Cathy C. Schubert

The cognitive impact of anticholinergics:a clinical review

Context: 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. Objective: Evaluate the existing evidence regarding the effects of anticholinergic medications on cognition in older adults. Data sources: We searched the MEDLINE, OVID, and CINAHL databases from January, 1966 to January, 2008 for eligible studies. Study selection: 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. Data extraction: We extracted the method used to determine anticholinergic activity of medications and its association with cognitive outcomes. Results: 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. Conclusions: 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.

Comorbidity profile of dementia patients in primary care: Are they sicker?

OBJECTIVES: To compare the medical comorbidity of older patients with and without dementia in primary care.

Implementing Innovative Models of Dementia Care: The Healthy Aging Brain Center

Background: 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. Objective: To implement a sustainable collaborative dementia care program in a public health care system in Indianapolis. Methods: 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). Results: 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. Conclusion: 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.

Acute Care Utilization by Dementia Caregivers Within Urban Primary Care Practices

BACKGROUNDCaring 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.OBJECTIVETo study the impact of stress on the physical and mental health of the caregiver.DESIGNPatients 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.PARTICIPANTSOne 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.RESULTSTwenty-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).CONCLUSIONTo 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.

Improving Medical Student Attitudes Toward Older Patients Through a "Council of Elders" and Reflective Writing Experience

In an effort to reduce “agism” which is prevalent among medical trainees, a new geriatrics educational experience for medical students aimed at improving attitudes toward older patients was developed. Each 90‐minute Older Adult Session included four components: initial reflective writing exercise; introduction to the session; 75‐minute dialogue with the “Council of Elders,” a group of active, “well” older adults; and final reflective writing exercise. The new session was provided to 237 first‐ and second‐year medical students during the 2006/07 academic year at Indiana University School of Medicine. Session evaluation included comparing scores on the 14‐item Geriatrics Attitude Scale administered before and after the session, identifying attitude changes in the reflective writing exercises, and a student satisfaction survey. Student responses on the Geriatrics Attitude Scale after the session were significantly improved in seven of 14 items, demonstrating better attitudes toward being with and listening to older people and caring for older patients. Analysis of the reflective writings revealed changing of negative to positive or reinforced positive attitudes in 27% of medical students, with attitudes not discernable in the remaining 73% (except one student, in whom positive attitudes changed to negative). Learner satisfaction with the Older Adult Session was high, with 98% agreeing that the session had a positive effect on insight into the care of older adults. A Council of Elders coupled with a reflective writing exercise is a promising new approach to improving attitudes of medical students toward their geriatric patients.

The challenge of supporting care for dementia in primary care

Most patients with dementia receive care within primary care systems and have challenging medical and psychiatric issues. Their dementia related symptoms are often not recognized by the primary care system; they suffer from multiple chronic medical conditions; receive numerous psychotropic medications including anticholinergics; and display clinically relevant behavioral and psychological symptoms. Improving the care for such vulnerable patients demands supporting the primary care system with various resources, including dementia care managers, access to and coordination with interdisciplinary dementia specialists, and a feasible dementia screening and diagnosis process. Understanding primary care clinics as a complex adaptive system may enhance our capacity to deliver a flexible supportive process using the above crucial resources to adequately assess and effectively manage patients with dementia. Such a complex adaptive system process would have the best probability of surviving the unknowable future challenges that will face the primary care system.

Dementia: The complexities of comorbidity in dementia.

A large claims-based study has identified several comorbidity clusters in individuals with dementia, corroborating the notion that comorbid conditions are an important contributor to health outcomes. The complexity of comorbidities calls for a patient-centred approach for care. Importantly, good management of comorbidities can improve quality of life in progressive dementia.

Implementing Geriatric Resources for Assessment and Care of Elders Team Care in a Veterans Affairs Medical Center: Lessons Learned and Effects Observed.

In a randomized clinical trial, Geriatric Resources for Assessment and Care of Elders (GRACE), a model of care that works in collaboration with primary care providers (PCPs) and patient‐centered medical homes to provide home‐based geriatric care management focusing on geriatric syndromes and psychosocial problems commonly found in older adults, improved care quality and reduced acute care use for high‐risk, low‐income older adults. To assess the effect of GRACE at a Veterans Affairs (VA) Medical Center (VAMC), veterans aged 65 and older from Marion County, Indiana, with PCPs from four of five VAMC clinics who were not on hospice or dialysis were enrolled in GRACE after discharge home from an acute hospitalization. After an initial home‐based transition visit to GRACE enrollees, the GRACE team returned to conduct a geriatric assessment. Guided by 12 protocols and input from an interdisciplinary panel and the PCP, the GRACE team developed and implemented a veteran‐centric care plan. Hospitalized veterans from the fifth clinic, who otherwise met enrollment criteria, served as a usual‐care comparison group. Demographic, comorbidity, and usage data were drawn from VA databases. The GRACE and comparison groups were similar in age, sex, and burden of comorbidity, although predicted risk of 1‐year mortality in GRACE veterans was higher. Even so, GRACE enrollment was associated with 7.1% fewer emergency department visits, 14.8% fewer 30‐day readmissions, 37.9% fewer hospital admissions, and 28.5% fewer total bed days of care, saving the VAMC an estimated

GRACE Team Care Model

200,000 per year after program costs during the study for the 179 veterans enrolled in GRACE. Having engaged, enthusiastic VA leadership and GRACE staff; aligning closely with the medical home; and accommodating patient acuity were among the important lessons learned during implementation.

Functional Assessment of the Older Patient With Cancer

The goal of the Geriatric Resources for Assessment and Care of Elders (GRACE) model is to improve the quality of geriatric care for high-risk older adults with complex medical and psychosocial comorbidity. GRACE utilizes in-home comprehensive geriatric assessment and an interdisciplinary team to develop and implement a patient-centered plan of care and then provides ongoing, proactive care management in collaboration with primary care and the medical home. Outcomes observed from GRACE model implementation in several health systems include higher quality of life for patients enrolled in GRACE, reduced acute care utilization, and overall cost savings when compared to usual care.