共查询到20条相似文献，搜索用时 31 毫秒
1.
Lucas Morin Davide L. Vetrano Giulia Grande Laura Fratiglioni Johan Fastbom Kristina Johnell 《Journal of the American Medical Directors Association》2017,18(6):551.e1-551.e7
Objectives
To investigate the prevalence and factors associated with the use of medications of questionable benefit throughout the final year of life of older adults who died with dementia.Design
Register-based, longitudinal cohort study.Setting
Entire Sweden.Participants
All older adults (≥75 years) who died with dementia between 2007 and 2013 (n = 120,067).Measurements
Exposure to medications of questionable benefit was calculated for each of the last 12 months before death, based on longitudinal data from the Swedish Prescribed Drug Register.Results
The proportion of older adults with dementia who received at least 1 medication of questionable benefit decreased from 38.6% 12 months before death to 34.7% during the final month before death (P < .001 for trend). Among older adults with dementia who used at least 1 medication of questionable benefit 12 months before death, 74.8% remained exposed until their last month of life. Living in an institution was independently associated with a 15% reduction of the likelihood to receive ≥1 medication of questionable benefit during the last month before death (odds ratio 0.85, 95% confidence interval 0.88–0.83). Antidementia drugs accounted for one-fifth of the total number of medications of questionable benefit. Lipid-lowering agents were used by 8.3% of individuals during their final month of life (10.2% of community-dwellers and 6.6% of institutionalized people, P < .001).Conclusion
Clinicians caring for older adults with advanced dementia should be provided with reliable tools to help them reduce the burden of medications of questionable benefit near the end of life. 相似文献2.
Shubing Cai Susan C. Miller Pedro L. Gozalo 《Journal of the American Medical Directors Association》2018,19(5):439-443
Objectives
Nursing homes (NHs) collaboration with hospices appears to improve end-of-life (EOL) care among dying NH residents. However, the potential benefits of NH-hospice collaboration may vary with the patterns of this collaboration. This study examines the relationship between the attributes of NH-hospice collaboration, especially the exclusivity of NH-hospice collaboration (ie, the number of hospice providers in a NH), and EOL hospitalizations among dying NH residents.Design
This national retrospective cohort study linked 2000-2009 NH assessments (ie, the Minimum Data Set 2.0) and Medicare data. A linear probability model with facility fixed-effects was estimated to examine the relationship between EOL hospitalization and the attributes of NH-hospice collaborations, adjusting for individual and facility characteristics. We also performed a set of sensitivity analyses, including stratified analyses by volume of hospice services in a NH and stratified analyses by rural vs urban NH locations.Settings
All Medicare and/or Medicaid certified US NHs with at least 8 years of data and at least 30 beds.Participants
NH decedents resided in Medicare and/or Medicaid certified NHs in the US between 2000 and 2009. We restricted the analyses to those continuously enrolled in Medicare fee-for-service in the last 6 months of life and those who were in NHs for the last 30 days of life. In total, we identified 2,954,276 NH decedents over the study period.Measurements
The outcome variable was measured as dichotomous, indicating whether a dying NH resident was hospitalized in the last 30 days of life. The attributes of NH-hospice collaboration were measured by the volume of hospice services (defined as the ratio of number of hospice days to the total NH days per NH per calendar year) and the number of hospice providers in a NH (defined as the number of unique hospice providers in a NH per year). We categorized NHs into groups based on the number of hospice providers (1, 2 or 3, and ≥4) in the NH, and conducted sensitivity analysis using a different categorization (1, 2, and 3+ hospice providers).Results
The pattern of NH-hospice collaboration changed significantly over years; the average number of hospices in a NH increased from 1.4 in 2000 to 3.2 in 2009. The volume of NH-hospice collaboration also increased substantially. The multivariate regression analyses indicated that having more hospice providers in the NH was not associated with lower risks of EOL hospitalizations. After accounting for individual and facility characteristics, increasing hospice providers from 1 to at least 4 was associated with an overall 1 percentage point increase in the likelihood of EOL hospitalizations among dying residents (P < .01), and such relationship remained in NHs with moderate or high volume NHs in the stratified analyses. Stratified analysis by rural vs urban NHs suggested that the relationship between the number of hospice providers and EOL hospitalizations was mainly in urban NHs.Conclusions
More hospice providers in the NH was not associated with lower EOL hospitalizations, especially among NHs with relatively high volume of hospice services. 相似文献3.
Margot Darragh Ho Seok Ahn Bruce MacDonald Amy Liang Kathryn Peri Ngaire Kerse Elizabeth Broadbent 《Journal of the American Medical Directors Association》2017,18(12):1099.e1-1099.e4
Objectives
This scoping study is the first step of a multiphase, international project aimed at designing a homecare robot that can provide functional support, track physical and psychological well-being, and deliver therapeutic intervention specifically for individuals with mild cognitive impairment.Design
Observational requirements gathering study.Participants and settings
Semistructured interviews were conducted with 3 participant groups: (1) individuals with memory challenges, mild cognitive impairment (MCI), or mild dementia (patients; n = 9); (2) carers of those with MCI or dementia (carers; n = 8); and (3) those with expertise in MCI or dementia research, clinical care, or management (experts; n = 16). Interviews took place at the university, at dementia care facilities or other workplaces, at participant's homes, or via skype (experts only).Measurements
Semistructured interviews were conducted, transcribed, and reviewed.Results
Several key themes were identified within the 4 topics of: (1) daily challenges, (2) safety and security, (3) monitoring health and well-being, and (4) therapeutic intervention.Conclusions
A homecare robot could provide both practical and therapeutic benefit for the mildly cognitively impaired with 2 broad programs providing routine and reassurance; and tracking health and well-being. The next phase of the project aims to program homecare robots with scenarios developed from these results, integrate components from project partners, and then test the feasibility, utility, and acceptability of the homecare robot. 相似文献4.
Karla T. Washington George Demiris Debra Parker Oliver Gemille Purnell Paul Tatum 《Journal of the American Medical Directors Association》2018,19(2):136-140
Objectives
Older adults in need of residential services are increasingly spending their final days in small, domestic-style care settings such as adult family homes. In this study, we sought to identify processes that facilitated the provision of quality hospice care to seriously ill residents of adult family homes and their family members.Design
We conducted a secondary analysis of qualitative data collected as part of a randomized clinical trial of a problem-solving intervention for family members of hospice patients.Setting
The original trial was conducted in partnership with 2 large, community-based hospice agencies in the state of Washington.Participants
Data from 73 family members of residents of adult family homes receiving hospice services were included in the analysis.Measurements
Data were collected via semi-structured individual interviews, which were audio-recorded and transcribed prior to analysis.Results
Family members described quality hospice care in the adult family home as care that is consistent with residents and families' values and that results in comfort and social connectedness for residents while promoting peace of mind and decreasing burden for residents' families. They identified numerous processes that facilitated the provision of quality care including personalizing care, sharing information and expertise, working together to resolve conflicts, and prioritizing residents and families' values over existing or competing philosophies of care.Conclusion
The adult family home setting can amplify both the benefits and challenges associated with receipt of hospice. When choosing an adult family home, older adults and their families should strongly consider selecting a home with a track record of positive collaborations with hospice agencies if the need for end-of-life care is anticipated. 相似文献5.
Miquel À. Mas Sebastià J. Santaeugènia Francisco J. Tarazona-Santabalbina Sara Gámez Marco Inzitari 《Journal of the American Medical Directors Association》2018,19(10):860-863
Objectives
To compare clinical outcomes in older patients with acute medical crises attended by a geriatrician-led home hospitalization unit (HHU) vs an inpatient intermediate-care geriatric unit (ICGU) in a post-acute care setting.Design
Quasi-experimental longitudinal study, with 30-day follow-up.Participants
Older patients with chronic conditions attended at the emergency department or day hospital for an acute medical crisis.Interventions
Patients were referred to geriatrician-led HHU or ICGU wards.Setting
An acute care hospital, an intermediate care hospital, and the community of an urban area in the North of Barcelona, in Southern Europe.Measurements
We compared health crisis outcomes (recovery from the acute health crisis, referral to an acute hospital, or death), length of stay, relative functional gain (RFG) at discharge, readmission to an acute care unit within 30 days of discharge, and mortality within 30 days of discharge.Results
We included 171 older adults (57 in the HHU and 114 in the ICGU) with complex conditions at risk of negative outcomes. At baseline, HHU patients were significantly younger and less likely to be cognitively impaired and referred from an emergency department. Most patients in both groups recovered from their health crises (91.2% in the HHU group vs 88.6% in the ICGU group, P = .79). No differences were found between the 2 groups in 30-day mortality (8.6% vs 9.6%, P = >.99). There was a trend toward lower 30-day readmission to an acute care unit in the HHU group (10.5% vs 19.3% in the ICGU group, P = .19). HHU patients had higher RFG (mean 0.75 days vs 0.51 in the ICGU group, P = .01), and a longer stay in the unit (9.7 vs 8.2 days in the ICGU group, P < .01).Conclusions
These preliminary results suggest that the geriatrician-led HHU seems effective in resolving acute medical crises in older patients with chronic disease. Patients attended by the HHU obtained better functional outcomes compared to those from the ICGU, although the groups did have some baseline differences. 相似文献6.
Marta Miarons Pere Clavé Robin Wijngaard Omar Ortega Viridiana Arreola Weslania Nascimento Laia Rofes 《Journal of the American Medical Directors Association》2018,19(9):812.e1-812.e10
Objectives
The objective of this study was to assess the pathophysiology of oropharyngeal dysphagia (OD) in patients with dementia, specifically in those taking antipsychotics (APs).Design
A cross-sectional study was performed from January 2011 to May 2017 in a general hospital.Setting and Participants
We included 114 patients with dementia, of which 39 (34.2%) were taking APs (82.5 ± 7.8 years, Barthel Index 52.28 ± 30.42) and 29 patients without dementia (82.4 ± 6.7 years, Barthel Index 77.71 ± 24.7) and OD confirmed by a videofluoroscopy.Measures
Demographical and clinical factors as well as swallowing function of patients with dementia with OD were compared with older patients without dementia with OD. We also compared patients with dementia taking and not taking APs. Impaired efficacy during videofluoroscopy was defined as the presence of oral and/or pharyngeal residue, and impaired safety (unsafe swallow) was defined as aspiration or penetration. Receiver operating characteristic curves were drawn for laryngeal vestibule closure (LVC) time to predict unsafe swallow.Results
87.7% of patients with dementia presented impaired efficacy of swallow and 74.6% impaired safety [penetration-aspiration scale (PAS) 3.94 ± 1.94]. 86.2% of patients without dementia presented impaired efficacy and 44.8% impaired safety (PAS 2.21 ± 1.92). Time to LVC was significantly delayed in patients with dementia taking APs in comparison with patients without dementia (LVC 0.377 ± 0.093 vs 0.305 ± 0.026, P = .003). In contrast, there were no differences in the PAS and LVC time in patients with dementia taking and not taking APs (PAS 3.96 ± 0.26 vs 3.88 ± 0.22, LVC 0.398 ± 0.117 vs 0.376 ± 0.115, NS). LVC time ≥0.340 seconds predicted unsafe swallow in patients with dementia with an accuracy of 0.71.Conclusions/Implications
Patients with dementia presented high prevalence and severity of videofluoroscopy signs of impaired efficacy and safety of swallow and a more severe impairment in airway protection mechanisms (higher PAS and LVC delay). Clinical practice should implement specific protocols to prevent OD and its complications in these patients. AP treatment did not significantly worsen swallowing impairments. 相似文献7.
Sara Garcia-Ptacek Beatriz Contreras Escamez Eva Zupanic Dorota Religa Lena von Koch Kristina Johnell Mia von Euler Ingemar Kåreholt Maria Eriksdotter 《Journal of the American Medical Directors Association》2018,19(2):154-161
Objectives
To explore the association between prestroke mobility dependency and dementia on functioning and mortality outcomes after stroke in patients>65 years of age.Design
Longitudinal cohort study based on SveDem, the Swedish Dementia Registry and Riksstroke, the Swedish Stroke Registry.Participants
A total of 1689 patients with dementia >65 years of age registered in SveDem and suffering a first stroke between 2007 and 2014 were matched with 7973 controls without dementia with stroke.Measurements
Odds ratios (ORs) and 95% confidence intervals (CIs) for intrahospital mortality, and functioning and mortality outcomes at 3 months were calculated. Functioning included level of residential assistance (living at home without help, at home with help, or nursing home) and mobility dependency (independent, needing help to move outdoors, or needing help indoors and outdoors).Results
Prestroke dependency in activities of daily living and mobility were worse in patients with dementia than controls without dementia. In unadjusted analyses, patients with dementia were more often discharged to nursing homes (51% vs 20%; P < .001). Mortality at 3 months was higher in patients with dementia (31% vs 23% P < .001) and fewer were living at home without help (21% vs 55%; P < .001). In adjusted analyses, prestroke dementia was associated with higher risk of 3-month mortality (OR 1.34; 95% CI 1.18–1.52), requiring a higher level of residential assistance (OR 4.07; 3.49–.75) and suffering from more dependency in relation to mobility (OR 2.57; 2.20–3.02). Patients with dementia who were independent for mobility prestroke were more likely to be discharged to a nursing home compared with patients without dementia with the same prestroke mobility (37% vs 16%; P < .001), but there were no differences in discharge to geriatric rehabilitation (19% for both; P = .976). Patients, who moved independently before stroke, were more often discharged home (60% vs 28%) and had lower mortality. In adjusted analyses, prestroke mobility limitations were associated with higher odds for poorer mobility, needing more residential assistance, and death.Conclusions
Patients with mobility impairments and/or dementia present a high burden of disability after a stroke. There is a need for research on stroke interventions among these populations. 相似文献8.
Gilles Allali Cyrille P. Launay Helena M. Blumen Michele L. Callisaya Anne-Marie De Cock Reto W. Kressig Velandai Srikanth Jean-Paul Steinmetz Joe Verghese Olivier Beauchet 《Journal of the American Medical Directors Association》2017,18(4):335-340
Objectives
Falls are highly prevalent in individuals with cognitive decline. The complex relationship between falls and cognitive decline (including both subtype and severity of dementia) and the influence of gait disorders have not been studied. This study aimed to examine the association between the subtype (Alzheimer disease [AD] versus non-AD) and the severity (from preclinical to moderate dementia) of cognitive impairment and falls, and to establish an association between falls and gait parameters during the course of dementia.Design
Multicenter cross-sectional study.Setting
“Gait, cOgnitiOn & Decline” (GOOD) initiative.Participants
A total of 2496 older adults (76.6 ± 7.6 years; 55.0% women) were included in this study (1161 cognitively healthy individuals [CHI], 529 patients with mild cognitive impairment [MCI], 456 patients with mild dementia, and 350 with moderate dementia) from 7 countries.Measurements
Falls history was collected retrospectively at baseline in each study. Gait speed and stride time variability were recorded at usual walking pace with the GAITRite system.Results
The prevalence of individuals who fall was 50% in AD and 64% in non-AD; whereas it was 25% in CHIs. Only mild and moderate non-AD dementia were associated with an increased risk for falls in comparison with CHI. Higher stride time variability was associated with falls in older adults without dementia (CHI and each MCI subgroup) and mild non-AD dementia, whereas lower gait speed was associated with falls in all participant groups, except in mild AD dementia. When gait speed was adjusted for, higher stride time variability was associated with falls only in CHIs (odds ratio 1.14; P = .012), but not in MCI or in patients with dementia.Conclusions
These findings suggest that non-AD, but not AD dementia, is associated with increased falls in comparison with CHIs. The association between gait parameters and falls also differs across cognitive status, suggesting different mechanisms leading to falls in older individuals with dementia in comparison with CHIs who fall. 相似文献9.
Addie Middleton Yong-Fang Kuo James E. Graham Amol Karmarkar Yu-Li Lin James S. Goodwin Allen Haas Kenneth J. Ottenbacher 《Journal of the American Medical Directors Association》2018,19(10):896-901
Objective
Examine readmission patterns over 90-day episodes of care in persons discharged from hospitals to post-acute settings.Design
Retrospective cohort study.Setting
Acute care hospitals.Participants
Medicare fee-for-service enrollees (N = 686,877) discharged from hospitals to post-acute care in 2013-2014. The cohort included beneficiaries >65 years of age hospitalized for stroke, joint replacement, or hip fracture and who survived for 90 days following discharge.Measurements
90-day unplanned readmissions.Results
The cohort included 127,680 individuals with stroke, 442,195 undergoing joint replacement, and 117,002 with hip fracture. Thirty-day readmission rates ranged from 3.1% for knee replacement patients discharged to home health agencies (HHAs) to 14.4% for hemorrhagic stroke patients discharged to skilled nursing facilities (SNFs). Ninety-day readmission rates ranged from 5.0% for knee replacement patients discharged to HHAs to 26.1% for hemorrhagic stroke patients discharged to SNFs. Differences in readmission rates decreased between stroke subconditions (hemorrhagic and ischemic) and increased between joint replacement subconditions (knee, elective hip, and nonelective hip) from 30 to 90 days across all initial post-acute discharge settings.Conclusions
We observed clear patterns in readmissions over 90-day episodes of care across post-acute discharge settings and subconditions. Our findings suggest that patients with hemorrhagic stroke may be more vulnerable than those with ischemic over the first 30 days after hospital discharge. For patients receiving nonelective joint replacements, readmission prevention efforts should start immediately after discharge and continue, or even increase, over the 90-day episode of care. 相似文献10.
Merehau C. Mervin Wendy Moyle Cindy Jones Jenny Murfield Brian Draper Elizabeth Beattie David H.K. Shum Siobhan O&#x;Dwyer Lukman Thalib 《Journal of the American Medical Directors Association》2018,19(7):619-622.e1
Objectives
To examine the within-trial costs and cost-effectiveness of using PARO, compared with a plush toy and usual care, for reducing agitation and medication use in people with dementia in long-term care.Design
An economic evaluation, nested within a cluster–randomized controlled trial.Setting
Twenty-eight facilities in South-East Queensland, Australia.Participants
A total of 415 residents, all aged 60 years or older, with documented diagnoses of dementia.Intervention
Facilities were randomized to 1 of 3 groups: PARO (individual, nonfacilitated 15-minute sessions, 3 afternoons per week for 10 weeks); plush toy (as per PARO but with artificial intelligence disabled); and usual care.Measurements
The incremental cost per Cohen-Mansfield Agitation Inventory–Short Form (CMAI-SF) point averted from a provider's perspective. Australian New Zealand Clinical Trials Registry (BLINDED FOR REVIEW).Results
For the within-trial costs, the PARO group was $50.47 more expensive per resident compared with usual care, whereas the plush toy group was $37.26 more expensive than usual care. There were no statistically significant between-group differences in agitation levels after the 10-week intervention. The point estimates of the incremental cost-effectiveness ratios were $13.01 for PARO and $12.85 for plush toy per CMAI-SF point averted relative to usual care.Conclusion
The plush toy used in this study offered marginally greater value for money than PARO in improving agitation. However, these costs are much lower than values estimated for psychosocial group activities and sensory interventions, suggesting that both a plush toy and the PARO are cost-effective psychosocial treatment options for agitation. 相似文献11.
Edwin C.K. Tan Chengxuan Qiu Yajun Liang Rui Wang J. Simon Bell Johan Fastbom Laura Fratiglioni Kristina Johnell 《Journal of the American Medical Directors Association》2018,19(7):577-583
Objective
To investigate the association between antihypertensive medication regimen intensity and risk of incident dementia in an older population.Design
Prospective, longitudinal cohort study.Participants/Setting
A total of 1208 participants aged ≥78 years, free of dementia, and residing in central Stockholm at baseline (2001–2004).Measurements
Participants were examined at 3- and 6-year follow-up to detect incident dementia. Data were collected through face-to-face interviews, clinical examinations, and laboratory tests. Data on antihypertensive use were obtained by a physician through patient self-report, visual inspection, or medical records. Cox proportional hazards models were used to compute hazard ratios (HRs) and 95% confidence intervals (CIs) for the association between time-varying antihypertensive regimen intensity and incident dementia after adjusting for potential confounders.Results
During the follow-up period, 125 participants were diagnosed with dementia. Participants who developed dementia were more likely to have vascular disease at baseline (66.4% vs 55.3%, P = .02). In fully adjusted analyses, the number of antihypertensive classes (HR 0.68, 95% CI 0.55–0.84) and total prescribed daily dose (HR 0.70, 95% CI 0.57–0.86) were significantly associated with reduced dementia risk. After considering all-cause mortality as a competing risk, the number (HR 0.75, 95% CI 0.62–0.91) and doses (HR 0.71, 95% CI 0.59–0.86) of antihypertensive classes, and the independent use of diuretics (HR 0.66, 95% CI 0.44–0.99), were significantly associated with lower dementia risk.Conclusions
Greater intensity of antihypertensive drug use among older people may be associated with reduced incidence of dementia. 相似文献12.
Pavla Cermakova Karolina Szummer Kristina Johnell Johan Fastbom Bengt Winblad Maria Eriksdotter Dorota Religa 《Journal of the American Medical Directors Association》2017,18(1):19-23
Objectives
We aimed to (1) study factors that determine the use of invasive procedures in the management of acute myocardial infarction (AMI) in patients with dementia and (2) determine whether the use of invasive procedures was associated with their better survival.Design
Cohort study based on patients registered in the Swedish Dementia Registry (SveDem), 2007–2012. Median follow-up time was 228 days.Setting
Patients diagnosed with dementia in specialist memory clinics and primary care units in Sweden.Participants
A total of 525 patients with dementia who suffered AMI (mean age 89 years, 54% women).Measurements
Information on AMI and use of invasive procedures (coronary angiography and percutaneous coronary intervention) was obtained from Swedish national health registers. Binary logistic regression was applied to study associations of patients’ characteristics with the use of invasive procedures; odds ratios (ORs) with 95% confidence intervals (CIs) were calculated. Survival was analyzed with Kaplan-Meier curves; log-rank test was used to compare survival of patients who received an invasive procedure versus those who did not receive it. Cox regression was applied to study association of the invasive procedures with all-cause mortality; hazard ratios (HRs) with 95% CIs were calculated.Results
One hundred ten patients (21%) with dementia received an invasive procedure in the management of AMI. After multivariate adjustment, lower age and higher global cognitive status were associated with the use of invasive procedures. The invasively managed patients survived longer (P = .001). The use of invasive procedures was associated with a lower risk of all-cause mortality, adjusting for type of AMI and dementia disorder, age, gender, registration unit, history of AMI and comorbidity score (HR 0.35, 95% CI 0.21–0.59), or total number of drugs (HR 0.34, 95% CI 0.20–0.58).Conclusion
Age and cognitive status determine the use of invasive procedures in patients with dementia. This study suggests that the invasive management of AMI has a benefit for survival of patients with dementia. 相似文献13.
Nadège Costa Ansgar Wübker Adelaïde De Mauléon Sandra M.G. Zwakhalen David Challis Helena Leino-Kilpi Ingalill R. Hallberg Astrid Stephan Adelaida Zabalegui Kai Saks Laurent Molinier Anders Wimo Bruno Vellas Dirk Sauerland Ingrid Binot Maria E. Soto 《Journal of the American Medical Directors Association》2018,19(1):95.e1-95.e10
Objective
To estimate the additional societal costs for people living with dementia (PwD) with agitation in home care (HC) and institutional long-term care (ILTC) settings in 8 European countries.Design
Cross-sectional data from the RightTimePlaceCare cohort.Setting
HC and ILTC settings from 8 European countries (Estonia, Finland, France, Germany, Netherlands, Spain, Sweden, and England).Participants
A total of 1997 PwD (1217 in HC group and 780 lived in an ILTC) and their caregivers.Main Outcome Measures
Medical care, community care, and informal care were recorded using the Resource Utilization in Dementia (RUD) questionnaire. Agitation was assessed based on the agitation symptoms cluster defined by the presence of agitation and/or irritability and/or disinhibition and/or aberrant motor behavior items of the Neuropsychiatric Inventory Questionnaire (NPI-Q).Results
Total monthly mean cost differences due to agitation were 445€ in the HC setting and 561€ in the ILTC setting (P = .01 and .02, respectively). Informal care costs were the main driver in the HC group (73% of total costs) and institutional care costs were the main driver in the ILTC group (53% of total costs). After adjustments, the log link generalized linear mixed model showed an association between agitation symptoms and an increase of informal care costs by 17% per month in HC setting (P < .05).Conclusion
This study found that agitation symptoms have a substantial impact on informal care costs in the community care setting. Future research is needed to evaluate which strategies may be efficient by improving the cost-effectiveness ratio and reducing the burden associated with informal care in the management of agitation in PwD. 相似文献14.
Niklas Ekerstad Björn W. Karlson David Andersson Magnus Husberg Per Carlsson Emelie Heintz Jenny Alwin 《Journal of the American Medical Directors Association》2018,19(10):871-878.e2
Objective
The objective of this study was to estimate the 3-month within-trial cost-effectiveness of comprehensive geriatric assessment (CGA) in acute medical care for frail elderly patients compared to usual medical care, by estimating health-related quality of life and costs from a societal perspective.Design
Clinical, prospective, controlled, 1-center intervention trial with 2 parallel groups.Intervention
Structured, systematic interdisciplinary CGA-based care in an acute elderly care unit. If the patient fulfilled the inclusion criteria, and there was a bed available at the CGA unit, the patient was included in the intervention group. If no bed was available at the CGA unit, the patient was included in the control group and admitted to a conventional acute medical care unit.Setting and Participants
A large county hospital in western Sweden. The trial included 408 frail elderly patients, 75 years or older, in need of acute in-hospital treatment. The patients were allocated to the intervention group (n = 206) or control group (n = 202). Mean age of the patients was 85.7 years, and 56% were female.Measures
The primary outcome was the adjusted incremental cost-effectiveness ratio associated with the intervention compared to the control at the 3-month follow-up.Results
We undertook cost-effectiveness analysis, adjusted by regression analyses, including hospital, primary, and municipal care costs and effects. The difference in the mean adjusted quality-adjusted life years gained between groups at 3 months was 0.0252 [95% confidence interval (CI): 0.0082-0.0422]. The incremental cost, that is, the difference between the groups, was ?3226 US dollars (95% CI: ?6167 to ?285).Conclusion
The results indicate that the care in a CGA unit for acutely ill frail elderly patients is likely to be cost-effective compared to conventional care after 3 months. 相似文献15.
Jennifer L. Carnahan James E. Slaven Christopher M. Callahan Wanzhu Tu Alexia M. Torke 《Journal of the American Medical Directors Association》2017,18(10):853-859
Background
Many adults are discharged to skilled nursing facilities (SNFs) prior to returning home from the hospital. Patient characteristics and factors that can help to prevent postdischarge adverse outcomes are poorly understood.Objective
To identify whether early post–SNF discharge care reduces likelihood of 30-day hospital readmissions.Design
Secondary data analysis using the Electronic Medical Record, Medicare, Medicaid and the Minimum Data Set.Participants/setting
Older (age > 65 years), community-dwelling adults admitted to a safety net hospital in the Midwest for 3 or more nights and discharged home after an SNF stay (n = 1543).Measurements
The primary outcome was hospital readmission within 30 days of SNF discharge. The primary independent variables were either a home health visit or an outpatient provider visit within a week of SNF discharge.Results
Out of 8754 community-dwelling, hospitalized older adults, 3025 (34.6%) were discharged to an SNF, of whom 1543 (51.0%) returned home. Among the SNF to home group, a home health visit within a week of SNF discharge was associated with reduced hazard of 30-day hospital readmission [adjusted hazard ratio (aHR) 0.61, P < .001] but outpatient provider visits were not associated with reduced risk of hospital readmission (aHR = 0.67, P = .821).Conclusion
For patients discharged from an SNF to home, the finding that a home health visit within a week of discharge is associated with reduced hazard of 30-day hospital readmissions suggests a potential avenue for intervention. 相似文献16.
Simone Reppermund Rachael C. Birch John D. Crawford Jacqueline Wesson Brian Draper Nicole A. Kochan Julian N. Trollor Katharina Luttenberger Henry Brodaty Perminder S. Sachdev 《Journal of the American Medical Directors Association》2017,18(2):117-122
Objectives
The distinction between dementia and mild cognitive impairment (MCI) relies upon the evaluation of independence in instrumental activities of daily living (IADL). Self- and informant reports are prone to bias. Clinician-based performance tests are limited by long administration times, restricted access, or inadequate validation. To close this gap, we developed and validated a performance-based measure of IADL, the Sydney Test of Activities of Daily Living in Memory Disorders (STAM).Design
Prospective cohort study (Sydney Memory and Ageing Study).Setting
Eastern Suburbs, Sydney, Australia.Participants
554 community-dwelling individuals (54% female) aged 76 and older with normal cognition, MCI, or dementia.Measurements
Activities of daily living were assessed with the STAM, administered by trained psychologists, and the informant-based Bayer-Activities of Daily Living Scale (B-ADL). Depressive symptoms were measured with the Geriatric Depression Scale (15-item version). Cognitive function was assessed with a comprehensive neuropsychological test battery. Consensus diagnoses of MCI and dementia were made independently of STAM scores.Results
The STAM showed high interrater reliability (r = 0.854) and test-retest reliability (r = 0.832). It discriminated significantly between the diagnostic groups of normal cognition, MCI, and dementia with areas under the curves ranging from 0.723 to 0.948. A score of 26.5 discriminated between dementia and nondementia with a sensitivity of 0.831 and a specificity of 0.864. Correlations were low with education (r = 0.230) and depressive symptoms (r = ?0.179), moderate with the B-ADL (r = ?0.332), and high with cognition (ranging from r = 0.511 to r = 0.594). The mean time to complete the STAM was 16 minutes.Conclusions
The STAM has good psychometric properties. It can be used to differentiate between normal cognition, MCI, and dementia and can be a helpful tool for diagnostic classification both in clinical practice and research. 相似文献17.
Sandra F. Simmons Chris S. Coelho Andrew Sandler John F. Schnelle 《Journal of the American Medical Directors Association》2018,19(3):262-269
Purpose
To describe a feasible quality improvement system to manage feeding assistance care processes in an assisted living facility (ALF) that provides dementia care and the use of these data to maintain the quality of daily care provision and prevent unintentional weight loss.Design and methods
Supervisory ALF staff used a standardized observational protocol to assess feeding assistance care quality during and between meals for 12 consecutive months for 53 residents receiving dementia care. Direct care staff received feedback about the quality of assistance and consistency of between-meal snack delivery for residents with low meal intake and/or weight loss.Results
On average, 78.4% of the ALF residents consumed more than one-half of each served meal and/or received staff assistance during meals to promote consumption over the 12 months. An average of 79.7% of the residents were offered snacks between meals twice per day. The prevalence of unintentional weight loss averaged 1.3% across 12 months.Implications
A quality improvement system resulted in sustained levels of mealtime feeding assistance and between-meal snack delivery and a low prevalence of weight loss among ALF residents receiving dementia care. Given that many ALF residents receiving dementia care are likely to be at risk for low oral intake and unintentional weight loss, ALFs should implement a quality improvement system similar to that described in this project, despite the absence of regulations to do so. 相似文献18.
Jana Hummel Cecilia Weisbrod Leila Boesch Katharina Himpler Klaus Hauer Martin Hautzinger Andrea Gaebel Tania Zieschang Andrea Fickelscherer Slawomira Diener Ilona Dutzi Bertram Krumm Peter Oster Daniel Kopf 《Journal of the American Medical Directors Association》2017,18(4):341-349
Background
Comorbid depression is highly prevalent in geriatric patients and associated with functional loss, frequent hospital re-admissions, and a higher mortality rate. Cognitive behavioral psychotherapy (CBT) has shown to be effective in older depressive patients living in the community. To date, CBT has not been applied to older patients with acute physical illness and comorbid depression.Objectives
To evaluate the effectiveness of CBT in depressed geriatric patients, hospitalized for acute somatic illness.Design
Randomized controlled trial with waiting list control group.Setting
Postdischarge intervention in a geriatric day clinic; follow-up evaluations at the patients’ homes.Participants
A total of 155 randomized patients, hospitalized for acute somatic illness, aged 82 ± 6 years and suffering from depression [Hospital Anxiety and Depression Scale (HADS) scores >7]. Exclusion criteria were dementia, delirium, and terminal state of medical illness.Intervention
Fifteen, weekly group sessions based on a CBT manual. Commencement of psychotherapy immediately after discharge in the intervention group and a 4-month waiting list interval with usual care in the control group.Measurements
HADS depression total score after 4 months. Secondary endpoints were functional, cognitive, psychosocial and physical status, resource utilization, caregiver burden, and amount of contact with physician.Results
The intervention group improved significantly in depression scores (HADS baseline 18.8; after 4 months 11.4), whereas the control group deteriorated (HADS baseline 18.1; after 4 months 21.6). Significant improvement in the intervention group, but not in the control group, was observed for most secondary outcome parameters such as the Barthel and Karnofsky indexes. Intervention effects were less pronounced in patients with cognitive impairment or acute fractures.Conclusions
CBT is feasible and highly effective in geriatric patients. The benefits extend beyond effective recovery and include improvement in physical and functional parameters. Early diagnosis, good access to psychotherapy, and early intervention could improve care for depressive older patients.19.
Anne Michel Eric Vérin Xavier Gbaguidi Laurent Druesne Frédéric Roca Philippe Chassagne 《Journal of the American Medical Directors Association》2018,19(9):770-774
Objectives
To define the prevalence of oropharyngeal dysphagia (OD) in community-dwelling older persons with dementia, using V-VST (Volume-Viscosity Swallow Test), the reference clinical screening test for swallowing disorders, to assess the feasibility of the V-VST in an ambulatory care setting, to search for associations between geriatric parameters and OD, and to identify a relationship between severities of cognitive impairment and OD.Design
Prospective, monocentric study.Setting
Population from a geriatric outpatients clinic.Participants
Patients older than 70 with a diagnosis of dementia (NINCDS-ADRDA criteria), effective cough, and ability of voluntary swallowing for testing.Measurements
OD screening was realized using V-VST during consultation. Severity of cognitive impairment was estimated by the MMSE and severity of OD by the Dysphagia Outcome Severity Scale (DOSS). Six geriatric domains were evaluated (comorbidities, functional abilities, cognition, nutrition, mood disorders, frailty).Results
117 patients participated in the study (77 women, mean age = 84.5 ± 5.1 years). Prevalence of OD was 86.6%. Among the 97 patients with OD, 3 (3.1%) had only safety impairment, 52 (53.6%) had only efficacy impairment and 42 (43.3%) had both. The mean time necessary to realize V-VST was 8.7 ± 2.7 minutes with a rate of success of 96%. Dependency was independently associated with OD [odds ratio (OR) 4.8; 95% confidence interval (CI) 1.5-15.9; P < .05], and age and grip strength were associated with safety impairment (OR 1.1; 95% CI 1.0-1.2 and OR 1.9; 95% CI 1.2-3.2 respectively; both P < .05). No significant relationship was found between severity of OD and severity of cognitive impairment.Conclusion
OD is very frequent in community-dwelling older persons with dementia and is associated with dependency and frailty. The V-VST is an easy-to-perform and well tolerated screening test in this population and therefore should be systematically included in the geriatric assessment of older persons with dementia. The role of V-VST in therapeutic strategies of OD remains to be evaluated. 相似文献20.
Mikaela Jorgensen Joyce Siette Andrew Georgiou Andrew Warland Johanna Westbrook 《Journal of the American Medical Directors Association》2018,19(2):117-121.e3