[Show abstract][Hide abstract] ABSTRACT: Dementia affects over 4 million people in the US and is frequently unrecognized and underdiagnosed in primary care. Routine dementia screening in primary care is not recommended by the US Preventive Services Task Force due to lack of empirical data on the benefits and harms of screening. This trial seeks to fill this gap and contribute information about the benefits, harms, and costs of routine screening for dementia in primary care.Methods/design: Single-blinded, parallel, randomized controlled clinical trial with 1:1 allocation. A total of 4,000 individuals aged >=65 years without a diagnosis of dementia, cognitive impairment, or serious mental illness receiving care at primary care practices within two cities in Indiana. Subjects will be randomized to either i) screening for dementia using the Memory Impairment Screen Telephone version or ii) no screening for dementia. Subjects who screen positive for dementia will be referred to the local Aging Brain Care program that delivers an evidence-based collaborative care model for dementia and depression. Research assistants will administer the 15-item Health Utility Index, Patient Health Questionnaire, Generalized Anxiety Disorder Scale, and Medical Outcomes Study at baseline, 1, 6, and 12 months. Information about advanced care planning will be collected at baseline and 12 months. All enrollees' medical records will be reviewed to collect data on health care utilization and costs.
[Show abstract][Hide abstract] ABSTRACT: To evaluate whether race influences agreement between screening results and documentation of cognitive impairment and delirium.
Secondary data analysis.
An urban, public hospital and healthcare system.
Hospitalized older adults aged 65 and older admitted to general inpatient medical services evaluated for cognitive impairment (n = 851) and evaluated for delirium (n = 424).
Cognitive impairment and delirium were measured in each participant using the Short Portable Mental Status Questionnaire (SPMSQ) and the Confusion Assessment Method (CAM), respectively, as the reference identification method. Clinical documentation of cognitive impairment and delirium was defined according to the presence of International Classification of Diseases, Ninth Revision (ICD-9), codes from within 1 year before hospitalization through discharge for cognitive impairment or from hospital admission through discharge for delirium.
Two hundred ninety-four participants (34%) had cognitive impairment based on SPMSQ performance, and 163 (38%) had delirium based on CAM results. One hundred seventy-one (20%) of those with cognitive impairment had an ICD-9 code for cognitive impairment, whereas 92 (22%) of those with delirium had an ICD-9 code for delirium. After considering age, sex, education, socioeconomic status, chronic comorbidity, and severity of acute illness, of those who screened positive on the SPMSQ, African Americans had a higher adjusted odds ratio (AOR) than non-African Americans for clinical documentation of cognitive impairment (AOR = 1.66, 95% confidence interval (CI) = 0.95-2.89), and of those who screened negative on the SPMSQ, African Americans had higher odds of clinical documentation of cognitive impairment (AOR = 2.10, 95% CI = 1.17-3.78) than non-African Americans. There were no differences in clinical documentation rates of delirium between African Americans and non-African Americans.
Racial differences in coding for cognitive impairment may exist, resulting in higher documentation of cognitive impairment in African Americans screening positive or negative for cognitive impairment.
Journal of the American Geriatrics Society 02/2014; · 4.22 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Background:Caregivers of persons with dementia are stressed. Stressors not related to care recipients' needs impact caregiver outcomes, yet are seldom reported. The purpose of this study was to report the most stressful events experienced by spouse caregivers of older adults with Alzheimer s disease during a 6-month period.Methods:31 caregivers completed the Most Stressful Event form, Patient Health Questionnaire (PHQ-9) and the Revised Memory Behavioral Problem Checklist (R-MBPC). Fisher's exact test and two-sample t-test were used to compare Most Stressful Events between caregivers. ANOVA model tested whether the PHQ-9 and R-MBPC subscales differed by stressor.Results:Caregivers reported no stressors 21.5% of the time, 1-2 stressors 25% of the time, and 3 stressors 53% of the time with 318 stressors reported in total. Care recipient needs (30.2%), caregiver needs (26.7%), and decision-making (16.7%) were the most frequently reported stressors. Using a mixed effects model, there were associations between the Most Stressful Events and depression (p = 0.016), mobility (p = 0.024) and caregiver issues (p = 0.009) subscales of R-MBPC.Conclusion:Results can be used to develop targeted intervention and support strategies for spouse caregivers experiencing non-caregiving related stressorsas well as the traditional challenges with caregiving related issues.
American Journal of Alzheimer s Disease and Other Dementias 01/2014; · 1.52 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Objective
Although depression is a risk and prognostic factor for cardiovascular disease (CVD), depression trials involving cardiac patients have not observed the anticipated cardiovascular benefits. To test our hypothesis that depression treatment delivered before clinical CVD onset reduces risk of CVD events, we conducted an 8-year follow-up study of the Indiana sites of the Improving Mood-Promoting Access to Collaborative Treatment (IMPACT) randomized controlled trial.Methods
Participants were 235 primary care patients 60 years or older with major depression or dysthymia who were randomized to a 12-month collaborative care program involving antidepressants and psychotherapy (85 without and 35 with baseline CVD) or usual care (83 without and 32 with baseline CVD). Hard CVD events (fatal/nonfatal) were identified using electronic medical record and Medicare/Medicaid data.ResultsA total of 119 patients (51%) had a hard CVD event. As hypothesized, the treatment × baseline CVD interaction was significant (p = .021). IMPACT patients without baseline CVD had a 48% lower risk of an event than did usual care patients (28% versus 47%, hazard ratio = 0.52, 95% confidence interval = 0.31-0.86). The number needed to treat to prevent one event for 5 years was 6.1. The likelihood of an event did not differ between IMPACT and usual care patients with baseline CVD (86% versus 81%, hazard ratio = 1.19, 95% confidence interval, 0.70-2.03).Conclusions
Collaborative depression care delivered before CVD onset halved the excess risk of hard CVD events among older, depressed patients. Our findings raise the possibility that the IMPACT intervention could be used as a CVD primary prevention strategy.Trial Registrationclinicaltrials.gov Identifier: NCT01561105.
Psychosomatic Medicine 12/2013; · 4.08 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Minnesota's Performance-Based Incentive Payment Program uses a collaborative, provider-initiated approach to nursing home quality improvement: up-front funding of evidence-based projects selected and designed by participating facilities, with accountable performance targets. During the first 4 rounds of funding (2007-10), 66 projects were launched at 174 facilities. Using a composite quality measure representing multiple dimensions of clinical care, we found that facilities participating during this period exhibited significantly greater gains than did nonparticipating facilities, in both targeted areas and overall quality, and maintained their quality advantage after project completion. Participating and nonparticipating facilities were similar at baseline with respect to quality scores and improvement trends, as well as acuity-adjusted payment, operating costs, and nurse staffing. Although self-selection precludes firm conclusions regarding the program's impacts, early findings indicate that the program shows promise for incentivizing nursing home quality improvement, both in facility-identified areas of concern and overall.
Health Affairs 09/2013; 32(9):1631-8. · 4.64 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: BACKGROUND: The class of acetylcholinesterase inhibitors (ChEI), including donepezil, rivastigmine, and galantamine, have similar efficacy profiles in patients with mild to moderate Alzheimer's disease (AD). However, few studies have evaluated adherence to these agents. We sought to prospectively capture the rates and reasons for nonadherence to ChEI and determine factors influencing tolerability and adherence.Methods/design: We designed a pragmatic randomized clinical trial to evaluate the adherence to ChEIs among older adults with AD. Participants include AD patients receiving care within memory care practices in the greater Indianapolis area. Participants will be followed at 6-week intervals up to 18 weeks to measure the primary outcome of ChEI discontinuation and adherence rates and secondary outcomes of behavioral and psychological symptoms of dementia. The primary outcome will be assessed through two methods, a telephone interview of an informal caregiver and electronic medical record data captured from each healthcare system through a regional health information exchange. The secondary outcome will be measured by the Healthy Aging Brain Care Monitor and the Neuropsychiatric Inventory. In addition, the trial will conduct an exploratory evaluation of the pharmacogenomic signatures for the efficacy and the adverse effect responses to ChEIs. We hypothesized that patient-specific factors, including pharmacogenomics and pharmacokinetic characteristics, may influence the study outcomes. DISCUSSION: This pragmatic trial will engage a diverse population from multiple memory care practices to evaluate the adherence to and tolerability of ChEIs in a real world setting. Engaging participants from multiple healthcare systems connected through a health information exchange will capture valuable clinical and non-clinical influences on the patterns of utilization and tolerability of a class of medications with a high rate of discontinuation.Trial Registration: Clinicaltrials.gov: NCT01362686.
[Show abstract][Hide abstract] ABSTRACT: Background Elderly patients with cognitive impairment are at increased risk of developing delirium, especially in the intensive care unit. Objective To evaluate the efficacy of a computer-based clinical decision support system that recommends consulting a geriatrician and discontinuing use of urinary catheters, physical restraints, and unnecessary anticholinergic drugs in reducing the incidence of delirium. Methods Data for a subgroup of patients enrolled in a large clinical trial who were transferred to the intensive care units of a tertiary-care, urban public hospital in Indianapolis were analyzed. Data were collected on frequency of orders for consultation with a geriatrician; discontinuation of urinary catheterization, physical restraints, or anticholinergic drugs; and the incidence of delirium. Results The sample consisted of 60 adults with cognitive impairment. Mean age was 74.6 years; 45% were African American, and 52% were women. No differences were detected between the intervention and the control groups in orders for consultation with a geriatrician (33% vs 40%; P = .79) or for discontinuation of urinary catheters (72% vs 76%; P = .99), physical restraints (12% vs 0%; P=.47), or anticholinergic drugs (67% vs 36%; P=.37). The 2 groups did not differ in the incidence of delirium (27% vs 29%; P = .85). Conclusion Use of a computer-based clinical decision support system may not be effective in changing prescribing patterns or in decreasing the incidence of delirium.
American Journal of Critical Care 05/2013; 22(3):257-262. · 1.41 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: OBJECTIVE: We examined the (a) influence of nursing facility characteristics on resident quality of life and (b) the impact of cognitive impairment and residence on a dementia special care unit(SCU) on QOL after controlling for resident and facility characteristics. METHOD: Multilevel models (resident and facility) were estimated for residents with and without cognitive impairment on conventional units and dementia SCU. Data came from the 2007 Minnesota Nursing Home Resident Quality of Life and Consumer Satisfaction Survey (N = 13,983). RESULTS: Level of resident CI was negatively related to QOL, although residing on a dementia SCU was positively related to QOL. Certified Nursing Assistant and activity personnel hours per resident day had a positive relationship with resident QOL. DISCUSSION: Our results highlight the need to ensure adequate levels of paraprofessional direct care staff and the availability of dementia-focused (SCU)s despite current constraints on long-term care funding.
Journal of Aging and Health 03/2013; · 1.56 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Currently, there are no valid and reliable biomarkers to identify delirious patients predisposed to longer delirium duration. We investigated the hypothesis that elevated S100 calcium binding protein B (S100β) levels will be associated with longer delirium duration in critically ill patients.
A prospective observational cohort study was performed in the medical, surgical, and progressive intensive care units (ICUs) of a tertiary care, university affiliated, and urban hospital. Sixty-three delirious patients were selected for the analysis, with two samples of S100β collected on days 1 and 8 of enrollment. The main outcome measure was delirium duration. Using the cutoff of <0.1 ng/mL and ≥0.1 ng/mL as normal and abnormal levels of S100β, respectively, on day 1 and day 8, four exposure groups were created: Group A, normal S100β levels on day 1 and day 8; Group B, normal S100β level on day 1 and abnormal S100β level on day 8; Group C, abnormal S100β level on day 1 and normal on day 8; and Group D, abnormal S100β levels on both day 1 and day 8.
Patients with abnormal levels of S100β showed a trend towards higher delirium duration (P=0.076); Group B (standard deviation) (7.0 [3.2] days), Group C (5.5 [6.3] days), and Group D (5.3 [6.0] days), compared to patients in Group A (3.5 [5.4] days).
This preliminary investigation identified a potentially novel role for S100β as a biomarker for delirium duration in critically ill patients. This finding may have important implications for refining future delirium management strategies in ICU patients.
International Journal of General Medicine 01/2013; 6:855-861.
[Show abstract][Hide abstract] ABSTRACT: OBJECTIVES: Prevention and public reporting of falls have suffered due to inadequate attention given to the association of falls and cognitive impairment (CI) among nursing home (NH) residents. This study examines the relationship between CI, residence on dementia special care units (SCUs) and other resident characteristics and likelihood of residents experiencing new falls in NHs. DESIGN: Retrospective cohort study. SETTING AND PARTICIPANTS: A total of 21,587 residents from 381 Minnesota NHs. MEASUREMENTS: The NH Minimum Data Set (MDS) for 21,587 residents from 381 Minnesota NHs in the first calendar quarter of 2008 were analyzed. New falls, (fall noted on a current MDS assessment but not on a prior assessment); cognitive status, (as defined by Cognitive Performance Scale); residence on an SCU, and health and functional status covariates were recorded. A random effects logistic regression model was used to examine relationships between new falls and the resident's cognitive status, type of unit, and covariates. RESULTS: The likelihood of a new fall had a nonlinear association with CI. Compared with residents with normal or mild CI, the likelihood of a new fall was significantly higher among residents with moderate CI (OR = 1.43). The risk decreased slightly (OR = 1.34) for residents with more advanced CI, whereas the presence of severe CI was not significantly associated with new falls. Overall the likelihood of new falls was significantly higher for residents on SCUs compared with those on conventional units (OR = 1.27). CONCLUSIONS: Severity of CI and residence on SCU impact fall incidence and should be accounted for in future fall- prevention interventions and quality-reporting indicators and measures.
Journal of the American Medical Directors Association 09/2012; · 5.30 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: To determine individuals' perceptions concerning dementia screening and to evaluate the possibility of an association between their perceptions and their willingness to undergo screening.
Cross-sectional study of primary care patients aged 65 and older.
Urban primary care clinics in Indianapolis, Indiana, in 2008 to 2009.
Five hundred fifty-four primary care patients without a documented diagnosis of dementia.
The Perceptions Regarding Investigational Screening for Memory in Primary Care Questionnaire (PRISM-PC) and agreement or refusal to undergo dementia screening.
Of the 554 study participants who completed the PRISM-PC, 65.5% were aged 70 and older, 70.0% were female, and 56.5% were African American; 57 (10.3%) refused screening for dementia. Of the 497 (89.7%) who agreed to screening, 63 (12.7%) screened positive. After adjusting for age, perception of depression screening, perception of colon cancer screening, and belief that no treatment is currently available for Alzheimer's disease, the odds of refusing screening were significantly lower in participants who had higher PRISM-PC domain scores for benefits of dementia screening (odds ratio (OR) = 0.85, 95% confidence interval (CI) = 0.75-0.97; P = .02). In the same regression model, the odds of refusing screening were significantly higher in participants aged 70 to 74 (OR = 5.65, 95% CI = 2.27-14.09; P < .001) and those aged 75 to 79 (OR = 3.63, 95% CI = 1.32-9.99; P = .01) than in the reference group of patients aged 65 to 69.
Age and perceived benefit of screening are associated with acceptance of dementia screening in primary care.
Journal of the American Geriatrics Society 06/2012; 60(6):1037-43. · 4.22 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Delirium evaluation in patients in the ICU requires the use of an arousal/sedation assessment tool prior to assessing consciousness. The Richmond Agitation-Sedation Scale (RASS) and the Riker Sedation-Agitation Scale (SAS) are well-validated arousal/sedation tools. We sought to assess the concordance of RASS and SAS assessments in determining eligibility of patients in the ICU for delirium screening using the confusion assessment method for the ICU (CAM-ICU).
We performed a prospective cohort study in the adult medical, surgical, and progressive (step-down) ICUs of a tertiary care, university-affiliated, urban hospital in Indianapolis, Indiana. The cohort included 975 admissions to the ICU between January and October 2009.
The outcome measures of interest were the correlation and agreement between RASS and SAS measurements. In 2,469 RASS and SAS paired screens, the rank correlation using the Spearman correlation coefficient was 0.91, and the agreement between the two screening tools for assessing CAM-ICU eligibility as estimated by the κ coefficient was 0.93. Analysis showed that 70.1% of screens were eligible for CAM-ICU assessment using RASS (7.1% sedated [RASS −3 to −1]; 62.6% calm ; and 0.4% restless, agitated [+1 to +3]), compared with 72.1% using SAS (5% sedated [SAS 3]; 66.5% calm ; and 0.6% anxious, agitated [5, 6]). In the mechanically ventilated subgroup, RASS identified 19.1% CAM-ICU eligible patients compared with 24.6% by SAS. The correlation coefficient in this subgroup was 0.70 and the agreement was 0.81.
Both SAS and RASS led to similar rates of delirium assessment using the CAM-ICU.
[Show abstract][Hide abstract] ABSTRACT: Approximately 40% of hospitalized older adults have cognitive impairment (CI) and are more prone to hospital-acquired complications. The Institute of Medicine suggests using health information technology to improve the overall safety and quality of the health care system.
Evaluate the efficacy of a clinical decision support system (CDSS) to improve the quality of care for hospitalized older adults with CI.
A randomized controlled clinical trial.
A public hospital in Indianapolis.
A total of 998 hospitalized older adults were screened for CI, and 424 patients (225 intervention, 199 control) with CI were enrolled in the trial with a mean age of 74.8, 59% African Americans, and 68% female.
A CDSS alerts the physicians of the presence of CI, recommends early referral into a geriatric consult, and suggests discontinuation of the use of Foley catheterization, physical restraints, and anticholinergic drugs.
Orders of a geriatric consult and discontinuation orders of Foley catheterization, physical restraints, or anticholinergic drugs.
Using intent-to-treat analyses, there were no differences between the intervention and the control groups in geriatric consult orders (56% vs 49%, P = 0.21); discontinuation orders for Foley catheterization (61.7% vs 64.6%, P = 0.86); physical restraints (4.8% vs 0%, P = 0.86), or anticholinergic drugs (48.9% vs 31.2%, P = 0.11).
A simple screening program for CI followed by a CDSS did not change physician prescribing behaviors or improve the process of care for hospitalized older adults with CI.
Journal of General Internal Medicine 02/2012; 27(5):561-7. · 3.28 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: We investigated the relationship between cognitive status and quality of life (QOL) of Minnesota nursing home (NH) residents and the relationship between conventional or Alzheimer's special care unit (SCU) placement and QOL. The study may inform development of dementia-specific quality measures.
Data for analyses came from face-to-face interviews with a representative sample of 13,130 Minnesota NH residents collected through the 2007 Minnesota NH Resident Quality of Life and Consumer Satisfaction survey. We examined 7 QOL domains: comfort, meaningful activities, privacy, environment, individuality, autonomy, relationships, and a positive mood scale. We applied multilevel models (resident and facility) to examine the relationship between the resident's score on each QOL domain and the resident's cognitive impairment (CI) level and SCU placement after controlling for covariates, such as activities of daily living dependency, pain, depression or psychiatric diagnosis, and length of stay.
Residents with more severe CI reported higher QOL in the domains of comfort and environment and lower QOL in activities, individuality, privacy and meaningful relationships, and the mood scale. Residents on SCU reported higher QOL in the meaningful activities, comfort, environment, and autonomy domains but had lower mood scores.
Our findings point to QOL domains that show significant variation by CI and thus may be of greatest interest to consumers, providers, advocacy groups, and other stakeholders committed to improving dementia care. Findings are particularly applicable to the development of NH quality indicators that more accurately represent the QOL of NH residents with CI.
The Gerontologist 01/2012; 52(5):632-40. · 2.48 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Dementia care providers need a clinical assessment tool similar to the blood pressure cuff (sphygmomanometer) used by clinicians and patients for managing hypertension. A "blood pressure cuff " for dementia would be an inexpensive, simple, user-friendly, easily standardized, sensitive to change, and widely available multidomain instrument for providers and informal caregivers to measure severity of dementia symptoms. The purpose of this study was to assess the reliability and validity of the Healthy Aging Brain Care Monitor (HABC-Monitor) for measuring and monitoring the severity of dementia symptoms through caregiver reports.
The first prototype of the HABC-Monitor was developed in collaboration with the Indianapolis Discovery Network for Dementia, which includes 200 members representing 20 disciplines from 20 local organizations, and an expert panel of 22 experts in dementia care and research. The HABC-Monitor has three patient symptom domains (cognitive, functional, behavioral/psychological) and a caregiver quality of life domain. Patients (n = 171) and their informal caregivers (n = 171) were consecutively approached and consented during, or by phone shortly following, a patient's routine visit to their memory care provider.
The HABC-Monitor demonstrated good internal consistency (0.73-0.92); construct validity indicated by correlations with the caregiver-reported Neuropsychiatric Inventory (NPI) total score and NPI caregiver distress score; sensitivity to three-month change compared with NPI "reliable change" groups; and known-groups validity, indicated by significant separation of Mini-Mental Status Examination severity groups and clinical diagnostic groups. Although not designed as a screening study, there was evidence for good operating characteristics, according to area under the receiver-operator curve with respect to gold standard clinical diagnoses, relative to Mini-Mental Status Examination or NPI.
The HABC-Monitor demonstrates good reliability and validity as a clinically practical multidimensional tool for monitoring symptoms of dementia through the informal caregiver.
Clinical Interventions in Aging 01/2012; 7:143-57. · 2.65 Impact Factor
[Show abstract][Hide abstract] 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. · 4.22 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Emergency physicians routinely perform emergency department procedural sedation (EDPS), and its safety is well established. We are unaware of any published reports directly evaluating the safety of EDPS in older patients (≥65 years old). Many EDPS experts consider seniors to be at higher risk. The objective was to evaluate the complication rate of EDPS in elderly adults.
This was a prospective, observational study of EDPS patients at least 65 years old, as compared with patients aged 18 to 49 and 50 to 64 years. Physicians were blind to the objectives of this research. The study protocol required an ED nurse trained in data collection to be present to record vital signs and assess for any prospectively defined complications. We used American Society of Anesthesiologists (ASA) physical status classification for systemic disease to evaluate and account for the comorbidities of patients. We used the Fisher exact test for the difference in proportions across age groups and analysis of variance for the differences in dosing across age and ASA categories.
During the 4-year study, we enrolled 50 patients at least 65 years old, 149 patients aged 50 to 64 years, and 665 patients aged 18 to 49 years. Adverse event rates were 8%, 5.4%, and 5.2%, respectively (P = .563). The at least 65 years age group represented a greater percentage of those with higher ASA scores (P < .001). The average total sedative dose in the at least 65 years group was significantly lower than the comparisons (P < .001).
This study demonstrated no statistically significant difference in complication rate for patients 65 years or older. There was a significant decrease in mean sedation dosing with increased age and ASA score.
The American journal of emergency medicine 06/2011; 29(5):541-4. · 1.54 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: To compare attitudes toward dementia screening of older adults with and without an experience of dementia caregiving.
A cross-sectional study.
Primary care clinics in Indianapolis, Indiana.
Eighty-one participants with dementia caregiving experience (CG) and a random sample of 125 participants without dementia caregiving experience (NCG).
Attitudes of dementia screening, including acceptance of dementia screening and its perceived harms and benefits, as determined according to the Perceptions Regarding Investigational Screening for Memory in Primary Care questionnaire.
After adjusting for age, race, sex, and education, CGs had a lower dementia screening acceptance mean score (53.9 vs 60.6; P=.03) and a higher perceived suffering score (61.6 vs 55.9, P=.04) than NCGs, but there were no differences in perceived benefits of dementia screening (72.8 vs 69.0; P=.50), perceived stigma (32.9 vs 37.5; P=.12), and perceived negative effect on independence (47.6 vs 54.0; P=.20). The top three barriers to screening identified by both groups were emotional suffering by the family (86% of CGs and 75% of NCGs), loss of driving privileges (75% of CGs and 78% of NCGs), and becoming depressed (64% of CGs and 43% of NCGs).
The experience of being a dementia caregiver may influence one's own attitude about accepting dementia screening for oneself.
Journal of the American Geriatrics Society 03/2011; 59(4):681-6. · 4.22 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Delirium prevalence in the intensive care unit (ICU) is high. Numerous psychotropic agents are used to manage delirium in the ICU with limited data regarding their efficacy or harms.
This is a randomized controlled trial of 428 patients aged 18 and older suffering from delirium and admitted to the ICU of Wishard Memorial Hospital in Indianapolis. Subjects assigned to the intervention group will receive a multicomponent pharmacological management protocol for delirium (PMD) and those assigned to the control group will receive no change in their usual ICU care. The primary outcomes of the trial are (1) delirium severity as measured by the Delirium Rating Scale revised-98 (DRS-R-98) and (2) delirium duration as determined by the Confusion Assessment Method for the ICU (CAM-ICU). The PMD protocol targets the three neurotransmitter systems thought to be compromised in delirious patients: dopamine, acetylcholine, and gamma-aminobutyric acid. The PMD protocol will target the reduction of anticholinergic medications and benzodiazepines, and introduce a low-dose of haloperidol at 0.5-1 mg for 7 days. The protocol will be delivered by a combination of computer (artificial intelligence) and pharmacist (human intelligence) decision support system to increase adherence to the PMD protocol.
The proposed study will evaluate the content and the delivery process of a multicomponent pharmacological management program for delirium in the ICU.
[Show abstract][Hide abstract] ABSTRACT: Recent randomized controlled trials have demonstrated the effectiveness of the collaborative dementia care model targeting both the patients suffering from dementia and their informal caregivers.
To implement a sustainable collaborative dementia care program in a public health care system in Indianapolis.
We used the framework of Complex Adaptive System and the tool of the Reflective Adaptive Process to translate the results of the dementia care trial into the Healthy Aging Brain Center (HABC).
Within its first year of operation, the HABC delivered 528 visits to serve 208 patients and 176 informal caregivers. The mean age of HABC patients was 73.8 (standard deviation, SD 9.5), 40% were African-Americans, 42% had less than high school education, 14% had normal cognitive status, 39% received a diagnosis of mild cognitive impairment, and 46% were diagnosed with dementia. Within 12 months of the initial HABC visit, 28% of patients had at least one visit to an emergency room (ER) and 14% were hospitalized with a mean length of stay of five days. The rate of a one-week ER revisit was 14% and the 30-day rehospitalization rate was 11%. Only 5% of HABC patients received an order for neuroleptics and only 16% had simultaneous orders for both definite anticholinergic and anti-dementia drugs.
The tools of 'implementation science' can be utilized to translate a health care delivery model developed in the research laboratory to a practical, operational, health care delivery program.
Aging and Mental Health 01/2011; 15(1):13-22. · 1.68 Impact Factor