Comorbidity Profile of Dementia Patients in Primary Care: Are They Sicker?

OBJECTIVES: To compare the medical comorbidity of older patients with and without dementia in primary care. DESIGN: Cross-sectional study. SETTING: Wishard Health Services, which includes a university-affiliated, urban public hospital and seven community-based primary care practice centers in Indianapolis. PARTICIPANTS: Three thousand thirteen patients aged 65 and older attending seven primary care centers in Indianapolis, Indiana. MEASUREMENTS: An expert panel diagnosed dementia using International Classification of Diseases, 10th Revision, criteria. Comorbidity was assessed using 10 physician-diagnosed chronic comorbid conditions and the Chronic Disease Score (CDS). RESULTS: Patients with dementia attending primary care have on average 2.4 chronic conditions and receive 5.1 medications. Approximately 50% of dementia patients in this setting are exposed to at least one anticholinergic medication, and 20% are prescribed at least one psychotropic medication. After adjusting for patients' age, race, and sex, patients with and without dementia have a similar level of comorbidity (mean number of chronic medical conditions, 2.4 vs 2.3, P=.66; average CDS, 5.8 vs 6.2, P=.83). CONCLUSION: Multiple medical comorbid conditions are common in older adults with and without dementia in primary care. Despite their cholinergic deficit, a substantial proportion of patients with dementia are exposed to anticholinergic medications. Models of care that incorporate this medical complexity are needed to improve the treatment of dementia in primary care.     

Practice Constraints,Behavioral Problems,and Dementia Care: Primary Care Physicians’ Perspectives

Objectives To examine how practice constraints contribute to barriers in the health care of persons with dementia and their families, particularly with respect to behavioral aspects of care. Design Cross-sectional qualitative interview study of primary care physicians. Setting Physicians’ offices. Participants Forty primary care physicians in Northern California. Measurements Open-ended interviews lasted 30–60 minutes and were structured by an interview guide covering clinician background and practice setting, clinical care of a particular patient, and general approach to managing patients with AD or dementia. Interviews were transcribed and themes reflecting constraints of practice were identified through a systematic coding process. Results Recurring themes (i.e., those present in ≥25% of physician interviews) included insufficient time, difficulty in accessing and communicating with specialists, low reimbursement, poor connections with community social service agencies, and lack of interdisciplinary teams. Physician narratives suggest that these constraints may lead to delayed detection of behavior problems, “reactive” as opposed to proactive management of dementia, and increased reliance on pharmacological rather than psychosocial approaches. Conclusion Physicians often feel challenged in caring for dementia patients, particularly those who are more behaviorally complex, because of time and reimbursement constraints as well as other perceived barriers. Our results suggest that more effective educational interventions (for families and physicians) and broader structural changes are needed to better meet the needs of the elderly with dementia and their families now and in the future. Without these changes, dementia care is likely to continue to fall short.     

Does Hospice Improve Quality of Care for Persons Dying from Dementia?

OBJECTIVES: To examine the effectiveness of hospice services for persons dying from dementia from the perspective of bereaved family members. DESIGN: Mortality follow‐back survey. SETTING: Death certificates were drawn from five states (AL, FL, TX, MA, and MN). PARTICIPANTS: Bereaved family members listed as the next of kin on death certificates when dementia was listed as the cause of death. MEASUREMENTS: Ratings of the quality of end‐of‐life care, perceptions of unmet needs, and opportunities to improve end‐of‐life care. Two questions were also asked about the peacefulness of dying and quality of dying. RESULTS: Of 538 respondents, 260 (48.3%) received hospice services. Family members of decedents who received hospice services reported fewer unmet needs and concerns with quality of care (adjusted odds ratio (AOR)=0.49, 95% confidence interval (CI)=0.33–0.74) and a higher rating of the quality of care (AOR=2.0, 95% CI=1.53–2.72). They also noted better quality of dying than those without hospice services. CONCLUSION: Bereaved family members of people with dementia who received hospice reported higher perceptions of the quality of care and quality of dying.     

Cardiac Transitional Care Effectiveness: Does Overall Comorbidity Burden Matter?

BackgroundCardiovascular disease is the most common cause of mortality and hospitalization in the United States. Transitional care initiatives can improve outcomes for cardiac patients, but it is unclear whether patients with different baseline comorbidity burden benefit equally. We evaluated the effectiveness of the Bridging the Discharge Gap Effectively (BRIDGE) program, a nurse-practitioner-led transitional care clinic, in mitigating adverse clinical outcomes in cardiac patients with varying Charlson comorbidity index (CCI).MethodsWe studied patients referred to BRIDGE between 2008 and 2017 postdischarge for a cardiac condition. Using proportional hazards regression models, we evaluated associations between attendance at BRIDGE and hospital readmission, emergency department (ED) visit, and a composite outcome consisting of readmission, ED visit, or mortality, and assessed interaction between BRIDGE attendance and CCI.ResultsOf 4559 patients, 3256 (71.4%) attended BRIDGE. In patients with low CCI, attendance at BRIDGE was inversely associated with hospital readmission (adjusted hazard ratio = 0.82, 95% confidence interval [CI]: 0.69, 0.97, P = .02) and the composite endpoint (adjusted hazard ratio = 0.84, 95% CI: 0.72, 0.98, P = .02). Associations of BRIDGE attendance with both readmission and ED visit were significantly weaker in patients with high CCI (adjusted P, interaction = .007 and .03, respectively). Overall, BRIDGE attendance was associated with an 11% lower hazard of developing the composite endpoint (95% CI: 2%, 19%, P = .01).ConclusionsAttendance at a transitional care clinic is inversely associated with risk of readmission and a composite endpoint in cardiac patients with low CCI. Future research should investigate modified transitional care programs in patients with varying comorbidity burden.     

Caring for Patients with Dementia: How Good Is the Quality of Care? Results from Three Health Systems

OBJECTIVES: To describe the quality of dementia care within one U.S. metropolitan area and to investigate associations between variations in quality and patient, caregiver, and health system characteristics. DESIGN: Observational, cross-sectional. SETTING AND PARTICIPANTS: Three hundred eighty-seven patient-caregiver pairs from three healthcare organizations MEASUREMENTS: Using caregiver surveys and medical record abstraction to assess 18 dementia care processes drawn from existing guidelines, the proportion adherent to each care process was calculated, as well as mean percentages of adherence aggregated within four care dimensions: assessment (6 processes), treatment (6 processes), education and support (3 processes), and safety (3 processes). For each dimension, associations between adherence and patient, caregiver, and health system characteristics were investigated using multivariable models. RESULTS: Adherence ranged from 9% to 79% for the 18 individual care processes; 11 processes had less than 40% adherence. Mean percentage adherence across the four care dimensions was 37% for assessment, 33% for treatment, 52% for education and support, and 21% for safety. Higher comorbidity was associated with greater adherence across all four dimensions, whereas greater caregiver knowledge (in particular, one item) was associated with higher care quality in three of four care dimensions. For selected dimensions, greater adherence was also associated with greater dementia severity and with more geriatrics or neurologist visits. CONCLUSION: In general, dementia care quality has considerable room for improvement. Although greater comorbidity and dementia severity were associated with better quality, caregiver knowledge was the most consistent caregiver characteristic associated with better adherence. These findings offer opportunities for targeting low quality and suggest potential focused interventions.     

Primary Care Clinicians’ Recognition and Management of Depression: A Model of Depression Care in Real-World Primary Care Practice

BACKGROUND

Depression is prevalent in primary care (PC) practices and poses a considerable public health burden in the United States. Despite nearly four decades of efforts to improve depression care quality in PC practices, a gap remains between desired treatment outcomes and the reality of how depression care is delivered.

OBJECTIVE

This article presents a real-world PC practice model of depression care, elucidating the processes and their influencing conditions.

DESIGN

Grounded theory methodology was used for the data collection and analysis to develop a depression care model. Data were collected from 70 individual interviews (60 to 70 min each), three focus group interviews (n?=?24, 2 h each), two surveys per clinician, and investigators’ field notes on practice environments. Interviews were audiotaped and transcribed for analysis. Surveys and field notes complemented interview data.

PARTICIPANTS

Seventy primary care clinicians from 52 PC offices in the Midwest: 28 general internists, 28 family physicians, and 14 nurse practitioners.

KEY RESULTS

A depression care model was developed that illustrates how real-world conditions infuse complexity into each step of the depression care process. Depression care in PC settings is mediated through clinicians’ interactions with patients, practice, and the local community. A clinician’s interactional familiarity (“familiarity capital”) was a powerful facilitator for depression care. For the recognition of depression, three previously reported processes and three conditions were confirmed. For the management of depression, 13 processes and 11 conditions were identified. Empowering the patient was a parallel process to the management of depression.

CONCLUSIONS

The clinician’s ability to develop and utilize interactional relationships and resources needed to recognize and treat a person with depression is key to depression care in primary care settings. The interactional context of depression care makes empowering the patient central to depression care delivery.     

Greater Risk of Dementia When Spouse Has Dementia? The Cache County Study

OBJECTIVES: To examine the effects of caring for a spouse with dementia on the caregiver's risk for incident dementia. DESIGN: Population‐based study of incident dementia in spouses of persons with dementia. SETTING: Rural county in northern Utah. PARTICIPANTS: Two thousand four hundred forty‐two subjects (1,221 married couples) aged 65 and older. MEASUREMENTS: Incident dementia was diagnosed in 255 subjects, with onset defined as age when subject met Diagnostic and Statistical Manual of Mental Disorders, Third Edition, Revised, criteria for dementia. Cox proportional hazards regression tested the effect of time‐dependent exposure to dementia in one's spouse, adjusted for potential confounders. RESULTS: A subject whose spouse experienced incident dementia onset had a six times greater risk for incident dementia as subjects whose spouses were dementia free (hazard rate ratio (HRR)=6.0, 95% confidence interval (CI)=2.2–16.2, P<.001). In sex‐specific analyses, husbands had higher risks (HRR=11.9, 95% CI=1.7–85.5, P=.01) than wives (HRR=3.7, 95% CI=1.2–11.6, P=.03). CONCLUSION: The chronic and often severe stress associated with dementia caregiving may exert substantial risk for the development of dementia in spouse caregivers. Additional (not mutually exclusive) explanations for findings are discussed.     

Advance Directives for Euthanasia in Dementia: How Do They Affect Resident Care in Dutch Nursing Homes? Experiences of Physicians and Relatives

OBJECTIVES: To gain insight into how advance directives for euthanasia affect resident care in Dutch nursing homes. DESIGN: Survey of elderly care physicians and additional qualitative interviews with a selection of elderly care physicians and relatives of people with dementia who had an advance directive for euthanasia. SETTING: Dutch nursing home practice. PARTICIPANTS: Four hundred thirty‐four elderly care physicians completed the general part of the questionnaire; 110 physicians provided case histories. Interviews were conducted with 11 physicians and eight relatives. MEASUREMENTS: The questionnaire contained general questions about the incidence of advance directives for euthanasia in people with dementia. A second part involved questions about the most recent case of a person with dementia and an advance directive for euthanasia who had died. The interviews with elderly care physicians and relatives focused on further exploration of the decision‐making process regarding adherence to the advance directive for euthanasia. RESULTS: Despite law‐based possibilities, advance directives for euthanasia of people with dementia were rarely adhered to, although they seem to have a supportive role in setting limitations on life‐sustaining treatments. Elderly care physicians and relatives were found to be reluctant to adhere to advance directives for euthanasia. Not being able to engage in meaningful communication played a crucial role in this reluctance. CONCLUSION: Advance directives for euthanasia are never adhered to in the Netherlands in the case of people with advanced dementia, and their role in advance care planning and end‐of‐life care of people with advanced dementia is limited. Communication with the patient is essential for elderly care physicians to consider adherence to an advance directive for euthanasia of a person with dementia.     

Hospice Care in Nursing Homes: Is Site of Care Associated with Visit Volume?

OBJECTIVES: To determine factors associated with hospice visit volume and to examine whether visit volume differs by nursing home (NH) versus non-NH setting. DESIGN: Retrospective cohort study. SETTING: Twenty-one hospices across seven states under the ownership of one parent provider. PARTICIPANTS: Hospice patients from October 1998 through September 1999 in NH (n=9,460) and non-NH (n=15,484) settings. MEASUREMENTS: Data were from the provider's centralized information system. Average daily visit volume was the number of visits divided by the number of hospice routine home care days (days not in hospice inpatient or continuous home care). Multivariate logistic regression tested the association between site of care and an individual's probability of having average daily visits above the sample median. RESULTS: Average daily visits+/-standard deviation were 1.1+/-1.1 for NH and 1.2+/-1.3 for non-NH hospice patients. Site of care was not significantly associated with having an average daily visit volume above the sample median, but patients in NH settings had a lower probability of having a nurse average daily visit volume above the median (adjusted odds ratio (AOR)=0.59, 95% confidence interval (CI)=0.46-0.74) and a greater probability of having social worker (AOR=2.46, 95% CI=1.87-3.24), aide (AOR=1.97; 95% CI=1.11-3.48), and clergy (AOR=3.23, 95% CI=2.21-4.44) average daily visits above the median than those in non-NH settings. CONCLUSION: A different mix, not volume, of services appears to be used to address the physical, psychosocial, and spiritual needs of hospice patients/families who reside in NH settings than of those in non-NH settings.     

What Do Long-Term Care Staff Know About the Differences Between Depression and Dementia?

A cross-sectional study was conducted of 159 long-term care staff who completed a series of questionnaires on knowledge of dementia and knowledge of depression, a series of forced-choice questions on the differentiation between dementia and depression, and a demographics questionnaire. Relative to professional staff, paraprofessional staff had lower scores in depression knowledge and differentiation knowledge. All staff had accurate knowledge of dementia. Differences in knowledge between type of staff were based on job type rather than level of education. Educational interventions about dementia have been effective in the long-term care community; however, there is a need for increased on-the-job training regarding depression in older adults in order to improve the ability to differentiate depression from dementia, especially for paraprofessional staff.     

Effectiveness of HIV Prevention for Women: What Is Working?

The HIV-AIDS remains a public health problem which disproportionally affects women. However, prevention strategies have rarely considered their specific efficacy for them. For this reason, this study examines the differential effectiveness of six intervention elements based on socio-cognitive theories addressing young women. A controlled between-groups design examined the change in risk profile among 167 young Spanish women (mean age 21.3 years old) involved in five sexual risk prevention interventions (informative talk, attitudinal discussion, role-play, fear induction and informative website) and one control non-intervening group (waiting list). Our findings support the differential efficacy of some HIV preventive intervention elements comparing others for women. In particular, the attitudinal discussion stands out followed by the informative talk and the role play. Contrarily, the fear induction component did not reveal relevant improvements. This study provides new evidence related to HIV prevention. Particularly, the higher efficacy of motivational components for these young Spanish women is revealed.