Clément Pimouguet

Impact of living alone on institutionalization and mortality: a population-based longitudinal study

BACKGROUNDnLiving alone is common among elderly people in Western countries, and studies on its relationship with institutionalization and all-cause mortality have shown inconsistent results. We investigated that the impact of living alone on institutionalization and mortality in a population-based cohort of elderly people.nnnMETHODSnData originate from the Swedish National study on Aging and Care-Kungsholmen. Participants aged ≥66 years and living at home (n = 2404) at baseline underwent interviews and clinical examination. Data on living arrangements were collected in interviews. All participants were followed for 6 years; survival status and admission into institutions were tracked continuously through administrative registers from 2001 to 2007. Data were analysed using Cox proportional hazard models, competing risk regressions and Laplace regressions with adjustment for potential confounders.nnnRESULTSnOf the 2404 participants, 1464 (60.9%) lived alone at baseline. During the follow-up, 711 (29.6%) participants died, and 185 (15.0%) were institutionalized. In the multi-adjusted Cox model, the hazard ratio (HR) of mortality in those living alone was 1.35 (95% confidence interval [CI] 1.18 to 1.54), especially among men (HR = 1.44, 95% CI 1.18 to 1.76). Living alone shortened survival by 0.6 years and was associated with the risk of institutionalization (HR = 1.74, 95% CI 1.10 to 2.77) after taking death into account as a competing risk.nnnCONCLUSIONSnLiving alone is associated with elevated mortality, especially among men and an increased risk of institutionalization. Over a 6-year period, living alone was related to a half year reduction in survival among elderly people in Sweden.

The 2008–2012 French Alzheimer Plan: A Unique Opportunity for Improving Integrated Care for Dementia

The 2008-2012 French Alzheimer plan has proposed measures to improve care for dementia patients in a more personalized and graduate approach owing to patients and caregivers needs. A key measure of the plan is the nationwide implementation of the MAIA (French acronym for Maison pour lAutonomie et lIntégration des malades dAlzheimer). The main goal is to implement a process of integration through a network of partners involved in elderly care, assistance, or support. The MAIA model comprises tools and mechanisms necessary to improve the integrated care process; in particular, case management for elderly in complex situations. The purpose of this paper is to describe the main measures from the national plan that aim to improve care for dementia patients with an emphasis on the MAIA measure. We summarize initial results of case management activity in one MAIA in the South West of France and we present two vignettes of cases benefiting from case management in order to demonstrate the nature of intervention. The French Alzheimer plan has promoted several non-pharmacological strategies for dementia patients. Implementation of both integrated care and case management represent a challenging perspective for the elderly and health professionals.

Effect of Early Referral to Specialist in Dementia on Institutionalization and Functional Decline: Findings from a Population-Based Study.

BACKGROUNDnAlthough early diagnosis has been hypothesized to benefit both patients and caregivers, until now studies evaluating the effect of early dementia diagnosis are lacking.nnnOBJECTIVEnTo investigate the influence of early specialist referral for dementia on the risk of institutionalization and functional decline in Activity of Daily Living (ADL).nnnMETHODSnIncident dementia cases were screened in a prospective population-based cohort, the Three-City Study, and initial specialist consultation for cognitive complaint was assessed at dementia diagnosis. Proportional hazard regression and illness-death models were used to test the association between specialist referral and, respectively, institutionalization and functional decline.nnnRESULTSnOnly one third of the incident individuals with dementia had consulted a specialist for cognitive problems early (36%). After adjustment on potential confounders (including cognitive and functional decline) and competing risk of death, participants who had consulted a specialist early in the disease course presented a higher rate of being institutionalized than those who did not (Hazard Ratiou200a=u200a2.00, 95% Confidence Interval (CI): 1.09- 3.64). But early specialist referral was not associated with further functional decline (HRu200a=u200a1.09, 95% CI: 0.71- 1.67).nnnCONCLUSIONSnEarly specialist referral in dementia is associated with increased risk of institutionalization but not with functional decline in ADL. These findings suggest that early care referral in dementia may be a marker of concern for patients and/or caregivers; subsequent medical and social care could be suboptimal or inappropriate to allow patients to stay longer at home.

Influence of Incipient Dementia on Hospitalization for Primary Care Sensitive Conditions: A Population-Based Cohort Study

BACKGROUNDnStudies have reported that moderate/severe stages of dementia are linked to increased hospitalization rates, but little is known about the influence of incipient dementia on hospitalizations for primary care sensitive conditions (PCSCs).nnnOBJECTIVEnTo examine the associations between incipient dementia and hospitalization outcomes, including all-cause and PCSC hospitalization.nnnMETHODSnA total of 2,268 dementia-free participants in the Swedish National study on Aging and Care-Kungsholmen were interviewed and clinically examined at baseline. Participants aged ≥78 years were followed for 3 years, and those aged 60-72 years, for 6 years. Number of hospitalizations was retrieved from the National Patient Register. Dementia was diagnosed in accordance with Diagnostic and Statistical Manual of Mental Disorders-IV criteria. Hospitalization outcomes were compared in participants who did and did not develop dementia. Zero-inflated Poisson regressions and logistic regressions were used in data analysis.nnnRESULTSnDuring the follow-up, 175 participants developed dementia. The unadjusted PCSC admission rate was 88.2 per 1000 person-years in those who developed dementia and 25.6 per 1000 person-years in those who did not. In the fully adjusted logistic regression model, incipient dementia was associated with an increased risk of hospitalization for PCSCs (ORu200a=u200a2.3, 95% CI 1.3-3.9) but not with the number of hospitalizations or with all-cause hospitalization. Risks for hospitalization for diabetes, congestive heart failure, and pyelonephritis were higher in those who developed dementia than in those who did not. About 10% participants had a PCSC hospitalization attributable to incipient dementia.nnnCONCLUSIONnPeople with incipient dementia are more prone to hospitalization for PCSCs but not to all-cause hospitalization.

[Determinants of support for dementia patients in general practice: a qualitative approach based on an epidemiological cohort].

BACKGROUNDnthe analysis of access to diagnosis and care pathway for dementia patients shows that the disease is not considered as a priority for the general practitioner (GP). Different studies have point out under diagnosis of dementia.nnnPURPOSEnthe purpose of this qualitative study was to document the determinants of the diagnosis and management of dementia by GP.nnnMETHODSnrecruitment of GPs (n = 12) was made from incident cases of dementia who were identified during the follow-up of subject enrolled in the 3 Cities cohort study. A semi-structured interview was conducted with an interview guide focused on the experience of the doctors. A phenomenological and pragmatic analysis, taking into account all the linguistic and extra linguistic evidence contained in the transcript was conducted.nnnRESULTSnseveral emerging categories have been described: the doctors believe that the management of Alzheimers disease is a public health problem and not an individual, the positioning of the GP in the care system is central. Determinants that influence the management are the identity of the physician, the impression of a fuzzy nosology, the finding of a therapeutic ineffectiveness, the priority given to severe co-morbidities and the workload of the general practitioner. However, the ordering of these categories according to the pragmatic phenomenological approach showed that the identity of the doctor, professional and personal, is at the origin of behavioral variability in their medical care.nnnCONCLUSIONnin a context of increased workload, the GP favors the assumption of comorbidities in the elderly given fuzzy nosology of dementia and uncertainty about the therapeutic efficacy. The phenomenological approach allows understanding that the human identity of the doctor, personal and professional identity, is the major factor that influence its care attitude for demented patients.

Benefits of Occupational Therapy in Dementia Patients: Findings from a Real-World Observational Study

BACKGROUNDnThere is a growing interest in developing non-pharmacological approaches in dementia. Clinical efficacy of occupational therapy (OT) under routine care conditions has not been investigated yet.nnnOBJECTIVEnTo analyze the short-term effects of OT in patients with dementia; and to identify factors related to greater benefit.nnnMETHODSnPatients referred to OT were evaluated before starting a 3-month intervention and at 3 and 6 months later. Measures included: Mini-Mental State Examination (MMSE), Disability Assessment in Dementia (DAD), Neuropsychiatric Inventory (NPI) Questionnaire, patients quality of life (EQ 5D-VAS), caregivers burden (Zarit scale), and amount of informal care. Linear mixed models were used to analyze trajectories of outcomes. Logistic regressions with stepwise descending selection were used to study factors associated with benefits.nnnRESULTSn421 dementia patients benefited from OT (mean MMSEu200a=u200a17.3). Patients remained cognitively stable over time. Functional performances also remained stable at 3 months and significantly decreased at 6 months (crude reduction of 2.8 points, pu200a<u200a0.01). Behavioral troubles were significantly reduced over the intervention period and remained stable after (pu200a<u200a0.01). Patients quality of life increased over the 3-month intervention (pu200a=u200a0.16) and significantly decreased thereafter. Caregivers burden and informal care significantly decreased over the 3-month intervention and remained stable thereafter. Patients who benefited from OT with regard to function were less educated and had higher cognitive level.nnnCONCLUSIONnOT may be an effective intervention to maintain cognition and functionality and to reduce psychiatric symptoms in dementia patients. Mild stages of dementia could gain more benefits from OT with regard to functional decline.

Description of general practitioners’ practices when suspecting cognitive impairment. Recourse to care in dementia (Recaredem) study

ABSTRACT Objective: General practitioners (GPs) play a major role in the assessment of dementia but it is still unrecognized in primary care and its management is heterogeneous. Our objective is to describe the usual practices, and their determinants, of French GPs in this field. Methods: GPs’ characteristics and practices when facing cognitive decline were collected through a telephone interview and a postal questionnaire. A descriptive analysis of all study variables was conducted. The study of quantitative explanatory variables was done by testing the equality of means and the choice of qualitative variables was based on the chi-square independence test or Fischer test. Results: Hundred two GPs completed the study. GPs were in majority men, working in urban areas. Mean age was 54.4 years old. GPs’ feeling of confidence and self-perception of follow-up of national recommendations is linked with their practices. Performing a clinical interview to assess cognitive impairment is linked with good communication skills. GPs feel less confident to give information about resources for dementia. The main reason alleged for underdiagnosis is the limited effectiveness of drug therapy. Conclusions: This study underlines the importance of GPs’ feeling of confidence when managing cognitively impaired patients with dementia, and the need of increasing training in the field of dementia, which could improve the awareness of GPs about diagnosis and available resources.

Living alone and unplanned hospitalizations among older adults: a population-based longitudinal study

BackgroundnThe association of living alone with hospitalization among the general elderly population has been rarely investigated, and the influence of common disorders on this association remains unknown.nnnMethodsnWe used data on participants in the Swedish National study on Aging and Care in Kungsholmen ( n = 3130). Risk and number of unplanned hospitalizations and length of hospital stays were studied over a period of 2 years. We used Cox proportional hazard models to estimate hazard ratios (HRs) of incident hospitalization and zero-inflated negative binomial regression models adjusted for potential confounders to estimate incident rate ratios (IRR) of the number of hospitalizations and total length of stay associated with living alone.nnnResultsnA total of 1768 participants (56.5%) lived alone. Five hundred and sixty-one (31.7%) of those who lived alone had at least one unplanned hospitalization. In the multivariate analyses, living alone was significantly associated with the risk of unplanned hospitalization (HR = 1.21, 95% confidence interval [CI] 1.01-1.45) and the number of hospitalizations (IRR = 1.35, 95% CI 1.04-1.76) but not with the length of hospital stays. In stratified analyses, the association between living alone and unplanned hospitalizations remained statistically significant only among men (HR = 1.52, 95% CI 1.17-1.99).nnnConclusionsnLiving alone is associated with higher risks of unplanned hospitalization in elderly, especially for men.