Dementia undiagnosed in poor older adults with functional impairment

OBJECTIVES: To identify variables associated with diagnosing dementia in poor older adults by comparing older people with dementia who were diagnosed by their primary care physicians (PCPs) with those not diagnosed by their PCP.
DESIGN: Observational study.
SETTING: Community-based, in-home cognitive assessment program.
PARTICIPANTS: Four hundred eleven adults aged 55 and older with cognitive impairment.
MEASUREMENTS: Instrumental activities of daily living (IADLs), activities of daily living (ADLs), Mini-Mental State Examination, Short Blessed Memory Orientation and Concentration Test, and Clinical Dementia Rating.
RESULTS: Alzheimer's disease was the most common diagnosis in this group of primarily African-American (73%) older people. Of the 411 participants, 232 (56%) were not diagnosed by their PCP. Participants without a previous diagnosis were older (mean age 81.7 vs 78.7, P =.01), more independent in IADLs ( P <.001), and more likely to live alone ( P =.001) than persons diagnosed by their PCP. Of the 201 who lived alone, 66% were not diagnosed with dementia by their PCP. Variables associated with PCP diagnosis were more severe cognitive impairment ( P <.001), spouse caregiver ( P =.009), younger age ( P =.02) and care from a university-based PCP ( P =.04).
CONCLUSION: Persons with dementia who were older and lived alone were less likely to be diagnosed by their PCP. Although persons not diagnosed by their PCP had less cognitive impairment, they had substantial impairment in activities, including handling finances, cooking, and managing medications.     

Psychometric Evaluation of the Symptoms of Dementia Screener (SDS) in a Geriatric Primary Care Population

ABSTRACT

Objectives: The Symptoms of Dementia Screener (SDS) is an 11-item scale developed to screen for cognitive impairment. We aim to evaluate the psychometric properties of the SDS for use in primary care.

Methods: We analyzed data from 192 patients: 25 not impaired, 42 with mild cognitive impairment (MCI), and 125 with dementia. Cronbach’s reliability, convergent validity, and clinical utility were examined. The SDS was investigated at the item level using binary two-parameter model item response theory (IRT) techniques.

Results: The SDS demonstrated good reliability (11 items; α = .74). We found negative correlations between SDS and the Mattis DRS-2 (r = ?.523, p < .01). Receiver operating characteristic (ROC) curves demonstrated acceptable clinical utility for detecting MCI and dementia with sensitivities and specificities of 83% and 52% for MCI; 78.4% and 84% for dementia, and 91% and 52% for any impairment. IRT analyses revealed 10 out of 11 items were moderately to very highly related to underlying latent factors of impairment.

Conclusions: The SDS demonstrates good psychometric properties and is useful for detecting cognitive impairment in primary care settings.

Clinical Implications: The SDS is an effective screening tool that does not require special training for its use in primary care. A positive screen indicates a need for further cognitive testing.     

Caring for individuals with dementia and cognitive impairment, not dementia: findings from the aging, demographics, and memory study

OBJECTIVES: To compare the characteristics and outcomes of caregivers of adults with dementia with those of caregivers of adults with cognitive impairment, not dementia (CIND). DESIGN: Cross‐sectional. SETTING: In‐home assessment for cognitive impairment and self‐administered caregiving questionnaire. PARTICIPANTS: One hundred sixty‐nine primary family caregivers of participants in the Aging, Demographics, and Memory Study (ADAMS). ADAMS participants were aged 71 and older drawn from the nationally representative Health and Retirement Study. MEASUREMENTS: Neuropsychological testing, neurological examination, clinical assessment, and medical history were used to assign a diagnosis of normal cognition, CIND, or dementia. Caregiving measures included caregiving time, functional limitations, depressive symptoms, physical and emotional strain, caregiving rewards, caregiver health, and demographic characteristics. RESULTS: Dementia caregivers spent approximately 9 hours per day providing care, compared with 4 hours per day for CIND caregivers (P=.001). Forty‐four percent of dementia caregivers exhibited depressive symptoms, compared with 26.5% of CIND caregivers (P=.03). Physical and emotional strains were similar in both groups of caregivers. Regardless of the strains, nearly all caregivers reported some benefits from providing care. Behavioral problems (P=.01) and difficulty with instrumental activities of daily living (P=.01) in persons with CIND partially explained emotional strain experienced by CIND caregivers. For those with dementia, behavioral problems predicted caregiver emotional strain (P<.001) and depressive symptoms (P=.01). CONCLUSION: Although support services are available to dementia caregivers, CIND caregivers also expend considerable time and experience strains. The real caregiver burden of cognitive impairment in the U.S. population may therefore be greatly underestimated if people who have reached the diagnostic threshold for dementia are focused on exclusively.     

Identifying residents at greater risk for cognitive decline by Minimum Data Set in long-term care settings

Background/PurposeDementia is associated with an individual's dependency and disability, and poses a great care burden to families and societies. Neuroimaging tools and screening questionnaires are important for early diagnosis. However, factors predicting cognitive decline still remain unknown among the elder population, especially in long-term care settings.MethodsA total of 1279 residents of veteran homes in Taiwan were enrolled in this prospective study. Demographic data and items retrieved from the Minimum Data Set, including resident assessment protocols (RAPs), Minimum Data Set Cognitive Scale scores, and Resource Utilization Group-III Activities of Daily Living (RUG-III ADL) Scale scores, were analyzed. The participants were also screened using the Mini-Mental Status Examination questionnaire and assessed by the 15-item Geriatric Depression Scale.ResultsAll participants were male (mean age: 83.2 ± 5.1 years), and 9.9% developed significant cognitive decline. Obvious discrepancy in the prevalence of dementia and depression was noted between the results of screening tests and physicians' diagnosis. Participants with cancer, chronic lung disease, and poor RUG-III ADL status were at greater risk of hospitalization or death. By contrast, those with poor RUG-III ADL status, positive RAP triggers for cognitive loss/dementia, and higher sum of RAP triggers were at higher risk of developing cognitive decline.ConclusionThe diagnosis of dementia and depression remained lower than expected among the elderly population. As presented here, poor physical function, presence of RAP triggers for cognitive loss/dementia, and a higher sum of RAP triggers were strong predictors for cognitive decline.     

Implementing Routine Cognitive Screening of Older Adults in Primary Care: Process and Impact on Physician Behavior

Background Early detection of cognitive impairment is a goal of high-quality geriatric medical care, but new approaches are needed to reduce rates of missed cases. Objective To evaluate whether adding routine cognitive screening to primary care visits for older adults increases rates of dementia diagnosis, specialist referral, or prescribing of antidementia medications. Setting Four primary care clinics in a university-affiliated primary care network. Design A quality improvement screening project and quasiexperimental comparison of 2 intervention clinics and 2 control clinics. The Mini-Cog was administered by medical assistants to intervention clinic patients aged 65+ years. Rates of dementia diagnoses, referrals, and medication prescribing were tracked over time using computerized administrative data. Results Twenty-six medical assistants successfully screened 70% (n = 524) of all eligible patients who made at least 1 clinic visit during the intervention period; 18% screened positive. There were no complaints about workflow interruption. Relative to baseline rates and control clinics, Mini-Cog screening was associated with increased dementia diagnoses, specialist referrals, and prescribing of cognitive enhancing medications. Patients without previous dementia indicators who had a positive Mini-Cog were more likely than all other patients to receive a new dementia diagnosis, specialty referral, or cognitive enhancing medication. However, relevant physician action occurred in only 17% of screen-positive patients. Responses were most related to the lowest Mini-Cog score level (0/5) and advanced age. Conclusion Mini-Cog screening by office staff is feasible in primary care practice and has measurable effects on physician behavior. However, new physician action relevant to dementia was likely to occur only when impairment was severe, and additional efforts are needed to help primary care physicians follow up appropriately on information suggesting cognitive impairment in older patients. An erratum to this article can be found at     

The association between vascular risk factor-mediating medications and cognition and dementia diagnosis in a community-based sample of African-Americans

OBJECTIVE: To determine the association between medications that ameliorate vascular risk factors and the prevalence of cognitive impairment and dementia in an older African-American population. DESIGN: A community-based survey to identify subjects with and without evidence of cognitive impairment and subsequent diagnostic evaluation of a stratified sample of these subjects using formal diagnostic criteria for dementia and Alzheimer's disease (AD). SETTING: Urban neighborhoods in Indianapolis, Indiana. SUBJECTS: A random sample of 2,212 African-American adults aged 65 years and older residing in 29 contiguous census tracts. MEASUREMENTS: Subjects' scores on the Community Screening Instrument for Dementia (CSID), formal diagnostic and clinical assessments for dementia, current medication use and history of medical illnesses, both self-report and, where possible, from an informant. Four outcome measures were defined by the following criteria: (1) cognitive impairment as defined by the subject's performance on the CSID cognitive scale; (2) cognitive/ functional impairment as defined by the total CSID score that included a relative's assessment of the subject's functional abilities; (3) dementia as defined by explicit diagnostic criteria; and (4) possible or probable Alzheimer's Disease as defined by explicit criteria. RESULTS: The vascular risk factor mediating medications, when analyzed together, were associated with a significantly decreased risk of diagnosis of cognitive impairment after controlling for age, education, and stroke (OR 0.73, P = .01) and also a significantly decreased risk of cognitive/functional impairment (OR 0.66, P = .02). Antihypertensive agents, excluding centrally acting sympatholytic drugs were associated with a significantly reduced risk of diagnosis of cognitive impairment (OR 0.56, P < .01) and cognitive/functional impairment (OR 0.64, P = .01). Centrally acting sympatholytic agents were associated with an increased risk of diagnosis of cognitive impairment (OR 2.24, P < .01). There was a trend toward protection from a diagnosis of AD and dementia for the vascular risk factor mediating medications and for the antihypertensive medication, but this did not reach significant levels. CONCLUSIONS: These data suggest that the use of medications to ameliorate vascular risk factors, particularly antihypertensive medication, may also be useful in reducing the risk of cognitive impairment in older subjects. However, they also suggest that physicians should be cautious in prescribing antihypertensive drugs with centrally acting sympatholytic properties to older subjects.     

Determinants of hospitalization and length of stay among people with dementia – An analysis of statutory health insurance claims data

ObjectiveDementia is a crucial challenge in acute care hospitals. Using a retrospective claims data cohort, this paper explores dementia patients' acute hospitalization rates, risk factors, and length of stay.MethodsThe study used claims data from AOK PLUS, the largest statutory health insurance service (SHI) in Saxony, a federal state of Germany. The analysis included 61,239 people with dementia and 183,477 control subjects, all 65 years and older. Control subjects were age, gender, and regionally matched in a 1:3 ratio. Negative binomial hurdle regression was used to compare differences in hospitalization for the year 2014.ResultsPeople with dementia had 1.49 times higher adjusted odds of being hospitalized at least once (95% confidence interval [CI], 1.46–1.52). Among those individuals hospitalized at least once, dementia increased the number of readmissions by 18% (95% CI, 1.15–1.20). Dementia patients also had a 1.74 times higher odds for at least one emergency admission compared to individuals without dementia (95% CI, 1.70–1.78). Dementia patients' admission risk factors included having care dependency, being recently diagnosed with dementia and living outside a metropolitan region. The increased length of stay for people with dementia per year was mainly attributable to higher admission rates.ConclusionsDementia patients are at higher risk for hospitalization, especially if they live outside the metropolitan region. Healthcare systems need to respond to the challenges resulting from the predicted demographic developments and increasing burden of dementia in the general population.     

Empowering the dementia care workforce to manage behavioral symptoms of dementia: Development and training outcomes from the VOICE Dementia Care Program

ABSTRACT

Nonpharmacological approaches for managing behavioral symptoms of dementia remain widely underutilized, due in part to near-universal training needs reported by dementia caregivers in recent research. This article examines the development, core components, and initial outcomes of an evidence-informed, competency-based training program in the prevention and management of behavioral symptoms of dementia among care managers and nurses within an aging services system. The Vital Outcomes Inspired by Caregiver Engagement (VOICE) Dementia Care Training Program was developed based on identification of state-of-the-art approaches to managing behaviors through expert review of the literature and structured needs assessment. Results reveal robust improvements in knowledge, attitudes, and self-efficacy among training participants, with largest effect sizes (d = 1.8) on domains of knowledge and self-efficacy to manage behaviors. Findings support the feasibility and effectiveness of training in improving the abilities and confidence of aging services providers in dementia care and, specifically, in the nonpharmacological management of dementia-related behaviors.     

Diagnosing cognitive impairment and dementia in primary health care -- a more active approach is needed

OBJECTIVE: to determine the documentation rate of dementia in primary health care, the clinical characteristics of patients with documented and undocumented dementia, and the diagnostic evaluations made in cognitive impairment. DESIGN: cross-sectional population-based study with a retrospective review of medical history. SETTING: primary health care in the municipality of Lieto, Southwestern Finland. SUBJECTS: all the inhabitants aged 64 and over in Lieto. Participation rate 82%, numbers = 1260. MEASUREMENTS: assessment of dementia according to DSM-IV criteria, and severity according to Clinical Dementia Rating. Possible documentation of dementia and evaluations done were reviewed from primary health care medical records. RESULTS: 112 patients with dementia were found. The sensitivity of the general practitioners' judgment of dementia was 48.2% and the specificity 99.6%. The documentation rate of dementia was 73% in severe, 46% in moderate and 33% in mild dementia. A greater proportion of the patients with undocumented dementia were male (P = 0.003), lived at home (P = 0.003), coped better with the instrumental activities of daily living (P = 0.006), had more depression (P = 0.029) and milder dementia (P = 0.005) than patients with documented dementia. Thyroid stimulating hormone was measured in 51% of the patients with suspected memory impairment or dementia, B12 vitamin in 20%, and serum calcium in 18%. Twenty-eight per cent of the patients had been tested for cognitive function, 68% for depressive symptoms, and 88% for social abilities. Forty-two per cent of patients were referred to a specialist, 32% of patients who were over 75 years. CONCLUSIONS: less than half of the patients with dementia had their diagnosis documented in primary care medical records. Documentation increased in more advanced dementia. The diagnostic evaluations for reversible causes of dementia were insufficient in primary care, and they were done at a late phase of cognitive impairment.     

Can dementia be diagnosed during hospitalisation?

IntroductionAcute hospitalisation can be an opportunity to diagnose dementia if it can be guaranteed that confounding factors are taken into account.ObjectiveTo study the validity of systematic criteria for the detection of cognitive impairment and of a standardised diagnostic protocol of dementia in elderly patients hospitalised in a geriatric service.MethodsPatients were included if they met any of the following criteria: a) previous score on the Red Cross Mental Scale (RCMS) ≥ 2, b) Pfeiffer Questionnaire score ≥ 5 errors and/or c) presence of delirium (Confusion Assessment Method criteria). A geriatrician conducted a cognitive history and physical examination and the following diagnostic protocol was applied: DSM-IV criteria for dementia, Mini Mental State Examination, Clock Drawing Test, Informant Questionnaire, Clinical Dementia Rating Scale, Pfeffer Scale of Instrumental Activities and Laboratory and neuroimaging tests. Each diagnosis was confirmed by another independent geriatrician.ResultsSeven hundred and fifty-five patients were hospitalised, of which 156 (21%) met the inclusion criteria. The study could be completed during hospitalization in 114 patients (73%). The definitive diagnosis was Alzheimer's disease or mixed dementia in 63 cases (40%), vascular dementia in 17 (11%), mild cognitive impairment in 6 (4%) and delirium without previous decline in 28 (18%). Treatment recommendations were given in all cases.ConclusionsApplication of systematic detection criteria and a standardised diagnostic protocol made it possible to discover unknown cognitive problems in one of every five hospitalised elders and to diagnose 73% of them. Most of the diagnosis were for established dementia.     

Cognitive Assessment of Older Primary Care Patients with and Without Memory Complaints

BACKGROUND Dementia screening is currently recommended only for symptomatic patients. OBJECTIVE To evaluate memory complaints, a mental status test, and several cognitive tests as dementia screens in primary care. DESIGN Cross-sectional clinical epidemiologic study. PARTICIPANTS Three hundred thirty-nine comprehensively assessed, primary care patients aged ≥65 years. MEASUREMENTS Memory complaints were abstracted from chart review. Scores on Mini-Mental State Examination (MMSE) and domain-specific cognitive testing were compared to a dementia diagnosis based on Clinical Dementia Rating score ≥ 1, and areas under the receiver operating characteristic curves (AUC) were calculated. Classification and regression tree analyses were performed on memory complaints and tests with the highest AUCs. RESULTS Of 33 patients with dementia, only 5 had documented memory complaints. In 25 patients with documented memory complaints, no cognitive tests further improved identification of the 5 with dementia. In 28 patients with dementia but without memory complaints, an MMSE score < 20 identified 8 cases; among those with MMSE scores 20–21, a visual memory test identified a further 11 cases. Further cognitive testing could not detect 9 dementia cases without memory complaints and with MMSE scores ≥ 22. CONCLUSIONS In older primary care patients with memory complaints, cognitive screening does not help identify those who require further examination for dementia. Most patients with dementia do not report memory complaints. In these asymptomatic individuals, general mental status testing, supplemented by a memory test when the mental status score is equivocal, will identify lower-scoring patients who need dementia assessment. However, high-scoring asymptomatic dementia cases will remain undetected.     

Dementia lifestyle coach pilot program

Objectives

This study aimed to conduct a feasibility pilot of the Dementia Lifestyle Coach program; an individual coaching and counselling program for people recently diagnosed with dementia, to help them to adjust to the diagnosis and live well.

Methods

A randomised controlled pilot trial (n = 11) with wait-list control group was undertaken over 12 months. Intervention group participants received immediate personalised counselling from a registered psychologist and monthly support (face-to-face or by telephone) from a trained peer mentor living with dementia. The wait-listed control group commenced treatment 6 months after baseline.

Results

Recruitment and delivery of the Dementia Lifestyle Coach program was highly feasible. The program was acceptable, with nine of the 11 participants describing benefits including informational and emotional support, improving their outlook and mood, and family relationships. The planned program was adapted to participants' individual needs.

Conclusions

This small pilot showed that it is feasible to recruit for and deliver a counselling and peer mentoring program for people recently diagnosed with dementia. A larger hybrid implementation randomised control trial should be conducted to evaluate efficacy and effectiveness.     

Multiple views reveal the complexity of dementia diagnosis

Objective: To reveal views about dementia diagnosis derived from a larger study of information needs of carers of people with dementia in Tasmania, Australia. Methods: Over 100 participants, including family carers, health professionals and dementia service personnel, met as discrete focus groups. Data pertinent to dementia diagnosis were segregated and subjected to across‐group comparative analysis. Results: The term dementia held connotations of stigma and futility, despite stated benefits of having a diagnosis. General practitioners were regarded as pivotal but having inadequate diagnostic and treatment options. While most health professionals advocated a longitudinal diagnostic process, this created considerable stress for family carers who sought a speedy process. Without a diagnosis, some dementia‐specific services were undeliverable. Conclusion: Dementia diagnosis is steeped in deep‐rooted difficulties and stressful implications, compounded by carers’ differing needs and interests. Better understanding between care providers of their conflicting and consistent views could contribute to better dementia care.     

The Mexican Cognitive Aging Ancillary Study (Mex-Cog): Study Design and Methods

ObjectiveDescribe the protocol sample and instruments of the Cognitive Aging Ancillary Study in Mexico (Mex-Cog). The study performs an in-depth cognitive assessment in a subsample of older adults of the ongoing Mexican Health and Aging Study (MHAS). The Mex-Cog is part of the Harmonized Cognitive Assessment Protocol (HCAP) design to facilitate cross-national comparisons of the prevalence and trends of dementia in aging populations around the world, funded by the National Institute on Aging (NIA).MethodsThe study protocol consists of a cognitive assessment instrument for the target subject and an informant questionnaire. All cognitive measures were selected and adapted by a team of experts from different ongoing studies following criteria to warrant reliable and comparable cognitive instruments. The informant questionnaire is from the 10/66 Dementia Study in Mexico.ResultsA total of 2,265 subjects aged 55-104 years participated, representing a 70% response rate. Validity analyses showed the adequacy of the content validity, proper quality-control procedures that sustained data integrity, high reliability, and internal structure.ConclusionsThe Mex-Cog study provides in-depth cognitive data that enhances the study of cognitive aging in two ways. First, linking to MHAS longitudinal data on cognition, health, genetics, biomarkers, economic resources, health care, family arrangements, and psychosocial factors expands the scope of information on cognitive impairment and dementia among Mexican adults. Second, harmonization with other similar studies around the globe promotes cross-national studies on cognition with comparable data. Mex-Cog data is publicly available at no cost to researchers.     

Predictors of the decision to yield care of a person with dementia

Objective: The aim of this study is to determine the relative contributions of caregiver and patient characteristics to the subsequent decision to yield care of a person with dementia. Method: The sample comprised 158 people with dementia and their spouse caregivers. The inclusion criteria were that the patient had a diagnosis of Alzheimer's disease, the patient and caregiver were both at least 65 years of age, were co‐resident, that the caregiver was the spouse of the patient, and was actively providing care. Caregiver measures were the Geriatric Depression Scale, SF36, Adelaide Activities Profile, self‐rated health, use of respite services and time as a caregiver. Patient measures were the Functional Dementia Scale, Adelaide Activities Profile, and time since diagnosis. Age and sex were also recorded. Data were obtained by personal interview with caregivers. Two years later, all caregivers were re‐contacted by telephone. At this time 60 (38%) were still providing care; the remaining 98 (62%) had yielded their role to formal institutional care, on average 11.2 months previously. Results: Caregiver characteristics significantly associated with yielding care included greater age, greater use of respite services, less social activities, poorer mental health and greater depression. Patient characteristics significantly associated with yielding care included greater dementia severity, lower activity level, and more frequent incontinence. Conclusion: Dementia severity was the key predictor of the decision to relinquish care. However, it is important to recognise the full range of factors that might indicate that a caregiver is in need of assistance and might be close to yielding the role.     

Evaluation of an Audio-Visual Novela to Improve Beliefs,Attitudes and Knowledge toward Dementia: A Mixed-Methods Approach

Objectives: Dementia is a clinical syndrome characterized by progressive degeneration in cognitive ability that limits the capacity for independent living. Interventions are needed to target the medical, social, psychological, and knowledge needs of caregivers and patients. This study used a mixed methods approach to evaluate the effectiveness of a dementia novela presented in an audio-visual format in improving dementia attitudes, beliefs and knowledge.

Methods: Adults from Los Angeles (N = 42, 83% female, 90% Hispanic/Latino, mean age = 42.2 years, 41.5% with less than a high school education) viewed an audio-visual novela on dementia. Participants completed surveys immediately before and after viewing the material.

Results: The novela produced significant improvements in overall knowledge (t(41) = ?9.79, p < .0001) and led to positive increases in specific attitudes toward people with dementia but not in beliefs that screening would be beneficial. Qualitative results provided concordant and discordant evidence for the quantitative findings.

Conclusions: Results indicate that an audio-visual novela can be useful for improving attitudes and knowledge about dementia, but further work is needed to investigate the relation with health disparities in screening and treatment behaviors.

Clinical Implications: Audio visual novelas are an innovative format for health education and change attitudes and knowledge about dementia.     

Enhancing dementia care: a primary care-based memory clinic

Memory clinics have been promoted as opportunities for improving dementia diagnosis and care. This article describes the implementation of an interdisciplinary memory clinic within primary care in Ontario, Canada, that aims to provide timely access to comprehensive assessment and care and to improve referring physicians' knowledge of the management of dementia through collaborative care and practice-based mentorship. Between July 2006 and September 2009, 246 initial and follow-up assessments were conducted with 151 patients, a high proportion of whom received a new diagnosis of mild cognitive impairment (44.4%) or dementia (19.2%). A trial of cholinesterase inhibitors was recommended for almost all patients newly diagnosed with dementia. Management interventions and recommendations included social worker outreach, long-term care planning, home safety or driving assessments, referral to community resources, and periodic follow-up and monitoring. A small proportion of patients (7.8%) were referred to a specialist. Surveyed patients and caregivers were very satisfied with their visit to the clinic. A chart audit conducted by two independent geriatricians indicated agreement with diagnosis and intervention, particularly related to use of specialists. The results indicate that memory clinics within primary care settings can support capacity building to ensure quality assessment and management of dementia at a primary care level.     

Dementia and its associations in type 2 diabetes mellitus: the Fremantle Diabetes Study

BACKGROUND: recent studies indicate that diabetes is an important risk factor for dementia in older patients, but the cause remains unknown. OBJECTIVES: to determine whether vascular or diabetes-related risk factors predict the development of dementia in older subjects with diabetes. PATIENTS: 63 patients with type 2 diabetes of mean age 75.3 years. METHODS: Subjects were screened for cognitive impairment using the Mini-Mental State Examination (MMSE) and informants who knew the subjects answered the Informant Questionnaire for Cognitive Decline in the Elderly (IQCODE). Probable dementia was diagnosed using highly specific criteria based on the combination of both tests. Potential risk factors for dementia obtained at the time of the cognitive test and annually from a median of 3.2 years previously were examined using univariate methods and simple general linear modelling. RESULTS: since there was a significant association between MMSE and English speaking ability, ten non-Anglo-Celt patients were excluded from the analysis. Probable dementia was diagnosed in six of the remaining 53 subjects (11%). Dementia was significantly and independently associated with higher diastolic and mean arterial blood pressure measurements over the 3 years before assessment. Blood pressure declined over this time in the patients with probable dementia and was similar to that in non-demented subjects at the time of cognitive assessment. CONCLUSIONS: these preliminary data suggest that the high rate of dementia found in older people with diabetes may be explained by the high rate of hypertension in this population.     

Clinical and Economic Burden of COPD in a Medicaid Population

Objective: To evaluate the clinical and economic burden of COPD patients to Medicaid. Study Design: Retrospective, observational matched cohort design. Methods: We calculated the incremental costs incurred and medical resources used by COPD patients relative to those without COPD. Data were obtained from 8 Medicaid states during 2003–2007. COPD patients were defined as Medicaid beneficiaries ≥40 years with a COPD diagnosis (ICD-9 CM: 491.xx, 492.xx, 496.xx) and treated with maintenance drugs for COPD. Patients were matched (1:3) to Medicaid beneficiaries without a COPD diagnosis on age, gender, race, index year, Medicare/Medicaid dual eligibility, and use of long-term care. Results were stratified by Medicare/Medicaid dual eligibility status and race. Results: A total of 10,221 COPD and 30,663 non-COPD patients were included. Cohorts were on average 65 years of age, 80% White, and 64.8% having Medicare/Medicaid dual eligibility. Inpatient hospitalizations and home healthcare visits/durable medical equipment were primary drivers of incremental medical costs. COPD patients were more than twice as likely to have a hospitalization (odds ratio [95% confidence interval] = 2.32 [2.19, 2.45]) or home healthcare visit/durable medical equipment (2.95 [2.82, 3.08]) compared to non-COPD patients. Medicaid incurred $2118/year in incremental costs due to COPD. On average, incremental costs were 7 times greater for non-dual-eligible patients ($4917) compared to dual-eligible patients ($667), and were more than double for Blacks compared to Whites ($4141 vs $1593). Conclusion: COPD imposes a substantial economic and clinical burden on the Medicaid program; this burden differs by dual eligibility status and race.