Predictors of institutionalization for people with dementia living at home with a carer

Objective. This article examines the relationships between behaviour, psychological functioning, the caring environment and subsequent institutionalization in patients with dementia living at home with a carer. Design. Longitudinal study of behaviour in dementia, with a nested case-control study to investigate predictors of institutionalization. Setting. Subjects with dementia, known to service, living at home with a carer. All lived in Oxfordshire, UK. Participants. 100 people with dementia (Alzheimer's disease and/or vascular dementia) who were living at home with a carer at the start of the study. Measures. At 4-monthly intervals, the carers were interviewed and the subjects with dementia were assessed cognitively. Subjects' behaviour and psychological functioning were assessed using the Present Behavioural Examination. Results. The characteristics which best predicted institutionalization 1 year later were: excessive night-time activity; immobility or difficulty in walking; incontinence; being away from a carer for more than 16 hours a week; and being cared for by a female. Aggressive behaviour was not associated with an increased chance of entry into an institution 1 year later, although it was more prevalent 4 months before entering an institution. Conclusions. Both behaviour and psychological functioning and the caring environment can help in predicting which patients with dementia currently living at home will enter an institution 1 year later. These predictors are not the same as those which are the immediate cause of institutionalization. Copyright© 1998 John Wiley & Sons, Ltd.     

Major depression as a risk factor for early institutionalization of dementia patients living in the community

OBJECTIVE: Although depression is known to be frequently associated with dementia, it is nonetheless under-diagnosed and under-treated among this patient population. Its effect on outcome for dementia patients is thought to be substantial, because depression appears to induce higher than normal rates of disability as well as supplementary cognitive decline. The aim of this study was to measure the impact of major depression on the institutionalization rate of community-dwelling dementia patients. DESIGN: Prospective cohort study. SETTING: Paris, France. PARTICIPANTS: Three-hundred forty-eight consecutive dementia outpatients of a geriatric clinic (mean age: 81 years, 69.8% women, 65.5% dementia of Alzheimer's type, mean baseline MMSE score: 20.5), followed between 1997 and 2002 (mean follow-up: 20.5 months). RESULTS: Twenty-five percent of the patients met the criteria of major depression at baseline, and only 30.3% of these received antidepressant medication. Major depression at baseline was independently associated with nursing home admission within one year of the baseline assessment. Antidepressant medication tended to protect against this outcome, but not to a statistically significant extent. CONCLUSIONS: Major depression at baseline is an independent risk factor for early institutionalization of dementia sufferers. Early institutionalization is defined in this study as nursing home placement within a year of diagnosis with dementia at our specialized outpatient center. The study highlights the need for better management of depression among dementia outpatients. Further investigation is needed to evaluate the protective effect of antidepressant medication (and/or non-pharmacological therapies) on the institutionalization rate.     

Predictors of institutionalization of cognitively-impaired elderly cared for by their relatives.

OBJECTIVES: The purpose of this study is to identify risk factors for nursing home placement of cognitively-impaired elderly, with special attention to the role of psychosocial factors such as the caregiver's preference for institutionalization and the quality of the dyadic relationship. METHODS: Partners, children and children-in-law caring for a relative suffering from dementia (n = 144) were interviewed at home. Sociodemographic variables, patient characteristics, characteristics of the caregiving situation, caregiver characteristics, the support with care and the quality of the caregiving relationship are included as predictors of the caregiver's preference for institutionalization and of the actual institutionalization six to nine months later. Data are analyzed using multiple (logistic) regression analyses. RESULTS: The hypothesis that a poor quality of the relationship, besides other determinants, will be predictive of institutionalization received partial support. No relationship is found between the premorbid relationship quality and institutionalization (preference and actual). However, a good current relationship between the caregiver and the patient reduced the risk of nursing home placement. Institutionalization rate was 16.5% and it was predicted by the caregiver's preference for institutionalization, the functional level of the patient, the quality of the current relationship and the performance of accommodation changes at home. CONCLUSION: Research and interventions directed at delaying or preventing institutionalization should pay more attention to the role of psychosocial aspects in the process of nursing home placement. Specifically the relationship quality in terms of criticism or warmth might be a critical factor in the continuation of home care.     

Performance of chronic schizophrenic patients on cognitive neuropsychological measures sensitive to dementia

Although many chronic schizophrenic patients manifest substantial global cognitive impairment, it is not clear as to whether this impairment should be characterized as dementia. Since many degenerative dementias have a characteristic signature of cognitive impairment and a specific pattern of cognitive decline, examination of schizophrenic patients on these measures can provide information about the qualitative similarity of their cognitive impairment to these other conditions. Three hundred and two chronically hospitalized schizophrenic patients ranging in age from 26 to 98 were examined with the Consortium to Establish a Registry for Alzheimer's Disease (CERAD) neuropsychological battery, as well as a more global measure of cognitive impairment, the Mini-Mental State Examination (MMSE). This assessment was repeated twice, with a 1-year follow-up interval. The CERAD battery measures the prototypical cognitive deficits of Alzheimer's disease, including word list learning and delayed recall, naming and praxis. In contrast to Alzheimer's disease, all aspects of cognitive impairment were linearly associated with MMSE scores and there were no qualitatively different patterns of deficits associated with MMSE scores in different ranges of severity. There was no change in performance on any measure across the follow-up period, regardless of the MMSE scores of the patients at baseline. These data suggest that the specific patterns of deficit in chronic schizophrenic patients with severe cognitive deficits differ from Alzheimer's disease in both course and profile of impairment.     

Factors contributing to institutionalization in patients with Huntington's disease

The objective of this study was to determine which factors are predictive of institutionalization in Huntington's disease. Seven hundred and ninety‐nine subjects with 4313 examinations from the Baltimore Huntington's Disease Center were included in the data set; 88 of these patients with an average follow‐up time of 9.2 years went from living at home to being institutionalized while being observed in our clinic. We examined demographic, genetic, and clinical variables for a relationship with institutionalization using linear regressions, a Cox proportional hazards model, and χ² or t tests in certain cases. In our linear models, scores on the Quantified Neurologic Examination (R² = 0.203, P < .001), Huntington's disease Activities of Daily Living Scale (R² = 0.259, P < .001), and Motor Impairment Score (R² = 0.173, P < .001) were found to have the strongest correlation with time until institutionalization. In addition, CAG repeat length (R² = 0.248, P < .001) was significantly associated with disease duration at institutionalization, when controlling for age at onset. In the Cox proportional hazards model, scores on the Activities of Daily Living Scale, Mini–Mental State Examination, Quantified Neurologic Examination, and Motor Impairment Score all significantly predicted placement in long‐term care. Finally, institutionalized patients were shown to have a higher CAG number and a lower level of educational attainment than patients who avoided institutionalization for at least 15 years after disease onset. Neurologic findings, functional capacity, cognitive impairment, and CAG repeat length are all likely determinants of institutionalization. In contrast with other dementing conditions like Parkinson's and Alzheimer's, psychiatric symptoms were not shown to predict institutionalization in Huntington's disease. This may illustrate the especially debilitating nature of the movement disorder of Huntington's disease in comparison with the other dementias. © 2011 Movement Disorder Society     

Care services for dementia patients: predictors for service utilization

Aim. The objective of this study was to examine service utilization figures among a representative sample of demented patients and to determine whether sociodemographic and health-related variables are associated with care utilization. Method. The study population was derived from a population-based, two-stage cross-sectional study in The Netherlands and consisted of 102 demented subjects. Four levels of care intensity were used: level 1, no use of professional care; level 2, use of one or more types of professional care by community-dwelling subjects; level 3, residential living in homes for the aged; level 4, long-term care in specialized nursing homes. Sociodemographic variables and variables related to mental and physical health, functional dependency and severity of dementia were studied as determinants of levels of care. Results. Eighty-two per cent of the study subjects used one or more types of formal care and 55% were institutionalized. Multivariate analysis yielded age, severity of dementia, somatic disorders, dependency in terms of ADL and martial status as predictors of higher levels of care. Sets of predictors differed across different care levels. Conclusions. The findings point to the importance of the social network and the relevance of general medical treatment and an active approach towards decreasing the impact of ADL dependency in demented subjects. © 1997 John Wiley & Sons, Ltd.     

Longitudinal study of the mental health of caregivers caring for elderly patients with dementia: Effect of institutional placement on mental health

Abstract  One hundred and three family caregivers of relatives with dementia were longitudinally surveyed to examine the course of caregivers' mental health after the relatives had been placed in full-time care facilities. Mental health was assessed twice, with a 6-month interval, using the Japanese version of the 60-item General Health Questionnaire. The degree of social dysfunction was significantly reduced within 6 months after placement, while the other indicators of mental health (e.g. anxiety-insomnia, depression, somatic symptom and psychiatric morbidity) were not reduced within this term. However, anxiety-insomnia and psychiatric morbidity were significantly reduced more than 6 months after placement. Analyses by caregivers' lineal relations to the relatives indicated that only daughters-in-law showed a significant decrease in anxiety-insomnia and a marginal reduction in psychiatric morbidity. This study suggests that caregivers' social dysfunction was more greatly reduced than anxiety-insomnia and psychiatric morbidity within a relatively short term after placement, and that its effects on mental health might vary with the lineal relations.     

Psychotic symptoms in patients with dementia

The current article reviews the current state of knowledge pertaining to psychotic symptoms in patients with dementia, drawing on over 70 studies in this area. The majority of studies utilizing a purpose-designed structured instrument have found a prevalence of psychotic symptoms in excess of 60%. The annual incidence and resolution rates are, however, considerably lower, in the region of 2%. There is little consensus about which factors are of aetiological importance, although it does seem that those with a dementia of moderate severity have the highest prevalence. Perhaps the lack of clarity in this aetiological research partly relates to the limited attention paid to phenomenology. Some suggestions about future research directions which might improve our phenomenological understanding of these conditions are made. Psychotic symptoms are associated with considerable secondary morbidity, including increased aggression, irritability and distress.     

87例老年期痴呆住院患者死亡分析

目的:探讨住院老年期痴呆的生存时间和死亡原因.方法:收集1994年4月～2002年4月间住院死亡的阿尔茨海默病(AD)和血管性痴呆(VD)病例共87例.了解其发病年龄,病程,住院天数和死亡原因.结果:AD组发病年龄和死亡年龄均显著高于VD组.两组生存时间差异无显著性.但AD组中男性生存时间显著短于女性.两组住院天数差异无显著性.两组死亡原因主要均为感染和全身衰竭.结论:我国住院的AD患者发病年龄和死亡年龄均晚于VD患者.女性AD患者生存时间长于男性患者.感染和全身衰竭是老年期痴呆的主要死亡原因.     

The Comprehensive Psychopathological Rating Scale in patients with dementia of Alzheimer type and multiinfarct dementia

ABSTRACT– Eighteen patients with the clinical diagnosis dementia of Alzheimer type (AD/SDAT) and 20 patients with the clinical diagnosis multiinfarct dementia (MID) were interviewed using a subscale to the Comprehensive Psychopathological Rating Scale (CPRS), consisting of items measuring psychopathological symptoms and signs commonly seen in patients with dementia. The aim of the investigation was to evaluate whether a difference in psychopathology between AD/SDAT and MID could be observed during a semistructured psychiatric interview using the CPRS. In both groups the duration of illness was similar and the dementia mild to moderate. All patients were subjected to somatic, psychiatric, laboratory, neurophysiologic and neuroradiologic examinations in order to obtain the correct clinical diagnoses. The results show that patients with AD/SDAT have a more variable psychopathology than patients with MID. Patients with MID were rated lower on all items used, especially those concerning verbal and personal contact. This might explain the generally accepted opinion that patients with MID have better contact with their surroundings and better preservation of their personality, even though they have the same degree of dementia as patients with AD/SDAT.     

Ethical issues in research with dementia patients

The conduct of scientific research involving dementia patients is an ethically complex issue. Increased insight into the causes and aetiology of this condition can be of paramount importance for future patients and society as a whole. However, the rights and interests of vulnerable and incompetent persons as subjects in research make ethical boundaries imperative. A distinction should be made between research that may directly be of benefit to the subject (therapeutic research) and research in which no direct benefit for the patient can reasonably be expected (non-therapeutic research). The majority of the research with dementia patients falls within the latter category. Several ethical issues are discussed, and special attention is paid to the ethical justification of non-therapeutic research involving incompetent subjects suffering from dementia. Five conditions that should be met in order to make this kind of research ethically acceptable are formulated.     

Apolipoprotein E in patients with dementia of the Alzheimer type and vascular dementia

The phenotypes of apolioprotein E (ApoE) in the plasma of patients with dementia of the Alzheimer type (DAT) and vascular dementia (VD) were determined by the isoelectric focusing method. The ApoE mRNA level in the skin fibroblasts was also determined by the Northern blot analysis. As compared with the control subjects, the frequency of the ApoE ε4 allele was significantly higher in the DAT group as well as the VD group, but was not significantly different in the cerebrovascular disease without dementia (CVD) group. The skin fibroblast ApoE mRNA level in the DAT group and the VD group was significantly lower than that in the control group. These findings suggest that the phenotype of ApoE is associated with DAT and VD, and that the lower level of ApoE mRNA may play an important role in the development of DAT as well as VD.     

The prevalence of dementia in a metropolitan city of South Korea

BACKGROUND: There are few studies on the prevalence of dementia in South Korea. This study was designed to estimate the prevalence rate of dementia in a metropolitan city of South Korea, Busan. METHODS: This was a cross-sectional epidemiological study of 1101 residents aged 65 or over in a metropolitan city (Busan) as of 31 December 2001 who were selected with the stratified three-stage cluster sampling. Dementia was assessed by two-stage examination with Mini-Mental State Examination-Korean version (MMSE-K), psychometric measures and the Barthel index. Crude and sex-age adjusted prevalence rate were obtained. RESULTS: The crude rate was 7.4% (men 2.4%, women 10.5%). The sex-age adjusted rate was 7.0% (men 2.5%, women 9.0%) and 8.0% (men 2.7%, women 10.0%) when adjusted with Busan and whole Korean population, respectively. CONCLUSION: These results were lower than those of other domestic studies. This is the first well-designed total-population based epidemiologic study on the prevalence rate of dementia of the aged residing in Busan city. Further studies for evaluating the relationships with type and severity of dementia are needed.     

Wandering behaviour of persons with dementia in Korea: investigation of related factors

Objectives: Despite being identified as a significant clinical phenomenon, wandering of persons with dementia (PWDs) has not been studied in Korea. As an initial trial, various factors chosen from the literature for their predictive relationships to wandering of Korean PWDs were evaluated in this study. Method: A total of 160 PWDs residing in 14 long-term care facilities participated in this study. The Mini-Mental State Exam (MMSE), Physical Activities of Daily Living (PADL) and Korean-translated Revised Algase Wandering Scale (Nursing Home version) (KRAWS-NH) were used to assess participants' degree of cognitive impairment, functional ability and wandering behaviour on six dimensions: persistent walking (PW), specific patterns (SP), spatial disorientation (SD), escape behaviour (EB), attention shift (AS) and negative outcomes (NO). Demographic, personal and environmental data were also collected. Results: The MMSE score was a significant negative predictor for KRAWS-NH overall and subscales except for EB; while age, PADL and history of falls were positive predictors for SD and NO. Total number of residents in a room was a significant negative predictor for EB and AS. Conclusion: Different factors found in PWDs may contribute to different aspects of wandering behaviour. Further studies on factors influencing multiple facets of wandering in various cultural settings are warranted.