Germaine Odenheimer

Caregiver outcomes of partners in dementia care: effect of a care coordination program for veterans with dementia and their family members and friends.

The objective is to test the effectiveness of Partners in Dementia Care (PDC), a care‐coordination program that integrates and improves access to medical and nonmedical services, while strengthening the informal care network and providing information, coaching, and emotional support. PDC was delivered via a partnership between Veterans Affairs (VA) Medical Centers (VAMCs) and Alzheimers Association chapters, for caregivers of veterans with dementia living in the community and receiving primary care from the VA. The initial sample was 486 caregivers of 508 veterans with diagnosed dementia. Outcomes were evaluated for 394 and 324 caregivers who completed 6‐ and 12‐ month follow‐up, respectively. PDC had a standardized protocol that included assessment and reassessment, action planning, and ongoing monitoring. It was delivered by telephone and e‐mail for cost efficiency and the ability to handle caseloads of 100 to 125. Care coordinators from VAMCs and Alzheimers Association chapters worked as a team using a shared computerized record. A variety of caregiver outcomes was measured after 6 and 12 months. Intervention group caregivers had significant improvements in outcomes representing unmet needs, three types of caregiver strains, depression, and two support resources. Most improvements were evident after 6 months, with more‐limited improvements from Months 6 to 12. Some outcomes improved for all caregivers, whereas some improved for caregivers experiencing more initial difficulties or caring for veterans with more‐severe impairments. PDC is a promising model that improves linkages between healthcare services and community services, which is a goal of several new national initiatives such as the National Plan to Address Alzheimers Disease and a proposed amendment to the Older Americans Act.

Quality improvement in neurology Dementia management quality measures

ACOVE= : Assessing Care of Vulnerable Elders; DWG= : Dementia Measures Work Group; EHR= : electronic health record; ICD-9 = : International Classification of Diseases , ninth revision; MU= : Meaningful Use; PCPI= : Physician Consortium for Performance Improvement; PQRS= :

Use of a questionnaire to screen for frailty in the elderly: An exploratory study

Background and aims: In a pilot study of community-dwelling geriatric clinic patients (N=48, aged 63–90) we examined the use of a questionnaire to classify frailty status by comparing it with standardized markers of frailty. The questionnaire, developed by Strawbridge et al. in 1998, defines frailty as difficulty in more than one of four domains of functioning: physical, cognitive, sensory, and nutritive. Methods: Subjects were classified as frail or not frail by questionnaire and assignment was compared with testing of physical and cognitive measures in cross-sectional analysis. Demographic variables, functional inventories, physical activity levels, clinician impression of frailty, and 3-year health outcomes were also examined. Results: Thirty-three percent of subjects were classified as frail. Frailty classification by the Strawbridge questionnaire was correlated to Timed Up and Go and repetitive Sit-to-Stand tests, bimanual dexterity and cognitive tests. A discrepancy was found between assignment of cognitive difficulty, by questionnaire and cognitive performance. When overall Strawbridge frailty scores were modified to account for those with poor cognitive performance who did not report cognitive difficulty, the prevalence of frailty increased to 42%. At 3-year follow-up, the modified Strawbridge frailty classification (p<0.05) and clinician impression of frailty (p<0.01) were both significant predictors of death and institution-alization combined. Conclusions: This study serves as an initial inquiry into the potential validity and utility of the Strawbridge frailty questionnaire as a simple screening tool to identify patients who may warrant detailed functional testing.

Quality Improvement in Neurology: Dementia Management Quality Measures

Professional and advocacy organizations have long urged that dementia should be recognized and properly diagnosed. With the passage of the National Alzheimers Project Act in 2011, an Advisory Council for Alzheimers Research, Care, and Services was convened to advise the Department of Health and Human Services. In May 2012, the Council produced the first National Plan to address Alzheimers disease, and prominent in its recommendations is a call for quality measures suitable for evaluating and tracking dementia care in clinical settings. Although other efforts have been made to set dementia care quality standards, such as those pioneered by RAND in its series Assessing Care of Vulnerable Elders (ACOVE), practitioners, healthcare systems, and insurers have not widely embraced implementation. This executive summary (full manuscript available at www.neurology.org) reports on a new measurement set for dementia management developed by an interdisciplinary Dementia Measures Work Group (DWG) representing the major national organizations and advocacy organizations concerned with the care of individuals with dementia. The American Academy of Neurology (AAN), the American Geriatrics Society, the American Medical Directors Association, the American Psychiatric Association, and the American Medical Association–convened Physician Consortium for Performance Improvement led this effort. The ACOVE measures and the measurement set described here apply to individuals whose dementia has already been identified and properly diagnosed. Although similar in concept to ACOVE, the DWG measurement set differs in several important ways; it includes all stages of dementia in a single measure set, calls for the use of functional staging in planning care, prompts the use of validated instruments in patient and caregiver assessment and intervention, highlights the relevance of using palliative care concepts to guide care before the advanced stages of illness, and provides evidence‐based support for its recommendations and guidance on the selection of instruments useful in tracking patient‐centered outcomes. It also specifies annual reassessment and updating of interventions and care plans for dementia‐related problems that affect families and other caregivers as well as individuals with dementia. Here, a brief synopsis of why major reforms in healthcare design and delivery are needed to achieve substantive improvements in the quality of care is first provided, and then the final measures approved for publication, dissemination, and implementation are listed.

A controlled trial of Partners in Dementia Care: veteran outcomes after six and twelve months

Introduction“Partners in Dementia Care” (PDC) tested the effectiveness of a care-coordination program integrating healthcare and community services and supporting veterans with dementia and their caregivers. Delivered via partnerships between Veterans Affairs medical centers and Alzheimer’s Association chapters, PDC targeted both patients and caregivers, distinguishing it from many non-pharmacological interventions. Hypotheses posited PDC would improve five veteran self-reported outcomes: 1) unmet need, 2) embarrassment about memory problems, 3) isolation, 4) relationship strain and 5) depression. Greater impact was expected for more impaired veterans. A unique feature was self-reported research data collected from veterans with dementia.Methods and FindingsFive matched communities were study sites. Two randomly selected sites received PDC for 12 months; comparison sites received usual care. Three structured telephone interviews were completed every 6 months with veterans who could participate.ResultsOf 508 consenting veterans, 333 (65.6%) completed baseline interviews. Among those who completed baseline interviews, 263 (79.0%) completed 6-month follow-ups and 194 (58.3%) completed 12-month follow-ups. Regression analyses showed PDC veterans had significantly less adverse outcomes than those receiving usual care, particularly for more impaired veterans after 6 months, including reduced relationship strain (B = −0.09; p = 0.05), depression (B = −0.10; p = 0.03), and unmet need (B = −0.28; p = 0.02; and B = −0.52; p = 0.08). PDC veterans also had less embarrassment about memory problems (B = −0.24; p = 0.08). At 12 months, more impaired veterans had further reductions in unmet need (B = −0.96; p < 0.01) and embarrassment (B = −0.05; p = 0.02). Limitations included use of matched comparison sites rather than within-site randomization and lack of consideration for variation within the PDC group in amounts and types of assistance provided.ConclusionsPartnerships between community and health organizations have the potential to meet the dementia-related needs and improve the psychosocial functioning of persons with dementia.Trial RegistryNCT00291161

Current Management Decisions in Mild Cognitive Impairment

Efforts toward early detection of Alzheimer disease (AD) have focused on refinement and identification of diagnostic markers, with the goal of preventing or delaying disease progression. Mild cognitive impairment (MCI) has emerged as a potential precursor to dementia. Though not without controversy, MCI has been associated with an increased risk for conversion to AD. In this article, with emphasis on meta-analyses, randomized controlled trials, and extant literature reviews, considerations and recommendations for optimal clinical management of MCI are offered. Given the substantial heterogeneity of this patient population and inconsistent research methodologies, the need for informed, clinical judgment is critical.

Quality Improvement in Neurology: Dementia Management Quality Measures (Executive Summary)

The interdisciplinary Dementia Measures Workgroup, composed of members from diverse national organizations, has defined optimal standards of dementia care for individual practitioners as well as multidisciplinary teams.

Managing Safety and Mobility Needs of Older Drivers

This chapter presents data related to senior driving and mobility issues in the U.S. and Canada, covering in particular the transition to nondriving status and its health-related effects. It discusses identification of unsafe older drivers, interventions to help support safe driving in this population group, and the psychology of driving and nondriving. The chapter makes a case for involving psychologists in managing impaired older drivers.

Understanding chronic disease: student exposure to support groups

What problem was addressed? The intensive care unit (ICU) is a daunting place in which to begin clinical training. Trainees often find the plethora of information, coupled with the severity and complexity of disease, overwhelming. They struggle to adapt because no formal textbook can fully prepare them for the nuances of caring for critically ill patients. The ICU is unique in that learners receive little formal training specifically for this environment. We believe this environment presents distinct educational challenges suited to online teaching methods tailored to the new generation of learner. What was tried? The new learner is technologically savvy regarding access to information and media via smartphones and tablets. We aimed to capitalise on this by developing visual media presentations on a YouTube channel (www.youtube.com/iucriticalcare) to allow learners to engage with humorous, pithy, visually stimulating videos that introduce key elements of caring for critically ill patients. We called this the ‘Critical Care Survival Guide’ and developed it for our local medical students and interns. The videos were created by a team of physicians (the authors), and were choreographed and edited utilising Chroma keying techniques, and then linked to PowerPoint slides via video-editing software. This enabled video and graphic interfaces that highlighted key teaching points, such as ventilator waveforms and ICU monitors. What lessons were learned? The response to our educational content surprised us. It has truly ‘gone viral’. In one year of online publication, our videos have been viewed over 77 000 times by learners from all over the world. YouTube allows us to track the duration of view (280 000 minutes in total), country of viewership (53% is USA-based), and receive feedback through comments posted. Interestingly, we now have 1550 current ‘subscribers’ to our channel on YouTube. Comments have included: ‘Great production and better than just still slides and voiceover’ and ‘Thank you so much for these videos, they are helping me as a nursing student!’ By tracking how long learners watch each video, we learn which videos are engaging and which videos need adjustment. Locally, our experience has been that students and interns who view the videos in advance of their ICU rotation feel more prepared than those who do not. Specifically, learners appreciate the videos that equip them in the psychomotor (central lines, intubation, running codes) and knowledge (X-ray interpretation, sepsis management, ventilator alarms) domains of learning. Our perspective on medical education has been changed by this project. The popularity of these videos attests to their demand and usefulness. The medical profession has not defined metrics to ‘measure’ the significance of scholarship in the YouTube realm; however, we believe that over 77 000 views is an impressive impact. Our success is likely to have resulted from the format, delivery and accessibility of the videos. They can be viewed anywhere, at any time and in any environment. Learners are using smartphones, tablets and personal computers to tune in. The content of the videos helps to equip learners from the medical, nursing and respiratory medicine fields. Finally, they showcase our teaching philosophy that learning can be fun! We encourage others to embrace YouTube as an educational tool and look forward to impacting more learners in the years to come.