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ABSTRACT: BACKGROUND: The role of interdisciplinary interventions in the nursing home (NH) setting remains unclear. We conducted a systematic evidence review to study the benefits of interdisciplinary interventions on outcomes of NH residents. We also examined the interdisciplinary features of successful trials, including those that used formal teams. DATA SOURCES: Medline was searched from January 1990 to August 2011. Search terms included residential facilities, long term care, clinical trial, epidemiologic studies, epidemiologic research design, comparative study, evaluation studies, meta-analysis and guideline. STUDY SELECTION: We included randomized controlled trials (RCTs) evaluating the efficacy of interdisciplinary interventions conducted in the NH setting. MEASUREMENTS: We used the Cochrane Collaboration tools to appraise each RCT, and an RCT was considered positive if its selected intervention had a significant positive effect on the primary outcome regardless of its effect on any secondary outcome. We also extracted data from each trial regarding the participating disciplines; for trials that used teams, we studied the reporting of various team elements, including leadership, communication, coordination, and conflict resolution. RESULTS: We identified 27 RCTs: 7 had no statistically significant effect on the targeted primary outcome, 2 had a statistically negative effect, and 18 demonstrated a statistically positive effect. Participation of residents' own primary physicians (all 6 trials were positive) and/or a pharmacist (all 4 trials were positive) in the intervention were common elements of successful trials. For interventions that used formal team meetings, presence of communication and coordination among team members were the most commonly observed elements. CONCLUSION: Overall interdisciplinary interventions had a positive impact on resident outcomes in the NH setting. Participation of the residents' primary physician and/or a pharmacist in the intervention, as well as team communication and coordination, were consistent features of successful interventions.
Journal of the American Medical Directors Association 04/2013; · 4.64 Impact Factor
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ABSTRACT: BACKGROUND: Older Americans are facing an epidemic of chronic diseases and are thus exposed to anticholinergics (ACs) that might negatively affect their risk of developing mild cognitive impairment (MCI) or dementia. OBJECTIVE: To investigate the association between impairment in cognitive function and previous AC exposure. DESIGN: A retrospective cohort study. SETTING: Primary care clinics in Indianapolis, Indiana. PARTICIPANTS: A total of 3690 older adults who have undergone cognitive assessment and had a 1-year medication-dispensing record. OUTCOME: Cognitive function was measured in two sequential steps: a two-step screening process followed by a formal diagnostic process for participants with positive screening results. EXPOSURE: Three patterns of AC exposure were defined by the duration of AC exposure, the number of AC medications dispensed at the same time, and the severity of AC effects as determined by the Anticholinergic Cognitive Burden list. RESULTS: Compared with older adults with no AC exposure and after adjusting for age, race, gender, and underlying comorbidity, the odds ratio for having a diagnosis of MCI was 2.73 (95% confidence interval, 1.27-5.87) among older adults who were exposed to at least three possible ACs for at least 90 days; the odds ratio for having dementia was 0.43 (95% confidence interval, 0.10-1.81). CONCLUSION: Exposure to medications with severe AC cognitive burden may be a risk factor for developing MCI.
Alzheimer's & dementia: the journal of the Alzheimer's Association 11/2012; · 5.90 Impact Factor
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ABSTRACT: Agitation in Alzheimer's disease (AD) is common and associated with poor patient life-quality and carer distress. The best evidence-based pharmacological treatments are antipsychotics which have limited benefits with increased morbidity and mortality. There are no memantine trials in clinically significant agitation but post-hoc analyses in other populations found reduced agitation. We tested the primary hypothesis, memantine is superior to placebo for clinically significant agitation, in patients with moderate-to-severe AD.
We recruited 153 participants with AD and clinically significant agitation from care-homes or hospitals for a double-blind randomised-controlled trial and 149 people started the trial of memantine versus placebo. The primary outcome was 6 weeks mixed model autoregressive analysis of Cohen-Mansfield Agitation Inventory (CMAI). Secondary outcomes were: 12 weeks CMAI; 6 and 12 weeks Neuropsychiatric symptoms (NPI), Clinical Global Impression Change (CGI-C), Standardised Mini Mental State Examination, Severe Impairment Battery. Using a mixed effects model we found no significant differences in the primary outcome, 6 weeks CMAI, between memantine and placebo (memantine lower -3.0; -8.3 to 2.2, p = 0.26); or 12 weeks CMAI; or CGI-C or adverse events at 6 or 12 weeks. NPI mean difference favoured memantine at weeks 6 (-6.9; -12.2 to -1.6; p = 0.012) and 12 (-9.6; -15.0 to -4.3 p = 0.0005). Memantine was significantly better than placebo for cognition. The main study limitation is that it still remains to be determined whether memantine has a role in milder agitation in AD.
Memantine did not improve significant agitation in people with in moderate-to-severe AD. Future studies are urgently needed to test other pharmacological candidates in this group and memantine for neuropsychiatric symptoms.
ClinicalTrials.gov NCT00371059.
International Standard Randomised Controlled Trial 24953404.
PLoS ONE 01/2012; 7(5):e35185. · 4.09 Impact Factor
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ABSTRACT: To describe the association between anticholinergic medications and incident delirium in hospitalized older adults with cognitive impairment and to test the hypothesis that anticholinergic medications would increase the risk of incident delirium.
Observational cohort study.
Urban public hospital in Indianapolis, Indiana.
One hundred forty-seven participants aged 65 and older with cognitive impairment who screened negative for delirium at the time of admission to a general medical ward.
Cognitive function at the time of admission was assessed using the Short Portable Mental Status Questionnaire (SPMSQ). Anticholinergic medication orders between the time of admission and the final delirium assessment were evaluated. Anticholinergic medication orders were identified using the Anticholinergic Cognitive Burden Scale. Delirium was assessed using the Confusion Assessment Method.
Fifty-seven percent of the cohort received at least one order for possible anticholinergic medications, and 28% received at least one order for definite anticholinergic medications. The incident rate for delirium was 22% of the entire cohort. After adjusting for age, sex, race, baseline SPMSQ score, and Charlson Comorbidity Index, the odds ratio (OR) for developing delirium in those with orders for possible anticholinergic medications was 0.33 (95% confidence interval (CI) = 0.10-1.03). The OR for developing delirium among those with orders for definite anticholinergic medications was 0.43 (95% CI = 0.11-1.63).
The results did not support the hypothesis that prescription of anticholinergic medications increases the risk of incident delirium in hospitalized older adults with cognitive impairment. This relationship needs to be established using prospective study designs with medication dispensing data to improve the performance of predictive models of delirium.
Journal of the American Geriatrics Society 11/2011; 59 Suppl 2:S277-81. · 3.74 Impact Factor
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ABSTRACT: to examine the effect of medications with anticholinergic effects on cognitive impairment and deterioration in Alzheimer's dementia (AD).
cognitive function was measured at baseline and at 6- and 18-month follow-up using the Mini-Mental State Exam (MMSE), the Severe Impairment Battery (SIB) and the Alzheimer's Disease Assessment Battery, Cognitive subsection (ADAS-COG) in a cohort study of 224 participants with AD. Baseline anticholinergic Burden score (ABS) was measured using the Anticholinergic Burden scale and included all prescribed and over the counter medication.
the sample was 224 patients with Alzheimer's dementia and 71.4% were women. Their mean age was 81.0 years [SD 7.4 (range 55-98)]. The mean number of medications taken was 3.6 (SD 2.4) and the mean anticholinergic load was 1.1 (SD 1.4, range 0-7). The total number of drugs taken and anticholinergic load correlated (rho = 0.44; P < 0.01). There were no differences in MMSE and other cognitive functioning at either 6 or 18 months after adjusting for baseline cognitive function, age, gender and use of cholinesterase inhibitors between those with, and those without high anticholinergenic load.
medications with anticholinergic effect in patients with AD were not found to effect deterioration in cognition over the subsequent 18 months. Our study did not support a continuing effect of these medications on people with AD who are established on them.
Age and Ageing 09/2011; 40(6):730-5. · 3.09 Impact Factor
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International Journal of Geriatric Psychiatry 06/2011; 27(5):439-42. · 2.42 Impact Factor
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ABSTRACT: To determine the acceptability of dementia screening in two populations of older adults in different primary care settings.
Cross-sectional study of consecutive patients presenting for primary care appointments in the Duke University Health System (n = 152) or Durham VA Medical Center (n = 193) were evaluated face to face using the Dementia Screening and Perceived Harms (SAPH) questionnaire.
Overall, 81% of primary care patients indicated that they would want to be screened to determine if they are developing dementia. After exposure to possible risks and benefits of screening, 86% of patients indicated they would like to be screened. The SAPH was easy to use and contained five relevant and cohesive domains. The items most associated with a desire for dementia screening were male gender, acceptance of other types of screening, and a belief that a treatment for dementia exists.
Primary care patients in two different health care systems indicated they would like to be screened for dementia. The SAPH was easy to use and contains cohesive domains.
International Journal of Geriatric Psychiatry 04/2011; 26(4):373-9. · 2.42 Impact Factor
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ABSTRACT: Delirium is a state of confusion characterized by an acute and fluctuating decline in cognitive functioning. Delirium is common and deadly in older adults with dementia, and is often referred to as delirium superimposed on dementia, or DSD. Interventions that treat DSD are not well-developed because the mechanisms involved in its etiology are not completely understood. We have developed a theory-based intervention for DSD that is derived from the literature on cognitive reserve and based on our prior interdisciplinary work on delirium, recreational activities, and cognitive stimulation in people with dementia. Our preliminary work indicate that use of simple, cognitively stimulating activities may help resolve delirium by helping to focus inattention, the primary neuropsychological deficit in delirium. Our primary aim in this trial is to test the efficacy of Recreational Stimulation for Elders as a Vehicle to resolve DSD (RESERVE- DSD).
This randomized repeated measures clinical trial will involve participants being recruited and enrolled at the time of admission to post acute care. We will randomize 256 subjects to intervention (RESERVE-DSD) or control (usual care). Intervention subjects will receive 30-minute sessions of tailored cognitively stimulating recreational activities for up to 30 days. We hypothesize that subjects who receive RESERVE-DSD will have: decreased severity and duration of delirium; greater gains in attention, orientation, memory, abstract thinking, and executive functioning; and greater gains in physical function compared to subjects with DSD who receive usual care. We will also evaluate potential moderators of intervention efficacy (lifetime of complex mental activities and APOE status). Our secondary aim is to describe the costs associated with RESERVE-DSD.
Our theory-based intervention, which uses simple, inexpensive recreational activities for delivering cognitive stimulation, is innovative because, to our knowledge it has not been tested as a treatment for DSD. This novel intervention for DSD builds on our prior delirium, recreational activity and cognitive stimulation research, and draws support from cognitive reserve theory.
ClinicalTrials.gov identifier: NCT01267682
Trials 01/2011; 12:119. · 2.02 Impact Factor
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ABSTRACT: Behavioral and psychological symptoms associated with dementia are common in nursing home residents. Quality indicators (QI) assessing quality of care for these residents are minimally risk adjusted and can provide inaccurate information regarding the quality of care provided by the facility.
Evaluate the performance of a new QI for the incidence of worsening behaviors in nursing home residents with behavioral and psychological symptoms association with dementia.
Retrospective cohort study.
A total of 381 Minnesota nursing homes with 26,165 residents.
Minimum Data Set records for the first 2 calendar quarters of 2008.
We calculated incidence of worsening behaviors QI by comparing items from the "behavior" section of the Minimum Data Set records from 2 consecutive quarters and reported the incidence rates by both the residents' level of cognitive impairment and the presence or absence of special care unit for dementia (SCU).
The incidence rates of the worsening behavior QI in SCU ranged from 14% in residents with very severe cognitive impairment (a cognitive performance score = 6) to 30% in those with moderate cognitive impairment (a cognitive performance score = 3). The incidence QI rates among residents residing in conventional unit ranged from 15% among those with very severe cognitive impairment to 20% among those with moderate cognitive impairment. These differences in QI rates between the 2 units were statistically significant with a P value = .001. After risk adjustment for level of cognitive impairment, number of facilities with SCUs that flagged for problem behaviors dropped from 18.4% to 12.4% and the number of conventional units in the low-risk category from 16.8% to 4.7%.
Resident cognitive function and the facility utility of SCU are associated with worsening behavior QI and should be adjusted for in any nursing home quality reporting measure.
Journal of the American Medical Directors Association 12/2010; 12(9):660-7. · 4.64 Impact Factor
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ABSTRACT: Delirium is a common neuropsychiatric syndrome that occurs most frequently in older adults with dementia and is referred to as delirium superimposed on dementia (DSD). Our aim in this pilot project was to demonstrate that implementation of cognitively stimulating activities is clinically feasible and has potential to reduce delirium severity and duration and functional loss in post-acute care settings. We randomized newly admitted participants with DSD to treatment (n = 11) and control (n = 5) conditions and conducted daily blinded assessments of delirium, delirium severity, and functional status for up to 30 days. The control group had a significantly greater decrease in physical function and mental status over time compared with the intervention group. Delirium, severity of delirium, and attention approached significance, and improvement over time favored the intervention group. Although not statistically significant, a difference in mean (7.0 versus 3.27) and median (7.0 versus 3.0) days with delirium was found, with the control group having more days of delirium.
Research in Gerontological Nursing 10/2010; 4(3):161-7. · 0.74 Impact Factor
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Malaz Boustani,
Mary Shearer Baker,
Noll Campbell,
Stephanie Munger,
Siu L Hui,
Pete Castelluccio,
Mark Farber,
Oscar Guzman,
Adetayo Ademuyiwa,
David Miller,
Chris Callahan
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ABSTRACT: Older adults are predisposed to developing cognitive deficits. This increases their vulnerability for adverse health outcomes when hospitalized.
To determine the prevalence and impact of cognitive impairment (CI) among hospitalized elders based on recognition by lCD-coding versus screening done on admission.
Observational cohort study.
Urban public hospital in Indianapolis.
997 patients age 65 and older admitted to medical services between July 2006 and March 2008.
Impact of CI in terms of length of stay, survival, quality of care and prescribing practices. Cognition was assessed by the Short Portable Mental Status Questionnaire (SPMSQ).
424 patients (43%) were cognitively impaired. Of those 424 patients with CI, 61% had not been recognized by ICD-9 coding. Those unrecognized were younger (mean age 76.1 vs. 79.1, P <0.001); had more comorbidity (mean Charlson index of 2.3 vs.1.9, P = 0.03), had less cognitive deficit (mean SPMSQ 6.3 vs. 3.4, P < 0.001). Among elders with CI, 163 (38%) had at least one day of delirium during their hospital course. Patients with delirium stayed longer in the hospital (9.2 days vs. 5.9, P < 0.001); were more likely to be discharged into institutional settings (75% vs. 31%, P < 0.001) and more likely to receive tethers during their care (89% vs. 69%, P < 0.001), and had higher mortality (9% vs. 4%, P = 0.09).
Cognitive impairment, while common in hospitalized elders, is under-recognized, impacts care, and increases risk for adverse health outcomes.
Journal of Hospital Medicine 02/2010; 5(2):69-75. · 1.40 Impact Factor
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ABSTRACT: Global levels of dementia are escalating but alongside this new innovations and service models are developing to improve outcome and the patient journey. This article describes some of the current and horizon issues in dementia care.
British journal of hospital medicine (London, England: 2005) 09/2009; 70(8):450-5. · 0.19 Impact Factor
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ABSTRACT: The number of older adults with Alzheimer's disease and related disorders is expected to triple over the next 50 years. While we may be on the cusp of important therapeutic advances, such advances will not alter the disease course for millions of persons already affected. Hoping for technology to spare the health care system from the need to care for older adults with dementia is no longer tenable. Most older adults with dementia will receive their medical care in the primary care setting and this setting is not prepared to provide for the complex care needs of these vulnerable elders. With an increasing emphasis on earlier diagnosis of dementia, primary care in particular will come under increasing strain from this new care responsibility. While primary care may remain the hub of care for older adults, it cannot and should not be the whole of care. We need to design and test new models of care that integrate the larger health care system including medical care as well as community and family resources. The purpose of this paper to describe the current health care infrastructure with an emphasis on the role of primary care in providing care for older adults with dementia. We summarize recent innovative models of care seeking to provide an integrated and coordinated system of care for older adults with dementia. We present the case for a more aggressive agenda to improving our system of care for older adults with dementia through greater training, integration, and collaboration of care providers. This requires investments in the design and testing of an improved infrastructure for care that matches our national investment in the search for cure.
Current Alzheimer research 09/2009; 6(4):368-74. · 4.97 Impact Factor
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ABSTRACT: (1) To describe the anticholinergic burden experienced by nursing home residents with dementia using the Anticholinergic Cognitive Burden (ACB) Scale; and (2) to determine the association of anticholinergic burden and engagement in activity.
Cross-sectional, using baseline data from an ongoing clinical trial.
Nine nursing homes in Pennsylvania.
Eighty-seven nursing home residents with dementia
The ACB Scale was used to classify the severity of each resident's prescribed drugs' anticholinergic activity on cognition. Engagement in activity was measured by direct observation using a standard instrument.
Across 775 observations, subjects were active approximately 54% of the time, doing nothing 24% of the time, and asleep over 21% of the time. Seventy-one (81.6%) subjects were prescribed at least one drug with anticholinergic properties and 32 (36.7%) were prescribed at least one drug with severe anticholinergic properties. On average, subjects had a total ACB score of 2.55 (+/- 1.9). Mental status (MMSE) and dependency (PGDRS) were associated with engagement, but use of anticholinergic drugs was not.
Nursing home residents are prescribed many drugs with anticholinergic properties. The ACB Scale has utility as a tool to alert practitioners to high anticholinergic burden, who can then use this information when choosing between equally efficacious medications. Further study using larger samples of persons with dementia in earlier stages of the disease, and use of intense measurement designs are needed to more clearly determine the association of ACB with quality of life indicators.
Journal of the American Medical Directors Association 06/2009; 10(4):252-7. · 4.64 Impact Factor
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ABSTRACT: Despite the significant burden of delirium among hospitalized adults, there is no approved pharmacologic intervention for delirium. This systematic review evaluates the efficacy and safety of pharmacologic interventions targeting either prevention or management of delirium.
We searched Medline, PubMed, the Cochrane Register of Controlled Trials, and the Cumulative Index to Nursing and Allied Health Literature (CINAHL) information systems from January 1966 to October 2008. We included randomized, controlled trials comparing pharmacologic compounds either to each other or placebo. We excluded non-comparison trials, studies with patients aged < 18 years, a history of an Axis I psychiatric disorder, and patients with alcohol-related delirium.
Three reviewers independently extracted the data for participants, interventions and outcome measures, and critically appraised each study using the JADAD scale.
We identified 13 studies that met our inclusion criteria and evaluated 15 compounds: second-generation antipsychotics, first-generation antipsychotics, cholinergic enhancers, an antiepileptic agent, an inhaled anesthetic, injectable sedatives, and a benzodiazepine. Four trials evaluated delirium treatment and suggested no differences in efficacy or safety among the evaluated treatment methods (first and second generation antipsychotics). Neither cholinesterase inhibitors nor procholinergic drugs were effective in preventing delirium. Multiple studies, however, suggest either shorter severity and duration, or prevention of delirium with the use of haloperidol, risperidone, gabapentin, or a mixture of sedatives in patients undergoing elective or emergent surgical procedures.
The existing limited data indicates no superiority for second-generation antipsychotics over haloperidol in managing delirium. Although preliminary results suggest delirium prevention may be accomplished through various mechanisms, further studies are necessary to prove effectiveness.
Journal of General Internal Medicine 05/2009; 24(7):848-53. · 2.83 Impact Factor
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Noll Campbell, Malaz Boustani,
Tony Limbil,
Carol Ott,
Chris Fox,
Ian Maidment,
Cathy C Schubert,
Stephanie Munger,
Donna Fick,
David Miller,
Rajesh Gulati
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ABSTRACT: The cognitive side effects of medications with anticholinergic activity have been documented among older adults in a variety of clinical settings. However, there has been no systematic confirmation that acute or chronic prescribing of such medications lead to transient or permanent adverse cognitive outcomes.
Evaluate the existing evidence regarding the effects of anticholinergic medications on cognition in older adults.
We searched the MEDLINE, OVID, and CINAHL databases from January, 1966 to January, 2008 for eligible studies.
Studies were included if the anticholinergic activity was systematically measured and correlated with standard measurements of cognitive performance. Studies were excluded if they reported case studies, case series, editorials, and review articles.
We extracted the method used to determine anticholinergic activity of medications and its association with cognitive outcomes.
Twenty-seven studies met our inclusion criteria. Serum anticholinergic assay was the main method used to determine anticholinergic activity. All but two studies found an association between the anticholinergic activity of medications and either delirium, cognitive impairment or dementia.
Medications with anticholinergic activity negatively affect the cognitive performance of older adults. Recognizing the anticholinergic activity of certain medications may represent a potential tool to improve cognition.
Clinical Interventions in Aging 02/2009; 4:225-33. · 2.08 Impact Factor
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Michael D Justiss, Malaz Boustani,
Chris Fox,
Cornelius Katona,
Anthony J Perkins,
Patrick J Healey,
Greg Sachs,
Siu Hui,
Christopher M Callahan,
Hugh C Hendrie,
Emma Scott
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ABSTRACT: Dementia is a common and growing global public health problem. It leads to a high burden of suffering for society with an annual cost of $100 billion in the US and $10 billion in the UK. New strategies for both treatment and prevention of dementia are currently being developed. Implementation of these strategies will depend on the presence of a viable community or primary care based dementia screening and diagnosis program and patient acceptance of such a program.
To compare the acceptance, perceived harms and perceived benefits of dementia screening among older adults receiving their care in two different primary health care systems in two countries.
A Cross-sectional study.
Primary care clinics in Indianapolis, USA and Kent, UK.
A convenience sample of 245 older adults (Indianapolis, n = 125; Kent, n = 120).
Acceptance of dementia screening and its perceived harms and benefits as determined by a 52-item questionnaire (PRISM-PC questionnaire).
Four of the five domains were significantly different across the two samples. The UK sample had significantly higher dementia screening acceptance scores (p < 0.05); higher perceived stigma scores (p < 0.05); higher perceived loss of independence scores (p < 0.01); and higher perceived suffering scores (p < 0.01) than the US sample. Both groups perceived dementia screening as beneficial (p = 0.218). After controlling for prior experience with dementia, acceptance and stigma were marginalized.
Older adults attending primary care clinics across the Atlantic value dementia screening but have significant concerns about dementia screening although these concerns differed between the two countries. Low acceptance rates and high rates of perceived harms might be a significant barrier for the introduction of treatment or preventive methods for dementia in the future.
International Journal of Geriatric Psychiatry 01/2009; 24(6):632-7. · 2.42 Impact Factor
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Journal of General Internal Medicine 11/2008; 23(12):2142-3. · 2.83 Impact Factor
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ABSTRACT: Caring for an individual with Alzheimer's dementia (AD) is stressful, and studies show that this stress has an impact on both the physical and mental health of the caregiver. However, many questions remain about the characteristics of AD patients and their caregivers that contribute to this stress and how it impacts caregivers' use of healthcare resources.
To study the impact of stress on the physical and mental health of the caregiver.
Patients underwent extensive testing to allow description of their degree of cognitive impairment, behavioral and psychological symptoms, medical comorbidities, and functional abilities. Caregivers were assessed for depressive symptoms and also for emergency department (ED) use and hospitalizations in the previous six months. Multivariate logistic regression was used to evaluate impact of patients' dementia symptoms on caregivers' acute care utilization.
One hundred and fifty-three AD patients and their caregivers attending two large, urban, university-affiliated primary care practices were enrolled in a cross-sectional study to examine the facets of dementia caregiving that impact caregiver acute health care utilization.
Twenty-four percent of the caregivers had at least one ED visit or hospitalization in the six months prior to enrollment. After adjusting for caregiver age, gender, and education, our logistic regression model found that the caregivers' acute care utilization was associated with their depression as measured by the PHQ-9 (OR 1.09, 95% CI 1.00-1.18), the patients' behavioral and psychological symptoms as measured by the NPI (OR 1.04, 95% CI 1.01-1.08), and the patients' functional status as measured by the ADCS-ADL (OR 1.05, 95% CI 1.01-1.09).
To improve the health of AD caregivers, a primary care system needs to reallocate resources to manage the functional, behavioral, and psychological symptoms related to the care-recipients suffering from AD.
Journal of General Internal Medicine 09/2008; 23(11):1736-40. · 2.83 Impact Factor
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Archives of internal medicine 07/2008; 168(12):1252-3. · 11.46 Impact Factor
