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ABSTRACT: BACKGROUND: Little is known about how a neighbourhood's unemployment history may set the stage for depressive symptomatology. This study examines the effects of urban neighbourhood unemployment history on current depressive symptoms and subsequent symptom trajectories among residentially stable late middle age and older adults. Contingent effects between neighbourhood unemployment and individual-level employment status (ie, cross-level interactions) are also assessed. METHODS: Individual-level survey data are from four waves (2000, 2002, 2004 and 2006) of the original cohort of the nationally representative US Health and Retirement Study. Neighbourhoods are operationalised with US Census tracts for which historical average proportion unemployed between 1990 and 2000 and change in proportion unemployed between 1990 and 2000 are used to characterise the neighbourhood's unemployment history. Hierarchical linear regressions estimate three-level (time, individual and neighbourhood) growth models. RESULTS: Symptoms in 2000 are highest among those residing in neighbourhoods characterised by high historical average unemployment beginning in 1990 and increasing unemployment between 1990 and 2000, net of a wide range of socio-demographic controls including individual-level employment status. These neighbourhood unemployment effects are not contingent upon individual-level employment status in 2000. 6-year trajectories of depressive symptoms decrease over time on average but are not significantly influenced by the neighbourhood's unemployment history. CONCLUSIONS: Given the current US recession, future studies that do not consider historical employment conditions may underestimate the mental health impact of urban neighbourhood context. The findings suggest that exposure to neighbourhood unemployment earlier in life may be consequential to mental health later in life.
Journal of epidemiology and community health 08/2012; · 3.04 Impact Factor
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ABSTRACT: To test the feasibility and validity of the Brief Interview for Mental Status (BIMS) as a performance-based cognitive screener that could be easily completed by nursing home staff. The current study examines the performance of the BIMS as part of the national testing of the Minimum Data Set 3.0 (MDS 3.0) for Nursing Homes.
The BIMS was tested as part of the national MDS 3.0 evaluation study among 3822 residents scheduled for MDS 2.0 assessments. Residents were from 71 community nursing homes (NHs) in eight states. Residents were randomly included in a feasibility sample (n = 3258) and a validation sample (n = 418). Cognition was assessed with three instruments: the Brief Interview for Mental Status (BIMS), the MDS 2.0 Cognitive Performance Scale (CPS), and the Modified Mini-Mental State Examination (3MS). Trained research nurses administered the 3MS and BIMS to all subjects in the validation study. The CPS score was determined based on the MDS 2.0 completed by nursing home staff who had undergone additional training on cognitive testing. Standard cutoff scores on the 100-point 3MS were used as the gold standard for any cognitive impairment (<78) and for severe impairment (<48). Staff impressions were obtained from anonymous surveys.
The BIMS was attempted and completed in 90% of the 3258 residents in the feasiblity sample. BIMS scores covered the full instrument range (0-15). In the validation sample, correlation with the criterion measure (3MS) was higher for BIMS (0.906, P < .0001) than for CPS (-0.739, P < .0001); P < .01 for difference. For identifying any impairment, a BIMS score of 12 had sensitivity = 0.83 and specificity = 0.91; for severe impairment, a BIMS score of 7 had sensitivity = 0.83 and specificity = 0.92. The area under the receiver operator characteristics curve, a measure of test accuracy, was higher for BIMS than for CPS for identifying any impairment (AUC = 0.930 and 0.824, respectively) and for identifying severe impairment (AUC = 0.960 and 0.857, respectively). Eighty-eight percent of survey respondents reported that the BIMS provided new insight into residents' cognitive abilities. The average time for completing the BIMS was 3.2 minutes.
The BIMS, a short performance-based cognitive screener expressly designed to facilitate cognitive screening in MDS assessments, was completed in the majority of NH residents scheduled for MDS assessments in a large sample of NHs, demonstrating its feasibility. Compared with MDS 2.0 observational items, the BIMS performance-based assessment approach was more highly correlated with a criterion cognitive screening test and demonstrated greater accuracy. The majority of surveyed staff reported improved assessments with the new approach.
Journal of the American Medical Directors Association 07/2012; 13(7):611-7. · 4.64 Impact Factor
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ABSTRACT: To analyze whether types of providers and frequency of encounters are associated with higher quality of care within a coordinated dementia care management (CM) program for patients and caregivers.
Secondary analysis of intervention-arm data from a dementia CM cluster-randomized trial, where intervention participants interacted with healthcare organization care managers (HOCMs), community agency care managers (CACMs), and/ or healthcare organization primary care providers (HOPCPs) over 18 months.
Encounters of 238 patient/caregivers (dyads) with HOCMs, CACMs, and HOPCPs were abstracted from care management electronic records. The quality domains of assessment, treatment, education/support, and safety were measured from medical record abstractions and caregiver surveys. Mean percentages of met quality indicators associated with exposures to each provider type and frequency were analyzed using multivariable regression, adjusting for participant characteristics and baseline quality.
As anticipated, for all 4 domains, the mean percentage of met dementia quality indicators was 15.5 to 47.2 percentage points higher for dyads with HOCM--only exposure than for dyads with none (all P < .008); not anticipated were higher mean percentages with increasing combinations of provider-type exposure-up to 73.7 percentage points higher for safety (95% confidence interval 65.2%-82.1%) with exposure to all 3 provider types compared with no exposure. While greater frequency of HOCM-dyad encounters was associated with higher quality (P < .04), this was not so for other provider types.
HOCMs' interactions with dyads was essential for dementia care quality improvement. Additional coordinated interactions with primary care and community agency staff yielded even higher quality.
The American journal of managed care 02/2012; 18(2):85-94. · 2.46 Impact Factor
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ABSTRACT: Care management approaches have been proven to improve outcomes for patients with dementia and their family caregivers (dyads). However, acceptance of services in these programs is incomplete, impacting effectiveness. Acceptance may be related to dyad as well as healthcare system characteristics, but knowledge about factors associated with program acceptance is lacking. This study investigates patient, caregiver, and healthcare system characteristics associated with acceptance of offered care management services.
This study analyzed data from the intervention arm of a cluster randomized controlled trial of a comprehensive dementia care management intervention. There were 408 patient-caregiver dyads enrolled in the study, of which 238 dyads were randomized to the intervention. Caregiver, patient, and health system factors associated with participation in offered care management services were assessed through bivariate and multivariate regression analyses.
Out of the 238 dyads, 9 were ineligible for this analysis, leaving data of 229 dyads in this sample. Of these, 185 dyads accepted offered care management services, and 44 dyads did not. Multivariate analyses showed that higher likelihood of acceptance of care management services was uniquely associated with cohabitation of caregiver and patient (p < 0.001), lesser severity of dementia (p = 0.03), and higher patient comorbidity (p = 0.03); it also varied across healthcare organization sites.
Understanding factors that influence care management participation could result in increased adoption of successful programs to improve quality of care. Using these factors to revise both program design as well as program promotion may also benefit external validity of future quality improvement research trials. Copyright © 2011 John Wiley & Sons, Ltd.
International Journal of Geriatric Psychiatry 12/2011; 27(10):1078-85. · 2.42 Impact Factor
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ABSTRACT: Frequent review and update of guidelines are necessary for them to remain current and useful for clinical practices. This second revision of the postdiagnostic management of Alzheimer's disease (AD) guideline by the California Workgroup was prompted by significant advances in knowledge about appropriate care management, including pharmacologic and nonpharmacologic approaches to treatment of the disease, accompanying behavioral problems, and functional decline. The focus remains explicitly on primary care, where the majority of it occurs for those with AD and other dementias.
In all, 40 experts in dementia care were recruited from a variety of disciplines across California. Four workgroups were created that reviewed recent research findings from a total of 569 publications since 2002. The revised Guideline incorporates 305 new references, including 11 state and federal laws, in addition to 78 references from the previous version.
The Guideline is divided into four sections that address postdiagnostic management: (1) assessment, (2) treatment, (3) patient and family education and support, and (4) legal considerations associated with AD. Significant revisions and changes in each area and the underlying research to support the recommendations are presented in this article. New topics related to early stage and end-of-life were identified and recommendations were developed for these specific populations.
The Guideline recommendations provide a framework to inform and improve medical care for AD by primary health care providers.
Alzheimer's & dementia: the journal of the Alzheimer's Association 05/2011; 7(3):e51-9. · 5.90 Impact Factor
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Dorothy P Harris,
Freddy Ortiz,
Fredric M Adler,
Katherine Yu,
Michele L Maines,
Dora Barba,
Sandra I Viggiani,
Sheldon M Wolf,
L Jaime Fitten, Joshua Chodosh,
Barbara G Vickrey
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ABSTRACT: Implement a memory impairment screening procedure for elderly Hispanic primary care patients, and analyze its yield and challenges to further triage and diagnostic evaluation.
Three hundred twenty nine Hispanic patients aged ≥60 years or proxy informants were enrolled from outpatient primary care clinics at an urban safety-net medical center. Patients were screened for memory impairment using the WHO-UCLA AVLT; for those without consent capacity, proxies were given the IQCODE. Bilingual research assistants conducted in-person or telephone screening. Age, gender, education, comorbidities, acculturation, overall health, access to care, and memory concerns were assessed as potential predictors of memory impairment. Based on identified implementation challenges, a multi-disciplinary stakeholder committee proposed revised approaches to increase diagnostic evaluation and sustainability.
Of 677 eligible patients approached, 329 (49%) were screened, and 77 (23%) met criteria for memory impairment using the WHO-UCLA AVLT (N=60) or the IQCODE (N=17). Only male gender and higher comorbidity uniquely predicted memory impairment (ps<0.05). Few screen-positive patients declined further triage and evaluation, but a substantial proportion could not be subsequently contacted. Challenges to implementing a memory screening program included staff time and adequate clinic space for in-person screening; challenges to follow-up of positive screening results included inability to contact patients and lack of primary care continuity to facilitate further triage and referral.
Nearly one-fourth of primary care Hispanic elders screened as memory-impaired, but few factors predicted positive screening. Stakeholder-guided adaptations are needed-particularly in resource-constrained settings-to overcome challenges to further diagnostic evaluation and referral.
International Journal of Geriatric Psychiatry 03/2011; 26(3):268-76. · 2.42 Impact Factor
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Journal of Health and Social Behavior 01/2011; 52(2):162. · 2.72 Impact Factor
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ABSTRACT: This study examines the association of cognitive functioning with urban neighborhood socioeconomic disadvantage and racial/ethnic segregation for a U.S. national sample of persons in late middle age, a time in the life course when cognitive deficits begin to emerge. The key hypothesis is that effects of neighborhood on cognitive functioning are not uniform but are most pronounced among subgroups of the population defined by socioeconomic status and race/ethnicity. Data are from the third wave of the Health and Retirement Survey for the birth cohort of 1931 to 1941, which was 55 to 65 years of age in 1996 (analytic N = 4,525), and the 1990 U.S. Census. Neighborhood socioeconomic disadvantage has an especially large negative impact on cognitive functioning among persons who are themselves poor, an instance of compound disadvantage. These findings have policy implications supporting "upstream" interventions to enhance cognitive functioning, especially among those most adversely affected by neighborhood socioeconomic disadvantage.
Journal of Health and Social Behavior 01/2011; 52(2):163-79. · 2.72 Impact Factor
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ABSTRACT: To determine the concurrent influence of depressive symptoms, medical conditions, and disabilities in activities of daily living (ADLs) on rates of decline in cognitive function of older Americans.
Prospective cohort.
National population based.
A national sample of 6,476 adults born before 1924.
Differences in cognitive function trajectories were determined according to prevalence and incidence of depressive symptoms, chronic diseases, and ADL disabilities. Cognitive performance was tested five times between 1993 and 2002 using a multifaceted inventory examined as a global measure (range 0-35, standard deviation (SD) 6.0) and word recall (range 0-20, SD 3.8) analyzed separately.
Baseline prevalence of depressive symptoms, stroke, and ADL limitations were independently and strongly associated with lower baseline cognition scores but did not predict future cognitive decline. Each incident depressive symptom was independently associated with a 0.06-point lower (95% confidence interval (CI)=0.02-0.10) recall score, incident stroke with a 0.59-point lower total score (95% CI=0.20-0.98), each new basic ADL limitation with a 0.07-point lower recall score (95% CI=0.01-0.14) and a 0.16-point lower total score (95% CI=0.07-0.25), and each incident instrumental ADL limitation with a 0.20-point lower recall score (95% CI=0.10-0.30) and a 0.52-point lower total score (95% CI=0.37-0.67).
Prevalent and incident depressive symptoms, stroke, and ADL disabilities contribute independently to poorer cognitive functioning in older Americans but do not appear to influence rates of future cognitive decline. Prevention, early identification, and aggressive treatment of these conditions may ameliorate the burdens of cognitive impairment.
Journal of the American Geriatrics Society 11/2010; 58(12):2350-7. · 3.74 Impact Factor
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ABSTRACT: To compare primary care providers' (PCPs') perceptions about dementia and its care within their healthcare organization with perceptions of other common chronic conditions and to explore factors associated with differences.
Cross-sectional survey.
Three California healthcare organizations.
One hundred sixty-four PCPs.
PCPs' views about primary care for dementia were analyzed and compared with views about care for heart disease, diabetes mellitus, and selected other conditions. Differences in views about conditions according to PCP type (internists, family physicians) were assessed. Multivariate analysis examined relationships between provider and practice characteristics and views about dementia care.
More PCPs strongly agreed that older patients with dementia are difficult to manage (23.8%) than for heart disease (5.0%) or diabetes mellitus (6.3%); PCPs can improve quality of life for heart disease (58.9%) and diabetes mellitus (61.6%) than for dementia (30.9%); older patients should be routinely screened for heart disease (63.8%) and diabetes mellitus (67.7%) than dementia (55.5%); and their organizations have expertise/referral resources to manage diabetes mellitus (49.4%) and heart disease (51.8%) than dementia (21.1%). More PCPs reported almost effortless organizational care coordination for heart disease (13.0%) or diabetes mellitus (13.7%) than for dementia (5.6%), and a great deal or many opportunities for improvement in their ability to manage dementia (50.6%) than incontinence, depression, or hypertension (7.4-34.0%; all P<.05). Internists' views regarding dementia care were less optimistic than those of family physicians, but PCP type was unrelated to views on diabetes mellitus or heart disease.
Improving primary care management of dementia should directly address PCP concerns about expertise and referral resources, difficulty of care provision, and PCP views about prospects for patient improvement.
Journal of the American Geriatrics Society 11/2009; 57(12):2209-16. · 3.74 Impact Factor
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ABSTRACT: Dementia is a common geriatric syndrome. It is unclear how best to predict survival among dementia patients, which leaves clinicians, patients, and families uncertain as to how to proceed with medical decisions and reassessing goals.
We performed a MEDLINE systematic review of studies that evaluated dementia prognosis and survival; 48 studies (cohort, cross-sectional, retrospective, and case-control studies) were included.
Increased age, male gender, decreased functional status, and medical comorbidities such as diabetes, cardiovascular disease, and malignancy were associated with a higher mortality rate in dementia patients. Patients' baseline education level showed no influence on survival. There was no consensus regarding the association among dementia type, baseline cognitive function, and neuropsychiatric symptoms with dementia prognosis.
Despite much data, we lack a unifying guideline for dementia prognostication. Moving forward, the creation of a risk score for dementia could be helpful for patients and families in reassessing goals of care and possible enrollment in services such as hospice or palliative care.
Journal of the American Medical Directors Association 10/2009; 10(7):466-71. · 4.64 Impact Factor
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ABSTRACT: To calculate intervention costs and the potential cost offset of a care management intervention that substantially improved the quality of dementia care.
From both a payer perspective and a social planner perspective, we analyzed data from a cluster randomized controlled trial (RCT) evaluating this intervention versus usual care. The RCT included 408 pairs of older adults with dementia and their caregivers. Caregivers were surveyed at baseline, at 12 months, and at 18 months to assess patient healthcare utilization and out-of-pocket costs.
We calculated fixed and per-patient intervention costs from RCT records. We combined the monthly per-patient costs of healthcare services, informal caregiving, and out-of-pocket costs, and we conducted multivariate analyses comparing this sum (potential cost offset) for intervention versus usual care patients. Covariates included patient age, sex, and baseline costs. We limited the main analysis to patients who survived until the 12-month survey or the 18-month survey.
The intervention required a start-up cost of $70,256 and mean intervention per-patient per month costs of $118. There were no significant differences in the mean monthly cost of healthcare and caregiving services for intervention versus usual care patients using the societal perspective (difference of -$555 per month, P = .28) or the payer perspective (difference of -$219 per month [including nursing home costs], P = .55; difference of -$256 per month [excluding nursing home costs], P = .47).
Although this analysis of a dementia care management intervention did not demonstrate a significant cost offset, the intervention may represent a worthwhile approach to improving the quality of care and health outcomes for patients with dementia and their caregivers.
The American journal of managed care 09/2009; 15(8):521-8. · 2.46 Impact Factor
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ABSTRACT: This study used mixed-effects modeling of data from a national sample of 6,476 US adults born before 1924, who were tested 5 times between 1993 and 2002 on word recall, serial 7's, and other mental status items to determine demographic and socioeconomic predictors of trajectories of cognitive function in older Americans. Mean decline with aging in total cognition score (range, 0-35; standard deviation, 6.00) was 4.1 (0.68 standard deviations) per decade (95% confidence interval: 3.8, 4.4) and in recall score (range, 0-20; standard deviation, 3.84) was 2.3 (0.60 standard deviations) per decade (95% confidence interval: 2.1, 2.5). Older cohorts (compared with younger cohorts), women (compared with men), widows/widowers, and those never married (both compared with married individuals) declined faster, and non-Hispanic blacks (compared with non-Hispanic whites) and those in the bottom income quintile (compared with the top quintile) declined slower. Race and income differences in rates of decline were not sufficient to offset larger differences in baseline cognition scores. Educational level was not associated with rate of decline in cognition scores. The authors concluded that ethnic and socioeconomic disparities in cognitive function in older Americans arise primarily from differences in peak cognitive performance achieved earlier in the life course and less from declines in later life.
American journal of epidemiology 09/2009; 170(3):331-42. · 5.59 Impact Factor
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ABSTRACT: To test the accuracy of a brief cognitive assessment of nursing home (NH) residents and to determine whether facility nurses can reliably perform this assessment.
Cross-sectional, independent cognitive screening tests with NH residents.
Six Department of Veteran Affairs nursing facilities.
Three hundred seventy-four residents from six regionally distributed Veteran Affairs NHs.
Three cognitive assessment instruments: the Brief Interview of Mental Status (BIMS), created for this study; the Minimum Data Set (MDS) 2.0 Cognitive Performance Scale (CPS), and the Modified Mini-Mental State Examination (3MS) as the criterion standard. The 15-point BIMS tests memory and orientation and includes free and cued recall items. Research assistants administered the 3MS and BIMS to all subjects. Facility nurses administered the same BIMS to a subsample.
Three hundred seventy-four of 417 (89.7%) residents approached completed the 3MS and research assistant-administered BIMS (BIMS-R); 212 residents also received a facility nurse-administered BIMS (BIMS-N). The BIMS-R was more highly correlated with the 3MS than was the CPS (Pearson correlation coefficient (r)=0.79 vs 0.62; P<.01 for difference). For the subset who received facility assessments, the BIMS-N was also more highly correlated with the 3MS (Pearson r=0.74 vs 0.65; P<.01 for difference). For any impairment (3MS<78), the area under the receiver operator characteristic curve (AUC) was 0.86 for the BIMS, versus 0.77 for the CPS. For severe impairment (3MS<48) the AUC was 0.94, versus 0.85 for the CPS.
In this population, a brief cognitive test is a more accurate approach to cognitive assessment than the current observational methods employed using the MDS 2.0.
Journal of the American Geriatrics Society 11/2008; 56(11):2069-75. · 3.74 Impact Factor
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ABSTRACT: To identify specific care management activities within a dementia care management intervention that are associated with 18-month change in caregiver mastery and relationship strain.
Exploratory analysis, using secondary data (care management processes and caregiver outcomes) from the intervention arm of a clinic-level randomized, controlled trial of a dementia care management quality improvement program.
Nine primary care clinics in three managed care and fee-for-service southern California healthcare organizations.
Two hundred thirty-eight pairs: individuals with dementia and their informal, nonprofessional caregivers.
Care management activity types extracted from an electronic database were used as predictors of caregiver mastery and relationship strain, which were measured through mailed surveys. Multivariable linear regression models were used to predict caregiver mastery and relationship strain.
For each care manager home environment assessment, caregiver mastery increased 4 points (range 0-100, mean+/-standard deviation 57.1+/-26.6, 95% confidence interval (CI)=2.4-5.7; P=.001) between baseline and 18 months. For every action linking caregivers to community agencies for nonspecific needs, caregiver mastery decreased 6.2 points (95% CI=-8.5 to -3.9; P<.001). No other care management activities were significantly associated with this outcome, and no specific activities were associated with a change in caregiver relationship strain.
Home assessments for specific needs of caregivers and persons with dementia are associated with improvements in caregivers' sense of mastery. Future work is needed to determine whether this increase is sustained over time and decreases the need for institutionalization.
Journal of the American Geriatrics Society 06/2008; 56(5):891-7. · 3.74 Impact Factor
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ABSTRACT: To describe end-of-life advance care planning among the oldest-old (those >/= 85 years) and to identify patient characteristics and healthcare utilization patterns associated with likelihood of care planning documentation.
Medical charts were abstracted for evidence of advance care planning documentation (including surrogate for health care decisions) and linked to patient demographic, clinical, and health utilization characteristics.
Veterans Affairs Greater Los Angeles Healthcare System (VA GLAHS).
All Veterans (n = 175) aged >/= 85 who died between September 1999 and October 2000 and used services at the VA GLAHS in the last year of life.
The association of patient demographic, clinical, and health care utilization characteristics with documentation of advance care planning and surrogates was modeled using multivariate logistic regression.
Among veterans (mean age at death, 89.4 +/- 3.8 years), 50 of 149 (34%) electronic available records had documented care preferences whereas 68 (46%) had documentation of surrogates. Considering demographic, clinical, and service use characteristics, only age (adjusted odds ratio [AOR]: 1.1 per year; 95% confidence interval [CI]: 1.0-1.2) and outpatient visits (AOR: 1.6 per quartile of general and geriatric medicine visit frequency; 95% CI: 1.1-;2.3) were associated with advance directive completion. A multivariable regression model using the same predictors to predict documentation of surrogates found similar associations with total outpatient visits (AOR: 1.5; 95% CI: 1.0-2.0) and general and geriatric medicine utilization. (AOR: 1.4; 95% CI: 1.0-2.0).
Even in a health care system known for high-quality chronic illness care, documentation of advance care planning and selected proxies for health care decisions at the end of life was infrequent. Outpatient primary care and geriatric providers' visits were more frequent among those who had documented advance care planning, suggesting that involvement of these practitioners may improve end-of-life care.
Journal of Palliative Medicine 03/2008; 11(2):152-7. · 1.85 Impact Factor
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Journal of the American Geriatrics Society 11/2007; 55 Suppl 2:S403-8. · 3.74 Impact Factor
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Joshua Chodosh,
Brian S Mittman,
Karen I Connor,
Stefanie D Vassar,
Martin L Lee,
Robert W DeMonte,
Theodore G Ganiats,
Lisa E Heikoff,
Laurence Z Rubenstein,
Richard D Della Penna,
Barbara G Vickrey
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ABSTRACT: 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.
Observational, cross-sectional.
Three hundred eighty-seven patient-caregiver pairs from three healthcare organizations
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.
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.
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.
Journal of the American Geriatrics Society 09/2007; 55(8):1260-8. · 3.74 Impact Factor
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ABSTRACT: Memory impairment is the most frequent cognitive dysfunction for older patients. Though studies have shown that dementia is often overlooked in primary care settings, there has been minimal focus specifically on memory impairment, on patients' concerns about memory, or their desire to address these concerns. The objectives of this study were to (1) investigate the prevalence of memory impairment among patients without dementia diagnoses, (2) determine the degree of patients' concern about memory impairment and (3) identify other patient characteristics associated with memory impairment among older primary care patients. Using telephone versions of a four-item memory test and proxy-reported cognitive decline for patients unable to complete interviews, we performed memory assessment of randomly selected patients, 75 years and older, without dementia diagnoses who see primary care physicians at least twice every six months. Among 260 patients and 20 proxies, 19.8% had memory impairment at a level indicative of probable dementia. Adjusting for age, ethnicity, and education, subjects who were more concerned about memory impairment were more likely to be impaired. (Adjusted odds ratio [AOR]: 1.4 (for each additional level of concern); 95% confidence interval [CI]: (1.0-2.0)). Similarly, subjects wanting their physician to discuss with them their memory concerns were more likely to be impaired (AOR: 1.4; 95% CI: 1.0-1.9). Memory impairment is common among older primary care patients without diagnosed dementia. Knowing patients' concerns about memory impairment and their desire to discuss these concerns may facilitate cognitive screening in this setting.
Aging and Mental Health 08/2007; 11(4):444-50. · 1.37 Impact Factor
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ABSTRACT: The prevalence of dementia continues to rise, and yet, there are few known modifiable risk factors. Depression, as a treatable condition, may be important in the development of dementia. Our objective was to examine the association between depressive symptoms and longitudinal cognitive changes in older adults who were high-functioning at baseline.
The authors analyzed data from a community-based cohort (aged 70-79 at baseline), who, at study entry, scored 7 or more (out of 9) on the Short Portable Mental Status Questionnaire (SPMSQ). Depressive symptoms were assessed at baseline using the depression subscale of the Hopkins Symptom Check List. Cognitive performance was measured at baseline and at seven-year follow up by the SPMSQ and by summary scores from standard tests of naming, construction, spatial recognition, abstraction, and delayed recall.
After adjusting for potential confounders, including age, education, and chronic health conditions such as diabetes, heart attack, stroke, and hypertension, a higher number of baseline depressive symptoms were strongly associated with greater seven-year decline in cognitive performance and with higher odds of incident cognitive impairment, i.e., decline in SPMSQ score to < or = 6 (adjusted odds ratio per quartile of depressive symptoms score: 1.34, 95% confidence interval: 1.10-1.68).
Depressive symptomatology independently predicts cognitive decline and incident cognitive impairment in previously high-functioning older persons.
American Journal of Geriatric Psychiatry 05/2007; 15(5):406-15. · 3.64 Impact Factor
