Care needs and clinical outcomes of older people with dementia: a population-based propensity score-matched cohort study

Insights into designing educational materials for persons living with dementia: a focus group study

BACKGROUND

Persons living with dementia (PLWD) may experience communication difficulties that impact their ability to process written and pictorial information. Patient-facing education may help promote discontinuation of potentially inappropriate medications for older adults without dementia, but it is unclear how to adapt this approach for PLWD. Our objective was to solicit feedback from PLWD and their care partners to gain insights into the design of PLWD-facing deprescribing intervention materials and PLWD-facing education material more broadly.

METHODS

We conducted 3 successive focus groups with PLWD aged ≥ 50 (n = 12) and their care partners (n = 10) between December 2022 and February 2023. Focus groups were recorded and transcripts were analyzed for overarching themes.

RESULTS

We identified 5 key themes: [1] Use images and language consistent with how PLWD perceive themselves; [2] Avoid content that might heighten fear or anxiety; [3] Use straightforward delivery with simple language and images; [4] Direct recipients to additional information; make the next step easy; and [5] Deliver material directly to the PLWD.

CONCLUSION

PLWD-facing educational material should be addressed directly to PLWD, using plain, non-threatening and accessible language with clean, straightforward formatting.

Rural-urban differences in use of health services before and after dementia diagnosis: a retrospective cohort study

BACKGROUND

Rural-urban differences in health service use among persons with prevalent dementia are known. However, the extent of geographic differences in health service use over a long observation period, and prior to diagnosis, have not been sufficiently examined. The purpose of this study was to examine yearly rural-urban differences in the proportion of patients using health services, and the mean number of services, in the 5-year period before and 5-year period after a first diagnosis of dementia.

METHODS

This population-based retrospective cohort study used linked administrative health data from the Canadian province of Saskatchewan to investigate the use of five health services [family physician (FP), specialist physician, hospital admission, all-type prescription drug dispensations, and short-term institutional care admission] each year from April 2008 to March 2019. Persons with dementia included 2,024 adults aged 65 years and older diagnosed from 1 April 2013 to 31 March 2014 (617 rural; 1,407 urban). Matching was performed 1:1 to persons without dementia on age group, sex, rural versus urban residence, geographic region, and comorbidity. Differences between rural and urban persons within the dementia and control cohorts were separately identified using the Z-score test for proportions (p < 0.05) and independent samples t-test for means (p < 0.05).

RESULTS

Rural compared to urban persons with dementia had a lower average number of FP visits during 1-year and 2-year preindex and between 2-year and 4-year postindex (p < 0.05), a lower likelihood of at least one specialist visit and a lower average number of specialist visits during each year (p < 0.05), and a lower average number of all-type prescription drug dispensations for most of the 10-year study period (p < 0.05). Rural-urban differences were not observed in admission to hospital or short-term institutional care (p > 0.05 each year).

CONCLUSIONS

This study identified important geographic differences in physician services and all-type prescription drugs before and after dementia diagnosis. Health system planners and educators must determine how to use existing resources and technological advances to support care for rural persons living with dementia.

Study protocol for the development and validation of a clinical prediction tool to estimate the risk of 1-year mortality among hospitalized patients with dementia

BACKGROUND

Patients with dementia and their caregivers could benefit from advance care planning though may not be having these discussions in a timely manner or at all. A prognostic tool could serve as a prompt to healthcare providers to initiate advance care planning among patients and their caregivers, which could increase the receipt of care that is concordant with their goals. Existing prognostic tools have limitations. We seek to develop and validate a clinical prediction tool to estimate the risk of 1-year mortality among hospitalized patients with dementia.

METHODS

The derivation cohort will include approximately 235,000 patients with dementia, who were admitted to hospital in Ontario from April 1st, 2009, to December 31st, 2017. Predictor variables will be fully prespecified based on a literature review of etiological studies and existing prognostic tools, and on subject-matter expertise; they will be categorized as follows: sociodemographic factors, comorbidities, previous interventions, functional status, nutritional status, admission information, previous health care utilization. Data-driven selection of predictors will be avoided. Continuous predictors will be modelled as restricted cubic splines. The outcome variable will be mortality within 1 year of admission, which will be modelled as a binary variable, such that a logistic regression model will be estimated. Predictor and outcome variables will be derived from linked population-level healthcare administrative databases. The validation cohort will comprise about 63,000 dementia patients, who were admitted to hospital in Ontario from January 1st, 2018, to March 31st, 2019. Model performance, measured by predictive accuracy, discrimination, and calibration, will be assessed using internal (temporal) validation. Calibration will be evaluated in the total validation cohort and in subgroups of importance to clinicians and policymakers. The final model will be based on the full cohort.

DISCUSSION

We seek to develop and validate a clinical prediction tool to estimate the risk of 1-year mortality among hospitalized patients with dementia. The model would be integrated into the electronic medical records of hospitals to automatically output 1-year mortality risk upon hospitalization. The tool could serve as a trigger for advance care planning and inform access to specialist palliative care services with prognosis-based eligibility criteria. Before implementation, the tool will require external validation and study of its potential impact on clinical decision-making and patient outcomes.

TRIAL REGISTRATION

NCT05371782.

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.

Using Hypothesis-Led Machine Learning and Hierarchical Cluster Analysis to Identify Disease Pathways Prior to Dementia: Longitudinal Cohort Study

BACKGROUND

Dementia development is a complex process in which the occurrence and sequential relationships of different diseases or conditions may construct specific patterns leading to incident dementia.

OBJECTIVE

This study aimed to identify patterns of disease or symptom clusters and their sequences prior to incident dementia using a novel approach incorporating machine learning methods.

METHODS

Using Taiwan's National Health Insurance Research Database, data from 15,700 older people with dementia and 15,700 nondementia controls matched on age, sex, and index year (n=10,466, 67% for the training data set and n=5234, 33% for the testing data set) were retrieved for analysis. Using machine learning methods to capture specific hierarchical disease triplet clusters prior to dementia, we designed a study algorithm with four steps: (1) data preprocessing, (2) disease or symptom pathway selection, (3) model construction and optimization, and (4) data visualization.

RESULTS

Among 15,700 identified older people with dementia, 10,466 and 5234 subjects were randomly assigned to the training and testing data sets, and 6215 hierarchical disease triplet clusters with positive correlations with dementia onset were identified. We subsequently generated 19,438 features to construct prediction models, and the model with the best performance was support vector machine (SVM) with the by-group LASSO (least absolute shrinkage and selection operator) regression method (total corresponding features=2513; accuracy=0.615; sensitivity=0.607; specificity=0.622; positive predictive value=0.612; negative predictive value=0.619; area under the curve=0.639). In total, this study captured 49 hierarchical disease triplet clusters related to dementia development, and the most characteristic patterns leading to incident dementia started with cardiovascular conditions (mainly hypertension), cerebrovascular disease, mobility disorders, or infections, followed by neuropsychiatric conditions.

CONCLUSIONS

Dementia development in the real world is an intricate process involving various diseases or conditions, their co-occurrence, and sequential relationships. Using a machine learning approach, we identified 49 hierarchical disease triplet clusters with leading roles (cardio- or cerebrovascular disease) and supporting roles (mental conditions, locomotion difficulties, infections, and nonspecific neurological conditions) in dementia development. Further studies using data from other countries are needed to validate the prediction algorithms for dementia development, allowing the development of comprehensive strategies to prevent or care for dementia in the real world.

Retrospective study of more than 5 million emergency admissions to hospitals in England: Epidemiology and outcomes for people with dementia

INTRODUCTION

People living with dementia (PwD) admitted in emergency to an acute hospital may be at higher risk of inappropriate care and poorer outcomes including longer hospitalisations and higher risk of emergency re-admission or death. Since 2009 numerous national and local initiatives in England have sought to improve hospital care for PwD. We compared outcomes of emergency admissions for cohorts of patients aged 65+ with and without dementia at three points in time.

METHODS

We analysed emergency admissions (EAs) from the Hospital Episodes Statistics datasets for England 2010/11, 2012/13 and 2016/17. Dementia upon admission was based on a diagnosis in the patient's hospital records within the last five years. Outcomes were length of hospital stays (LoS), long stays (> = 15 days), emergency re-admissions (ERAs) and death in hospital or within 30 days post-discharge. A wide range of covariates were taken into account, including patient demographics, pre-existing health and reasons for admission. Hierarchical multivariable regression analysis, applied separately for males and females, estimated group differences adjusted for covariates.

RESULTS

We included 178 acute hospitals and 5,580,106 EAs, of which 356,992 (13.9%) were male PwD and 561,349 (18.6%) female PwD. Uncontrolled differences in outcomes between the patient groups were substantial but were considerably reduced after control for covariates. Covariate-adjusted differences in LoS were similar at all time-points and in 2016/17 were 17% (95%CI 15%-18%) and 12% (10%-14%) longer for male and female PwD respectively compared to patients without dementia. Adjusted excess risk of an ERA for PwD reduced over time to 17% (15%-18%) for males and 17% (16%-19%) for females, but principally due to increased ERA rates amongst patients without dementia. Adjusted overall mortality was 30% to 40% higher for PwD of both sexes throughout the time-period; however, adjusted in-hospital rates of mortality differed only slightly between the patient groups, whereas PwD had around double the risk of dying within 30 days of being discharged.

CONCLUSION

Over the six-year period, covariate-adjusted hospital LoS, ERA rates and in-hospital mortality rates for PwD were only slightly elevated compared to similar patients without dementia and remaining differences potentially reflect uncontrolled confounding. PwD however, were around twice as likely to die shortly after discharge, the reasons for which require further investigation. Despite being widely used for service evaluation, LoS, ERA and mortality may lack sensitivity to changes in hospital care and support to PwD.

Health service use before and after dementia diagnosis: a retrospective matched case-control study

OBJECTIVES

This study investigated patterns in health service usage among older adults with dementia and matched controls over a 10-year span from 5 years before until 5 years after diagnosis.

DESIGN

Population-based retrospective matched case-control study.

SETTING

Administrative health data of individuals in Saskatchewan, Canada from 1 April 2008 to 31 March 2019.

PARTICIPANTS

The study included 2024 adults aged 65 years and older living in the community at the time of dementia diagnosis from 1 April 2013 to 31 March 2014, matched 1:1 to individuals without a dementia diagnosis on age group, sex, rural versus urban residence, geographical region and comorbidity.

OUTCOME MEASURES

For each 5-year period before and after diagnosis, we examined usage of health services each year including family physician (FP) visits, specialist visits, hospital admissions, all-type prescription drug dispensations and short-term care admissions. We used negative binomial regression to estimate the effect of dementia on yearly average health service utilisation adjusting for sex, age group, rural versus urban residence, geographical region, 1 year prior health service use and comorbidity.

RESULTS

Adjusted findings demonstrated that 5 years before diagnosis, usage of all health services except hospitalisation was lower among persons with dementia than persons without dementia (all p<0.001). After this point, differences in higher health service usage among persons with dementia compared to without dementia were greatest in the year before and year after diagnosis. In the year before diagnosis, specialist visits were 59.7% higher (p<0.001) and hospitalisations 90.5% higher (p<0.001). In the year after diagnosis, FP visits were 70.0% higher (p<0.001) and all-type drug prescriptions 29.1% higher (p<0.001).

CONCLUSIONS

Findings suggest the year before and year after diagnosis offer multiple opportunities to implement quality supports. FPs are integral to dementia care and require effective resources to properly serve this population.

Effects of continuity of care on hospitalizations and healthcare costs in older adults with dementia

INTRODUCTION

People with dementia have high rates of hospitalization, and a share of these hospitalizations might be avoidable with appropriate ambulatory care, also known as potentially preventable hospitalization (PAH). This study investigates the associations between continuity of care and healthcare outcomes in the following year, including all-cause hospitalization, PAHs, and healthcare costs in patients with dementia.

METHODS

This is a longitudinal retrospective cohort study of 69,658 patients with dementia obtained from the Taiwan National Health Insurance Research Database. The Continuity of Care Index (COCI) was calculated to measure the continuity of dementia-related visits across physicians. The PAHs were classified into five types as defined by the Medicare Ambulatory Care Indicators for the Elderly (MACIEs). Logistic regression models were used to examine the effect of COCI on all-cause hospitalizations and PAHs, while generalized linear models were used to analyze the effect of COCI on outpatient, hospitalization, and total healthcare costs.

RESULTS

The high COCI group was significantly associated with a lower likelihood of all-cause hospitalization than the low COCI group (OR = 0.848, 95%CI: 0.821-0.875). The COCI had no significant effect on PAHs but was associated with lower outpatient costs (exp(β) = 0.960, 95%CI: 0.941 ~ 0.979), hospitalization costs (exp(β) = 0.663, 95%CI: 0.614 ~ 0.717), total healthcare costs (exp(β) = 0.962, 95%CI: 0.945-0.980).

CONCLUSION

Improving continuity of care for dementia-related outpatient visits is recommended to reduce hospitalization and healthcare costs, although there was no statistically significant effect of continuity of care found on PAHs.

A Scoping Review of Care Trajectories across Multiple Settings for Persons with Dementia

Multiple transitions across care settings can be disruptive for older adults with dementia and their care partners, and can lead to fragmented care with adverse outcomes. This scoping review was conducted to identify and classify care trajectories across multiple settings for people with dementia, and to understand the prevalence of multiple transitions and associated factors at the individual and organizational levels. Searches of three databases, limited to peer-reviewed studies published between 2007 and 2017, provided 33 articles for inclusion. We identified 26 distinct care trajectories. Common trajectories involved hospital readmission or discharge from hospital to long-term care. Factors associated with transitions were identified mainly at the level of demographic and medical characteristics. Findings suggest a need for investing in stronger community-based systems of care that may reduce transitions. Further research is recommended to address knowledge gaps about complex and longitudinal care trajectories and trajectories experienced by sub-populations of people living with dementia.

Intrinsic Capacity Impairment Patterns and their Associations with Unfavorable Medication Utilization: A Nationwide Population-Based Study of 37,993 Community-Dwelling Older Adults

OBJECTIVES

Our aim was to explore the patterns of intrinsic capacity (IC) impairments among community-dwelling older adults and the associations of these different patterns with excessive polypharmacy, potentially inappropriate medications, and adverse drug reactions in a nationwide population-based study.

DESIGN

A cross-sectional study included older adults from the Taiwan Integrated Care for Older People (ICOPE) program in 2020.

SETTING AND PARTICIPANTS

The study subjects comprised 38,308 adults aged 65 years and older who participated in the ICOPE Step 1 screening and assessed six domains of IC following the World Health Organization (WHO) ICOPE approach.

METHODS

Latent class analysis was adopted to identify distinct subgroups with different IC impairments patterns. The associations between different IC impairments patterns and unfavorable medication utilization, including excess polypharmacy (EPP), potentially inappropriate medications (PIMs), and adverse drug reactions (ADRs), were assessed by multivariate logistic regression models.

RESULTS

Latent class analysis identified five distinct subgroups with different IC impairment patterns: robust (latent class prevalence: 59.4%), visual impairment (17.7%), physio-cognitive decline (PCD) with sensory impairment (12.3%), depression with cognitive impairment (7.7%), and impairments in all domains (2.9%). Compared to the robust group, all other groups were at higher odds for unfavorable medication utilization. The "depression with cognitive impairment" group (EPP: aOR=4.35, 95% CI 3.52-5.39, p<0.01; PIMs: aOR=2.73, 95% CI 2.46-3.02, p<0.01) and the "impairment in all domains" group (EPP: aOR=9.02, 95% CI 7.16-11.37, p<0.01; PIMs: aOR=3.75, 95% CI 3.24-4.34, p<0.01) remained at higher odds for EPP and PIMs after adjustment.

CONCLUSIONS

We identified five distinct impairment patterns of IC, and each impairment pattern, particularly the "depression with cognitive impairment" and "impairment in all domains", was associated with higher odds of EPP and PIMs. Further longitudinal and intervention studies are needed to explore long-term outcomes of different impairment pattern and their reversibility.

Acute care delivery to persons with cognitive impairment: a mixed method study of health professionals' care provision and associated challenges

Objectives: Cognitive impairment is common among older persons admitted to hospital and associated with adverse outcomes. Inadequate care has been widely reported, with health professionals tending to be ill-equipped to meet the specific needs of this patient group. This study aimed to investigate health professionals' care provision to persons with cognitive impairment and associated challenges.Design and Setting: A concurrent, cross-sectional mixed method study was conducted at two university-affiliated hospitals.Participants: A total of 339 health professionals participated in the study.Measurements: An online survey (n = 312) determined the extent to which health professionals perceived their care provision to be person-centered and evidence-based (POPAC-R), and experience distress in looking after this patient group (NPI-D). Four focus group interviews (n = 27) explored health professionals' experience of care provision.Results: More than half of the health professionals reported to act always or very frequently in person-centered and evidence-based ways, and two third experienced challenging behaviors as moderately to very distressing. Health professionals working in acute geriatric wards demonstrated statistically significant higher levels of person-centered and evidence-based care provision, and lower distress. Their caring practices pertained to building a relationship, addressing specific needs, involving family members, and working collaboratively.Conclusions: Findings suggest that geriatric models of care delivery support staff in meeting the needs of persons with cognitive impairment. Health professionals require an acute care culture that values relational, collaborative and coordinated care as essential to patient safety and quality of care, and supports the consistent implementation of evidence-based practices for this patient group.

Measurement Properties of the CAPACITY Instrument to Assess Perceived Communication With the Health Care Team Among Care Partners of Patients With Cognitive Impairment

BACKGROUND

The CAregiver Perceptions About CommunIcaTion with Clinical Team members (CAPACITY) instrument measures how care partners perceive themselves to be supported by the patient's health care team and their experiences communicating with the team.

OBJECTIVES

The objective of this study was to assess the measurement properties (ie, structural validity of the construct and internal consistency) of the CAPACITY instrument in care partners of patients with cognitive impairment, and to examine whether care partner health literacy and patient cognitive impairment are associated with a higher or lower CAPACITY score.

RESEARCH DESIGN

This was a retrospective cohort study.

SUBJECTS

A total of 1746 dyads of community-dwelling care partners and older adults in the United States with cognitive impairment who obtained an amyloid positron emission tomography scan.

MEASURES

The CAPACITY instrument comprises 12 items that can be combined as a total score or examined as subdomain scores about communication with the team and care partner capacity-assessment by the team. The 2 covariates of primary interest in the regression model are health literacy and level of cognitive impairment of the patient (Modified Telephone Interview Cognitive Status).

RESULTS

Confirmatory factor analysis showed the CAPACITY items fit the expected 2-factor structure (communication and capacity). Higher cognitive functioning of patients and higher health literacy among care partners was associated with lower communication domain scores, lower capacity domain scores, and lower overall CAPACITY scores.

CONCLUSIONS

The strong psychometric validity of the CAPACITY measure indicates it could have utility in other family caregivers or care partner studies assessing the quality of interactions with clinical teams. Knowing that CAPACITY differs by care partner health literacy and patient impairment level may help health care teams employ tailored strategies to achieve high-quality care partner interactions.

Trajectories of health system use and survival for community-dwelling persons with dementia: a cohort study

OBJECTIVES

To determine the long-term trajectories of health system use by persons with dementia as they remain in the community over time.

DESIGN

Population-based cohort study using health administrative data.

SETTING

Ontario, Canada from 1 April 2007 to 31 March 2014.

PARTICIPANTS

62 622 community-dwelling adults aged 65+ years with prevalent dementia on 1 April 2007 matched 1:1 to persons without dementia based on age, sex and comorbidity.

MAIN OUTCOME MEASURES

Rates of health service use, long-term care placement and mortality over time.

RESULTS

After 7 years, 49.0% of persons with dementia had spent time in long-term care (6.8% without) and 64.5% had died (30.0% without). Persons with dementia were more likely than those without to use home care (rate ratio (RR) 3.02, 95% CI 2.93 to 3.11) and experience hospitalisations with a discharge delay (RR 2.36, 95% CI 2.30 to 2.42). As they remained in the community, persons with dementia used home care at a growing rate (10.7%, 95% CI 10.0 to 11.3 increase per year vs 6.7%, 95% CI 4.3 to 9.0 per year among those without), but rates of acute care hospitalisation remained constant (0.6%, 95% CI -0.6 to 1.9 increase per year).

CONCLUSIONS

While persons with dementia used more health services than those without dementia over time, the rate of change in use differed by service type. These results, particularly enumerating the increased intensity of home care service use, add value to capacity planning initiatives where limited budgets require balancing services.

The Trend of Aggressive Treatments in End-of-Life Care for Older People With Dementia After a Policy Change in Taiwan

OBJECTIVES

We evaluated the trend of end-of-life healthcare utilization and life-sustaining interventions for older adults with dementia 3 to 4 years after the change in hospice policy.

DESIGN

Population-based retrospective cohort study.

SETTING AND PARTICIPANTS

We used the National Health Insurance Research database of enrolled patients ≥65 years of age diagnosed with dementia who died in 2010-2013 (n = 2062).

METHODS

Aggressive treatments, including healthcare utilization and life-sustaining interventions, were recorded within 6 months of death. Aggressive healthcare utilization included ≥1 emergency department visits, ≥1 hospitalizations, >14 days of hospitalization, intensive care unit admission, and death in an acute care hospital. Life-sustaining interventions were enteral tube, artificial nutrition, blood transfusion, hemodialysis, invasive ventilation, and cardiopulmonary resuscitation.

RESULTS

Compared with 2010‒2012, 2013 rates significantly decreased for all measures (P < .001). Composite scores of healthcare utilization and life-sustaining treatments in 2013 were significantly lower than for 2010‒2012, after controlling for confounding variables (both P < .001).

CONCLUSIONS AND IMPLICATIONS

Older patients with dementia had a trend of reduced healthcare utilization and fewer life-sustaining treatments near the end of life from 2010 to 2013 after a policy change.

Gender and Age Differences and the Trend in the Incidence and Prevalence of Dementia and Alzheimer's Disease in Taiwan: A 7-Year National Population-Based Study

Background

Very few nationwide studies have focused on the variations in the incidence and prevalence of dementia and Alzheimer's disease (AD) in Asian countries. This study aims to describe the gender and age differences in the incidence and prevalence of dementia and AD in Taiwan.

Methods

The data on dementia and AD were acquired from the Taiwan National Health Insurance Research Database from 2004 to 2010. The sex and age-specific rates were standardized, and the differences of gender and age on dementia or AD were assessed using Poisson regression analysis.

Results

Over seven years, the prevalence of dementia and AD significantly increased from 4.7 to 7.6 per hundred people (β = 0.0784, p < 0.0001) and 2.3 to 3.5 per hundred people (β = 0.0696, p < 0.0001), respectively. However, the incidence of both dementia and AD decreased but not significantly from 10.9 to 10.7 and 4.9 to 4.6 per thousand person-years, respectively. Noticeably, both incidence and prevalence increased with age and were higher in women than in men.

Conclusions

The standardized incidence rates of dementia and AD are much lower than the data reported in some studies from Europe, the US, and Japan. Further studies are warranted to explore which factors are associated with the differences in the incidence of dementia and AD in Taiwan.

Increased mortality and hospital readmission risk in patients with dementia and a history of cardiovascular disease: Results from a nationwide registry linkage study

OBJECTIVE

To evaluate the impact of cardiovascular disease (CVD) on mortality and readmission risk in patients with dementia.

METHODS

Prospective hospital-based cohort of 59 194 patients with dementia admitted to hospital or visiting a day-clinic between 2000 and 2010. Patients were divided in those with and without a history of CVD (ie, previous admission for CVD; coronary heart disease, heart failure, stroke, atrial fibrillation, or other CVD). Absolute mortality risks (ARs), median survival times, and hazard ratios (adjusted for age, sex, and comorbidity) were calculated.

RESULTS

Three-year ARs and HRs were higher, and survival times were shorter among patients visiting a day-clinic with a history of CVD than in those without. The differences were less pronounced for inpatients. Readmission risk was further increased in the presence of CVD in both day clinic and inpatients.

CONCLUSION

Clinicians need to be more aware of worse prognosis of the population with CVD and dementia.

Cognitive impairment is independently associated with mortality, extended hospital stays and early readmission of older people with emergency hospital admissions: A retrospective cohort study

BACKGROUND

Older adults admitted to hospital are often cognitively impaired. It is not clear whether the presence of cognitive impairment conveys an additional risk for poor hospital outcomes in this patient population.

OBJECTIVES

To determine whether cognitive impairment in hospitalised older adults is independently associated with poor outcomes.

DESIGN

Retrospective cohort study using electronic, routinely collected data from linked clinical and administrative databases.

SETTING

Large, acute district general hospital in England.

PARTICIPANTS

21,399 incident emergency admissions of people aged ≥75, screened for cognitive impairment, categorised to 3 groups: (i) cognitive impairment with a diagnosis of dementia, (ii) cognitive impairment with no dementia diagnosis, (iii) no cognitive impairment.

METHODS

Multivariable logistic regression and Fine and Gray competing risks survival models were employed to explore associations between cognitive impairment and mortality (in-hospital alone, and in-hospital plus up to 30 days after discharge), time to hospital discharge, and hospital readmission within 30 days of discharge. Covariates included age, severity of illness, main diagnosis, comorbidities and nutritional risk.

RESULTS

Twenty-seven percent of patients had cognitive impairment; of these, 61.5% had a diagnosis of dementia and 38.5% did not. Patients with cognitive impairment and no diagnosis of dementia were most likely to die in hospital or be readmitted, they also had the longest hospital stays. Cognitive impairment was independently associated with mortality in hospital (Odds Ratio 1.34 [1.17-1.55] with dementia; Odds Ratio 1.78 [1.52-2.07] without), mortality in hospital or within 30 days of discharge (Odds Ratio 1.66 [1.48-1.86]; Odds Ratio 1.67 [1.46-1.90]); readmission (Odds Ratio 1.21 [1.04-1.40]; Odds Ratio 1.47 [1.25-1.73]), and increased time until discharge (sub-hazard ratio 0.80 [0.76-0.83]; sub-hazard ratio 0.66 [0.63-0.69]).

CONCLUSIONS

Cognitive impairment is associated with an increased risk of adverse outcomes in hospitalised older people with an unscheduled admission, by increasing hospital mortality, extending hospital stays and increasing frequency of readmissions. Future research should focus on understanding the mechanisms contributing to poorer outcomes in this population.

Palliative medicine and end-of-life care

Palliative care is an approach to the care of patients, affected by serious illness, and their families that aims to reduce suffering through the management of medical symptoms, psychosocial issues, spiritual well-being, and setting goals of care. Patients and families affected by a neurodegenerative illness have significant palliative care needs beginning at the time of diagnosis and extending through end-of-life care and bereavement. We advocate an approach to addressing these needs where the patient's primary care provider or neurologist plays a central role. Key skills in providing effective palliative care to this population include providing the diagnosis with compassion, setting goals of care, anticipating safety concerns, caregiver assessment, advance care planning, addressing psychosocial concerns, and timely referral to a hospice. Managing distressing medical and psychiatric symptoms is critical to improving quality of life throughout the disease course as well as at end-of-life. Many symptoms are common across illnesses; however, there are issues that are specific to the most common classes of neurodegenerative illness, namely dementia, parkinsonism, and motor neuron disease. Incorporating a palliative approach to care, although challenging in many ways, empowers physicians to provide greater support and guidance to patients and families in making the difficult journey through a neurodegenerative illness.

Quality of acute care for persons with cognitive impairment and their families: A scoping review

BACKGROUND

An increasing number of older persons with cognitive impairment use inpatient services for co-occurring acute illness. Research has demonstrated that persons with cognitive impairment face more adverse health outcomes during hospitalization than their age counterparts without cognitive impairment. As hospitals tend to be ill equipped to meet the complex care needs of this population, various initiatives underscore the need to better utilize existing evidence to improve quality of care.

OBJECTIVES

To map the extent of knowledge about quality of acute care in inpatient settings, and to synthesize knowledge on strategies to improve quality care for persons with cognitive impairment and their families.

DESIGN

A scoping review using Arksey and O'Malley's methodological framework.

DATA SOURCES

CINAHL and Medline were searched and reference lists of pertinent articles screened to identify publications regarding acute care for persons with cognitive impairment.

REVIEW METHODS

Two reviewers independently screened and identified publications based on eligibility criteria. Publications were included if they targeted acute care issues relating to persons with cognitive impairment 65 years or older, their family members, or health professionals caring for them, and were published after 2000 in English or German. Publications were read and data were extracted using a predefined template. Thematic analysis was conducted by two reviewers.

RESULTS

Of the 1445 identified publications, 66 were included. Quality of acute inpatient services pertained to structural (such as staff capacity and knowledge) and process dimensions (such as forming a caring relationship, assessing and intervening). Strategies identified to improve care quality included interventions at the point of care, such as specific tools and specialist roles to improve patient outcomes, as well as educational and training interventions to enable staff to care for this patient group.

CONCLUSIONS

There is a discrepancy between clearly defined best practice for persons with cognitive impairment utilising inpatient services, and the quality of care actually experienced by patients, family members, and staff. Research reveals a sobering picture of inadequate care and manifold challenges encountered by this patient group, family members and staff alike. Promising strategies to improve care quality target health professionals' knowledge and capacity to work with this group and include specific tools and models of care, such as specialist roles and units. Organisation-wide efforts to ensure quality care for this patient group are needed, as is further research to determine which implementation and intervention strategies achieve the most beneficial outcomes for all involved.

Different impacts of dementia on two-year mortality after osteosynthesis and hemiarthroplasty in treating geriatric hip fractures

BACKGROUND

Geriatric hip fractures are mostly managed by internal fixation (IF) or hemiarthroplasty (HA). Survivorship of dementia patients following these surgeries has not been extensively compared in literature. By analysis of nationwide database, this study aimed to investigate the impact of dementia on two-year mortality after IF and HA in treating geriatric hip fractures.

METHOD

From retrospective review of Taiwan's National Health Insurance Research Database, we enrolled 153,623 subjects aged 65 years and older with hospitalization for first hip fracture operated by IF (93,029 cases) or HA (60,594 cases) between 2000 and 2011. Postoperative mortality was compared between subjects with and without dementia after adjustments of age, gender, Charlson comorbidity index and hospital level.

RESULTS

The prevalence of dementia was 5.24% in the IF and 5.29% in the HA group. In the IF group, dementia increased adjusted hazard ratio of one-year (1.06, 95%CI:1.00-1.13) and two-year mortality (1.10, 95%CI:1.05-1.16). However, short and long-term mortality following HA was not significantly impacted by dementia (in-hospital OR:0.79, 95%CI:0.60-1.03; three-month HR:0.99, 95%CI:0.87-1.12; one-year HR:1.01, 95%CI:0.93-1.10; two-year HR:1.03, 95%CI:0.96-1.09). In a subgroup of dementia patients, mortality following IF was 15% higher than HA in one (p = 0.004) and two years (p < 0.001). The negative prognostic factors included female (HR:1.10; 95%CI:1.03-1.18) and aging 65-84 years (HR:1.15; 95%CI:1.00-1.32).

CONCLUSION

Dementia increased one and two-year mortality following geriatric hip fracture treated by IF, rather than HA. Dementia patients undergoing HA, especially female or 65-84 years old, sustained better one and two-year survival than those receiving IF.

Hospital outcomes of older people with cognitive impairment: An integrative review

OBJECTIVES

To summarise existing knowledge of outcomes of older hospital patients with cognitive impairment, including the type and frequency of outcomes reported, and the additional risk experienced by this patient group.

METHODS

Integrative literature review. Health care literature databases, reports, and policy documents on key websites were systematically searched. Papers describing the outcomes of older people with cognitive impairment during hospitalisation and at discharge were analysed and summarised using integrative methods.

RESULTS

One hundred four articles were included. A range of outcomes were identified, including those occurring during hospitalisation and at discharge. Older people with a dementia diagnosis were at higher risk from death in hospital, nursing home admission, long lengths of stay, as well as intermediate outcomes such as delirium, falls, dehydration, reduction in nutritional status, decline in physical and cognitive function, and new infections in hospital. Fewer studies examined the relationship of all-cause cognitive impairment with outcomes. Patient and carer experiences of hospital admission were often poor. Few studies collected data relating to hospital environment, eg, ward type or staffing levels, and acuity of illness was rarely described.

CONCLUSIONS

Older people with cognitive impairment have a higher risk of a variety of negative outcomes in hospital. Prevalent intermediate outcomes suggest that changes in care processes are required to ensure maintenance of fundamental care provision and greater attention to patient safety in this vulnerable group. More research is required to understand the most appropriate ways of doing this and how changes in these care processes are best implemented to improve hospital outcomes.

Delaying cognitive and physical decline through multidomain interventions for residents with mild-to-moderate dementia in dementia care units in Taiwan: A prospective cohort study

AIM

To develop experimental multi-domain interventions for older people with mild-to-moderate dementia, and to evaluate the effect of delaying cognitive and physical decline, and improvement or prevention of geriatric syndromes during 1-year follow up.

METHODS

Participants aged 65 years and older with mild-to-moderate dementia (clinical dementia rating [CDR] 1 or 2) were grouped as intervention in Jia-Li Veterans Home and usual care model in the community (Memory clinic). All residents in Jia-Li Veterans Home received comprehensive intervention, including Multi-disciplinary team consultation and intervention, Multi-component non-pharmacological management, geriatric syndromes survey and intervention by CGA, and a dementia friendly medical Green channel Approach (2MCGA). The decline of cognitive and physical function are determined by the change of Mini-Mental State Examination score, CDR and the sum of CDR box, as well as activities of daily living based on the Barthel Index. We also screened geriatric syndromes at baseline and 1 year later.

RESULTS

Participants in the intervention group were older and had a lower educational level, lower body mass index, poor baseline activities of daily living function, lower visual impairment, and higher rates of hearing impairment, polypharmacy and risk of malnutrition. The residents receiving 2MCGA had lower baseline Mini-Mental State Examination scores, and higher CDR. For residents in Jia-Li Veterans Home, all cognitive measurements except Mini-Mental State Examination were significantly associated with delaying the decline of cognition after analyzing by multiple linear regression, and multivariate logistic regression also showed that patients living in the community was independently associated with a higher odds ratio for activities of daily living decline (3.180, 95% CI 1.384-7.308, P = 0.006). There are also more improvement in their baseline geriatric syndromes and suffered less from new geriatric syndromes, including falls, urinary incontinence, and risk of malnutrition.

CONCLUSIONS

The 2MCGA intervention shows strong delays in the decline of cognition and physical function for older residents with mild-to-moderate dementia. Furthermore, this strategy can also improve or prevent the onset of new geriatric syndromes, especially fall episodes, urinary incontinence and risk of malnutrition. Geriatr Gerontol Int 2017; 17 (Suppl. 1): 36-43.

Predicting mortality and hospitalization of older adults by the multimorbidity frailty index

Background

Existing operational definitions of frailty are personnel-costly and time-consuming, resulting in estimates with a small sample size that cannot be generalized to the population level. The objectives were to develop a multimorbidity frailty index using Taiwan’s claim database, and to understand its ability to predict adverse event.

Methods

This is a retrospective cohort study. Subjects aged 65 to 100 years who have full National Health Insurance coverage in 2005 were included. We constructed the multimorbidity frailty index using cumulative deficit approach and categorized study population according to the multimorbidity frailty index quartiles: fit, mild frailty, moderate frailty and severe frailty. The multimorbidity frailty index included deficits from outpatient and inpatient diagnosis. Associations with all-cause mortality, unplanned hospitalization and intensive care unit admission were assessed using Kaplan-Meier curves and Cox regression analyses.

Results

The multimorbidity frailty index incorporated 32 deficits, with mean multimorbidity frailty index score of 0.052 (standard deviation = 0.060) among 86,133 subjects included. Compared to subjects in fit category, subjects with severe frailty were associated with a 5.0-fold (adjusted hazard ratio, aHR 4.97; 95% confidence interval, 95% CI 4.49–5.50) increased risk of death at 1 year after adjusting for age and gender. Subjects with moderate frailty or mild frailty was associated with 3.1- (adjusted HR 3.08; 95% CI 2.80–3.39) or 1.9- (adjusted HR 1.86; 95% CI 1.71–2.01) folds increased risk, respectively.4.49–5.50). The risk trend of unplanned hospitalization and intensive care unit admission is similar among the study population. Besides, the association between the frailty categories and all three outcomes was slightly stronger among women.

Conclusion

The multimorbidity frailty index was highly associated with all-cause mortality, unplanned hospitalization and ICU admission. It could serve as an efficient tool for stratifying older adults into different risk groups for planning care management programs.

Comparative Associations Between Measures of Anti-cholinergic Burden and Adverse Clinical Outcomes

PURPOSE

No consensus has been reached regarding which anticholinergic scoring system works most effectively in clinical settings. The aim of this population-based cohort study was to examine the association between anticholinergic medication burden, as defined by different scales, and adverse clinical outcomes among older adults.

METHODS

From Taiwan's Longitudinal Health Insurance Database, we retrieved data on monthly anticholinergic drug use measured by the Anticholinergic Risk Scale (ARS), the Anticholinergic Cognitive Burden Scale (ACB), and the Drug Burden Index - Anticholinergic component (DBI-Ach) for 116,043 people aged 65 years and older during a 10-year follow-up. For all 3 scales, a higher score indicates greater anticholinergic burden. We used generalized estimating equations to examine the association between anticholinergic burden (ARS and ACB: grouped from 0 to ≥4; DBI-Ach: grouped as 0, 0-0.5, and 0.5-1) and adverse outcomes, and stratified individuals by age-group (aged 65-74, 75-84, and ≥85 years).

RESULTS

Compared with the ARS and DBI-Ach, the ACB showed the strongest, most consistent dose-response relationships with risks of all 4 adverse outcomes, particularly in people aged 65 to 84 years. For example, among those 65 to 74 years old, going from an ACB score of 1 to a score of 4 or greater, individuals' adjusted odds ratio increased from 1.41 to 2.25 for emergency department visits; from 1.32 to 1.92 for all-cause hospitalizations; from 1.10 to 1.71 for fracture-specific hospitalizations; and from 3.13 to 10.01 for incident dementia.

CONCLUSIONS

Compared with the 2 other scales studied, the ACB shows good dose-response relationships between anticholinergic burden and a variety of adverse outcomes in older adults. For primary care and geriatrics clinicians, the ACB may be a helpful tool for identifying high-risk populations for interventions.

Impact of living arrangements on clinical outcomes among older patients with dementia or cognitive impairment admitted to the geriatric evaluation and management unit in Taiwan

AIM

To evaluate the impact of living arrangements on mortality and functional decline among older patients with dementia or cognitive impairment after discharge from a geriatric evaluation and management unit (GEMU) in Taiwan.

METHODS

The present retrospective cohort study used data from the Veteran Affairs Comprehensive Geriatric Assessment from January 2015 to May 2016 for analysis. Data of patients aged 65 years and older with dementia or cognitive impairment at admission to the GEMU of Taipei Veterans General Hospital during the study period were retried for study. The Veteran Affairs Comprehensive Geriatric Assessment included demographic characteristics, Clinical Frailty Scale, Braden Scale, St. Thomas's Risk Assessment Tool in Falling Elderly Inpatients Scale, Cumulative Illness Rating Scale for Geriatrics, Barthel Index, Instrumental Activities of Daily Living, Mini-Mental State Examination, Geriatric Depression Scale-5 and Mini-Nutritional Assessment - Short Form, as well as common geriatric syndromes. All patients were categorized into the home care group and institutional care group based on their living arrangement before GEMU admissions. Six-month mortality and decline in Barthel Index were defined as adverse clinical outcomes.

RESULTS

Overall, data of 395 patients were used for analysis. The baseline comparisons showed that the institutional care group was more likely to be unmarried, have lower education, lower risk of falls and less polypharmacy, but more likely to experience functional decline at follow up than the home care group. Multivariate logistic regression showed that male (OR 3.59, 95% CI 1.04-12.38, P = 0.043) and higher Cumulative Illness Rating Scale for Geriatrics score (OR 4.08, 95% CI 1.49-11.19, P = 0.006) were associated with mortality, whereas the institutional care group (OR 0.30, 95% 0.09-0.99, P = 0.048) and lower Braden Scale (OR 0.80, 95% CI 0.67-0.94, P = 0.008) were protective against mortality. However, the institutional care group was independently associated with functional decline during the follow-up period (OR 2.19, 95% CI 1.12-4.29, P = 0.022).

CONCLUSIONS

Institutional care was associated with lower 6-month mortality risk for patients with dementia or cognitive impairment after discharge from the GEMU, but this group was more likely to experience functional decline. Further prospective study is required to clarify the clinical impact of living arrangements on long-term outcomes when people with dementia or cognitive impairment are admitted to acute hospitals. Geriatr Gerontol Int 2017: 17 (Suppl. 1): 44-49.

The relationship between in-hospital location and outcomes of care in patients diagnosed with dementia and/or delirium diagnoses: analysis of patient journey

Background

The discrepancy between the number of admissions and the allocation of hospital beds means that many patients admitted to hospital can be placed in units or wards other than that which specialise in the patient’s primary health issue (home-ward). These patients are called ‘outlier’ patients. Risk factors and health system outcomes of hospital care for ‘outlier’ patients diagnosed with dementia and/or delirium are unknown. Therefore, the aim of this research was to examine patient journeys of people with dementia and/or delirium diagnoses, to identify risk factors for ‘inlier’ or ‘outlier’ status and patient or health system outcomes (consequences) of this status.

Methods

A retrospective, descriptive study compared patients who had dementia and/or delirium according to the proportion of time spent on the home ward i.e. ‘inliers’ or ‘outliers’. Data from the patient journey database at Flinders Medical Centre (FMC), a public hospital in South Australia from 2007 and 2014 were extracted and analysed. The analysis was carried out on the patient journeys of people with a dementia and/or delirium diagnosis.

Results

When 6367 inpatient journeys with dementia and/or delirium within FMC were examined, the Emergency Department (ED) Length of Stay (LOS) after being admitted as inpatient was prolonged for ‘outlier’ patients compared to ‘inlier’ patients (OR: 1.068, 95% CI: 1.057–1.079, p = 0.000). However, the inpatient LOS for’outlier’ patients was only marginally shorter than that of the ‘inlier’ patients (OR: 0.998, 95% CI: 0.998–0.998, p = 0.000). The chances of dying within 48 h of admission increased for ‘outlier’ patients (OR: 1.973, 95% CI: 1.158–3.359, p = 0.012) and their Charlson co-morbidity Index was higher (OR: 1.059, 95% CI: 1.021–1.10, p = 0.002). Completion of discharge summaries within 2 days post-discharge for ‘outlier’ patients was compromised (OR: 1.754, 95% CI: 1.492–2.061, p = 0.000).Additionally, ‘outlier’ patients were more likely to be discharged to another hospital for other care types not offered at FMC (OR: 1.931, 95% CI: 1.559–2.391, p = 0.000).

Conclusion

An examination of the patient journeys at FMC has determined that the health system outcomes for patients with dementia and/or delirium who are admitted outside of their home-ward are affected by in-hospital location despite the homogenous nature of the study population.