The majority of older adults with dementia are either undiagnosed or unaware of the diagnosis, suggesting shortcomings in detection and communication of dementia. Individuals who may benefit from targeted screening include racial/ethnic minorities and persons who have lower educational attainment, any functional impairment, or attend medical visits alone.
Objective. To investigate effects of a novel dementia care coordination program on health services utilization. Data Sources/Study Setting. A total of 303 community-dwelling adults aged ≥70 with a cognitive disorder in Baltimore, Maryland (2008-2011. Study Design. Single-blind RCT evaluating efficacy of an 18-month care coordination intervention delivered through community-based nonclinical care coordinators, supported by an interdisciplinary clinical team. Data Collection/Extraction Methods. Study partners reported acute care/inpatient, outpatient, and home-and community-based service utilization at baseline, 9, and 18 months. Principal Findings. From baseline to 18 months, there were no significant group differences in acute care/inpatient or total outpatient services use, although intervention participants had significantly increased outpatient dementia/mental health visits from 9 to 18 months (p = .04) relative to controls. Home and community-based support service use significantly increased from baseline to 18 months in the intervention compared to control (p = .005). Conclusions. While this dementia care coordination program did not impact acute care/inpatient services utilization, it increased use of dementia-related outpatient medical care and nonmedical supportive community services, a combination that may have helped participants remain at home longer. Future care model modifications that emphasize delirium, falls prevention, and behavior management may be needed to influence inpatient service use.
Objective:Understanding which characteristics of persons with dementia (PWD) and their caregivers are associated with unmet needs can inform strategies to address those needs. Our purpose was to determine the percentage of PWD having unmet needs and significant correlates of unmet needs in PWD.Design:Cross-sectional data were analyzed using bivariate and hierarchical multiple linear regression analyses.Setting:Participants lived in the greater Baltimore, Maryland and Washington DC suburban area.Participants:A sample of 646 community-living PWD and their informal caregivers participated in an in-home assessment of dementia-related needs.Measurements:Unmet needs were identified using the Johns Hopkins Dementia Care Needs Assessment. Correlates of unmet needs were determined using demographic, socioeconomic, clinical, functional and quality of life characteristics of the PWD and their caregivers.Results:PWD had a mean of 10.6 (±4.8) unmet needs out of 43 items (24.8%). Unmet needs were most common in Home/Personal Safety (97.4%), General Health Care (83.1%), and Daily Activities (73.2%) domains. Higher unmet needs were significantly related to non-white race, lower education, higher cognitive function, more neuropsychiatric symptoms, lower quality of life in PWD, and having caregivers with lower education or who spent fewer hours/week with the PWD.Conclusions:Unmet needs are common in community-living PWD, and most are non-medical. Home-based dementia care can identify and address PWD’s unmet needs by focusing on care recipients and caregivers to enable PWD to remain safely at home.
Objectives To examine whether experiences with illness and end-of-life care are associated with increased readiness to participate in advance care planning (ACP). Design Observational cohort study. Setting Community. Participants Persons age ≥ 60 recruited from physician offices and a senior center. Measurements Participants were asked about personal experience with major illness or surgery and experience with others’ end-of-life care, including whether they had made a medical decision for someone dying, knew someone who had a bad death due to too much/too little medical care, or experienced the death of a loved one who made end-of-life wishes known. Stages of change were assessed for specific ACP behaviors: completion of living will and healthcare proxy, communication with loved ones regarding life-sustaining treatments and quantity versus quality of life, and communication with physicians about these same topics. Stages of change included precontemplation, contemplation, preparation and action/maintenance corresponding to whether the participant was not ready to complete the behavior, was considering participation in the next six months, was planning participation within thirty days, or had already participated. Results Of 304 participants, 84% had one or more personal experiences or experience with others. Personal experiences were not associated with increased readiness for most ACP behaviors. In contrast, having one or more experiences with others was associated with increased readiness to complete a living will and healthcare proxy, discuss life-sustaining treatment with loved ones and discuss quantity versus quality of life with loved ones and with physicians. Conclusion Older individuals who have experience with end-of-life care for others demonstrate increased readiness to participate in ACP. Discussions with older patients regarding these experiences may be a useful tool in promoting ACP.
Objectives To examine the prevalence of dementia in the absence of a reported dementia diagnosis and whether potentially unsafe activities and living conditions vary as a function of dementia diagnosis status in a nationally representative sample of older adults. Design Observational cohort study. Setting Community. Participants 7,609 Medicare beneficiaries age ≥ 65 enrolled in the National Health and Aging Trends Study. Measurements Participants were classified into four groups based on self-report of dementia diagnosis, proxy screening interview, and cognitive testing: 1) probable dementia with reported dementia diagnosis (n=457), 2) probable dementia without reported dementia diagnosis (n=581), 3) possible dementia (n=996), or 4) no dementia (n=5,575). We examined potentially unsafe activities (driving, preparing hot meals, managing finances or medications, attending doctor visits alone) and living conditions (falls, living alone, and unmet needs) by dementia status subgroups in stratified analyses and multivariate models, adjusting for sociodemographic factors, medical comorbidities, and physical capacity. Results The prevalence of driving (22.9%), preparing hot meals (31%), managing finances (21.9%), managing medications (36.6%), and attending doctor visits alone (20.6%) was lowest in persons with probable dementia. However, among persons with probable dementia, the covariate-adjusted rates of driving, preparing hot meals, managing finances, managing medications, and attending doctor visits alone were significantly higher in those without reported dementia diagnosis than for those with reported diagnosis (all odds ratios ≥ 2.00, p's < 0.01). Conclusion Older adults with probable dementia who are not aware of a dementia diagnosis are more likely to report engaging in potentially unsafe behaviors. Understanding the prevalence of potentially unsafe activities and living conditions can help clinicians focus safety screening and counseling in older adults with diagnosed or suspected dementia.
Objective Older adults commonly involve family (broadly defined) in their care. We examined communication behaviors of family companions during older adults’ primary care visits, including whether these behaviors vary with respect to how older adults manage their health, preferences for involving family in medical decision-making, and ratings of companion helpfulness. Methods Analysis of audio-taped primary care visits of older patients who were accompanied by a family companion (n=30 dyads) and linked patient surveys. Results Family companions predominantly facilitated doctor and patient information exchange. More than half of companion communication behaviors were directed at improving doctor understanding of the patient. Companions were more verbally active during visits of patients who delegated the management of their health to others than visits of patients who co-managed or self-managed their health. Companions were rated as more helpful by patients who preferred active involvement of family in medical decision-making. Conclusion Family companion participation and helpfulness in primary care communication varies by patients’ preferences for involving family in medical decision-making and approach to managing their health. Practice Implications Research to examine the effects of clarifying patient and family companion expectations for primary care visits could inform strategies to improve the patient-centeredness of medical communication.
Family companions actively participate in primary care visits of older adults with cognitive impairment in ways that promote and inhibit effective communication. Findings suggest the need for strategies that more effectively and purposefully involve family in the care of primary care patients with cognitive impairment. Copyright © 2017 John Wiley & Sons, Ltd.
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