased risk of incident cognitive impairment (HR = 1.31, 95%CI = 1.19-1.44), after accounting for age, sex, education, and SHARE country strata. The association was robust but reduced in magnitude when controlling for clinical and behavioral risk factors, health-related activity limitations, social isolation, social disengagement, and depressive symptoms. The association was not moderated by socio-demographic factors and was also apparent when using the three-item loneliness scale instead of the single-item measure.

CONCLUSIONS

These findings expand the extant literature on loneliness and the risk of cognitive impairment in older adulthood. Loneliness is one modifiable factor that can be intervened prior to the development of severe impairment or dementia.

Meaning in life and risk of cognitive impairment: A 9-Year prospective study in 14 countries

BACKGROUND

A meaningful and purpose-driven life is associated with better health outcomes. We test whether meaning in life is associated with risk of cognitive impairment using data from a large, multi-national study.

METHODS

Participants (N = 22,514) were from the Survey of Health, Ageing and Retirement in Europe (SHARE). Participants from 14 countries reported on their meaning in life. Cognitive impairment was derived from performance on cognitive tasks administered at baseline and at up to three follow-up waves (waves 2-6 assessed between 2010-2015).

RESULTS

Lack of meaning in life was associated with a more than 20 % increased risk of incident cognitive impairment over the up to 9-year follow-up (Hazard Ratio = 1.24; 95 % Confidence Interval = 1.17-1.31). Further, compared to participants who reported often feeling meaning in life, participants who reported never feeling meaning in life were at an approximately 75 % increased risk of impairment (Hazard Ratio = 1.75, 95 % Confidence Interval = 1.19-2.57). The association between meaning in life and risk of cognitive impairment was apparent across four regions of Europe (Northern, Southern, Eastern, Western) and in Israel and was not moderated by sociodemographic characteristics.

CONCLUSIONS

Reporting lower meaning in one's life is associated with risk of incident cognitive impairment. Meaning may be a potential target of intervention for healthier cognitive aging.