Greg A. Sachs

Cognitive Impairment: An Independent Predictor of Excess Mortality: A Cohort Study

BACKGROUNDnDementia is a leading cause of death among older adults, but less is known about the mortality risk associated with milder forms of cognitive impairment.nnnOBJECTIVEnTo determine whether cognitive impairment is independently associated with increased long-term mortality in primary care patients aged 60 years and older.nnnDESIGNnLinkage of electronic health records from a cohort recruited between January 1991 and May 1993 with data from the National Death Index through 31 December 2006.nnnSETTINGnA public safety-net hospital and its community health centers.nnnPATIENTSn3957 older adults aged 60 to 102 years who were screened at scheduled primary care appointments.nnnMEASUREMENTSnAt baseline, patients were screened for cognitive impairment by using the Short Portable Mental Status Questionnaire and were categorized into groups with no, mild, or moderate to severe cognitive impairment. Baseline data from comprehensive electronic health records were linked with vital status obtained from the National Death Index. Kaplan-Meier survival curves compared time to death for the groups with cognitive impairment. Cox proportional hazards models controlled for mortality risk factors.nnnRESULTSnAt baseline, 3157 patients had no cognitive impairment, 533 had mild impairment, and 267 had moderate to severe impairment. Overall, 2385 of the 3957 patients (60.3%) died during the observation period: 1812 (57.4%) patients with no cognitive impairment, 363 (68.1%) patients with mild impairment, and 210 (78.7%) patients with moderate to severe impairment. Both mild and moderate to severe cognitive impairment were associated with increased mortality hazard independent of other mortality risk factors (hazard ratio, 1.184 [95% CI, 1.051 to 1.334] and for mild impairment 1.447 [CI, 1.235 to 1.695] for moderate to severe impairment). Median survival for all 3957 participants was 129 months. Median survival for participants with no, mild, and moderate to severe cognitive impairment was 138, 106, and 63 months, respectively.nnnLIMITATIONSnCognition was assessed only at enrollment by using a screening instrument. Participants were drawn from a single safety-net health system and had low educational and socioeconomic status, which limits generalizability to other populations. Changes in cognition, function, and comorbid conditions were not measured over time.nnnCONCLUSIONnBoth mild and moderate to severe cognitive impairment as identified by the Short Portable Mental Status Questionnaire are associated with an increased risk for mortality.nnnPRIMARY FUNDING SOURCEnAgency for Healthcare Research and Quality.

Advanced Dementia: State of the Art and Priorities for the Next Decade

Dementia is a leading cause of death in the United States. This article outlines the current understanding of advanced dementia and identifies research priorities for the next decade. Research over the past 25 years has largely focused on describing the experience of patients with advanced dementia. This work has delineated abundant opportunities for improvement, including greater recognition of advanced dementia as a terminal illness, better treatment of distressing symptoms, increased access to hospice and palliative care services, and less use of costly and aggressive treatments that may be of limited clinical benefit. Addressing those opportunities must be the overarching objective for the field in the coming decade. Priority areas include designing and testing interventions that promote high-quality, goal-directed care; health policy research to identify strategies that incentivize cost-effective and evidence-based care; implementation studies of promising interventions and policies; and further development of disease-specific outcome measures. There is great need and opportunity to improve outcomes, contain expenditures, reduce disparities, and better coordinate care for the millions of persons in the United States who have advanced dementia.

Daily Medication Use in Nursing Home Residents with Advanced Dementia

OBJECTIVES: To describe the pattern and factors associated with daily medication use in nursing home (NH) residents with advanced dementia.

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.

Scope and Outcomes of Surrogate Decision Making Among Hospitalized Older Adults

IMPORTANCEnHospitalized older adults often lack decisional capacity, but outside of the intensive care unit and end-of-life care settings, little is known about the frequency of decision making by family members or other surrogates or its implications for hospital care.nnnOBJECTIVEnTo describe the scope of surrogate decision making, the hospital course, and outcomes for older adults.nnnDESIGN, SETTING, AND PARTICIPANTSnProspective, observational study conducted in medicine and medical intensive care unit services of 2 hospitals in 1 Midwestern city in 1083 hospitalized older adults identified by their physicians as requiring major medical decisions.nnnMAIN OUTCOMES AND MEASURESnClinical characteristics, hospital outcomes, nature of major medical decisions, and surrogate involvement.nnnRESULTSnAccording to physician reports, at 48 hours of hospitalization, 47.4% (95% CI, 44.4%-50.4%) of older adults required at least some surrogate involvement, including 23.0% (20.6%-25.6%) with all decisions made by a surrogate. Among patients who required a surrogate for at least 1 decision within 48 hours, 57.2% required decisions about life-sustaining care (mostly addressing code status), 48.6% about procedures and operations, and 46.9% about discharge planning. Patients who needed a surrogate experienced a more complex hospital course with greater use of ventilators (2.5% of patients who made decisions and 13.2% of patients who required any surrogate decisions; P <u2009.001), artificial nutrition (1.7% of patients and 14.4% of surrogates; P <u2009.001), and length of stay (median, 6 days for patients and 7 days for surrogates; P <u2009.001). They were more likely to be discharged to an extended-care facility (21.2% with patient decisions and 40.9% with surrogate decisions; P <u2009.001) and had higher hospital mortality (0.0% patients and 5.9% surrogates; P <u2009.001). Most surrogates were daughters (58.9%), sons (25.0%), or spouses (20.6%). Overall, only 7.4% had a living will and 25.0% had a health care representative document in the medical record.nnnCONCLUSIONS AND RELEVANCEnSurrogate decision making occurs for nearly half of hospitalized older adults and includes both complete decision making by the surrogate and joint decision making by the patient and surrogate. Surrogates commonly face a broad range of decisions in the intensive care unit and the hospital ward setting. Hospital functions should be redesigned to account for the large and growing role of surrogates, supporting them as they make health care decisions.

Older Adults and Forgoing Cancer Screening: “I Think It Would Be Strange”

IMPORTANCEnAlthough there is a growing recognition that older adults and those with extensive comorbid conditions undergo cancer screening too frequently, there is little information about patients perceptions regarding cessation of cancer screening. Information on older adults views of screening cessation would be helpful both for clinicians and for those designing interventions to reduce overscreening.nnnOBJECTIVEnTo obtain a deeper understanding of older adults perspectives on screening cessation and their experiences communicating with clinicians about this topic.nnnDESIGNnSemistructured interview study.nnnSETTINGnSenior health center affiliated with an urban hospital.nnnPARTICIPANTSnWe interviewed 33 older adults presenting to a senior health center. Their median age was 76 years (range, 63-91 years). Of the 33 participants, 27 were women; 15 were African American, 16 were white, 1 was Asian, and 1 was American Indian.nnnMAIN OUTCOME MEASURESnWe transcribed audio recordings of interviews and analyzed them using methods of grounded theory to identify themes and illustrative quotes.nnnRESULTSnUndergoing screening tests was perceived by participants as morally obligatory. Although many saw continued screening as a habit or custom not involving any decision, cessation of screening would require a major decision. Many asserted that they had never discussed screening cessation with their physicians or considered stopping on their own; some reported being upset when their physician recommended stopping. Although some would accept a physicians strong recommendation to stop, others thought that such a physicians recommendation would threaten trust or lead them to get another opinion. Participants were skeptical about the role of statistics and the recommendations of government panels in screening decisions but were more favorable toward stopping because of the balance of risks and benefits, complications, or test burdens.nnnCONCLUSIONS AND RELEVANCEnFor many older adults, stopping screening is a major decision, but continuing screening is not. A physicians recommendation to stop may threaten patient trust. Effective strategies to reduce nonbeneficial screening may include discussion of the balance of risks and benefits, complications, or burdens.

Can Primary Care Meet the Biopsychosocial Needs of Older Adults with Dementia

In an urban health care system that is responsible for delivering care to approximately 90,000 adult patients, a typical primary care provider delivers care to a panel of about 2,000 patients1, 2. Among the 300 patients aged 65xa0years and older in this typical primary care provider panel, 150 of these older adults suffer from at least three chronic conditions, 195 patients report musculoskeletal pain, 93 patients report feeling anxious, and 63 patients are hospitalized every year1–4. Applying relevant management guidelines for each chronic disease that is affecting the average older patient would lead to the prescription of approximately 12 medications with a cost of

Redesigning Systems Of Care For Older Adults With Alzheimer’s Disease

400 per patient per month, numerous complex non-pharmacological regimens, and attention to conflicting recommendations and drug interaction across disease-specific guidelines5. In addition to managing acute illnesses, this primary care provider needs an estimated 10xa0hours per working day to deliver all of the recommended care for patients with chronic conditions and an additional 7xa0hours per day to provide preventive services6. n nOnly 24 patients of the entire 2,000 patient panel would have dementia in any given year. Within 6xa0years, 10 of these patients with dementia would die, and another 10 would require care in a skilled facility due to dementia progression7. Sadly, only 8 patients out of the 24 patients would be recognized by the primary care system as having dementia1, 7, 8. Patients with dementia in the primary care system also suffer from numerous chronic medical conditions, receive multiple prescriptions including psychotropic drugs, display a wide range of behavioral and psychological symptoms, and extensively utilize the health care system2, 4, 8. More than 20% of these patients with dementia are exposed to at least one definitely inappropriate anticholinergic medication and less than 10% are prescribed appropriate pharmacotherapy for their dementing disorder4. Unfortunately, the complicated medical and psychiatric needs of these 24 demented patients affects not only their own care but also the health of their informal caregivers who become vulnerable to suffer from psychological burden, develop depression, use psychotropics and have high mortality rates2, 4, 7, 8. n nThe current primary care system is facing significant challenges in delivering safe, high quality, and cost-effective services to its patients in accordance with the various disease-specific chronic care and preventive service recommendations. In response to the complex biopsychosocial needs of its older primary care patients, in general, and those with dementia in particular, the system often falls short of excellence1, 4, 9–11. Primary care physicians report having insufficient time to spend with their patients and feel overworked and dissatisfied9–13. Changes in this care environment that continue to place increasing demands on providers are not only difficult, but may be harmful if the complexities of this environment are not taken into account. Thus, the most relevant and important question facing an older patient with dementia (and his or her family members) is: Does my primary care provider have the time, the resources, and the delivery vehicle to care for me? n nIn this issue of our journal, Hinton et al. 12 sheds more light on the challenges facing the primary care provider in caring for patients with dementia. They interviewed 40 providers from various health care organizations including academic medical centers, managed care, and solo private primary care practices. This excellent qualitative study again demonstrated that the current operational structure of primary care is not prepared to manage the biopsychosocial needs of patients suffering from dementia12. Reported limitations include insufficient provider time, inadequate reimbursement, poor access to dementia care expertise and community resources, lack of adequate communication across the various medical, social and community dementia care providers, and finally, the absence of an interdisciplinary dementia care team12. The results from this study are even more striking when one considers that Hinton et al. focused primarily on the challenges of managing behavioral problems in patients with dementia. It seems likely that similar or additional frustrations would be elicited by interviews focusing on a number of other aspects of caring for patients with dementia, such as the challenges of providing palliative care to this population18. n nDementia is characterized by a complex and prolonged interaction of cognitive, functional, behavioral, and psychological symptoms that decrease the quality of life for both the patient and the caregiver and lead to high health care utilization by both7, 8. Improving the health outcomes of this dyad requires three crucial steps. First, the development of multicomponent pharmacological and psychosocial interventions specific for dementia-related disability; second, the development of accurate outcome assessment methods that match the dosing of these interventions with the patient’s and caregiver’s individualized needs; and third, the development of innovative dementia care delivery processes such as those used in the Collaborative Chronic Care Models13. Notably, these models extend the dementia care setting beyond the primary care office into the homes and communities of patients and their caregivers. n nOver the past decade, several research groups have successfully developed and evaluated various comprehensive dementia care programs2, 14–17. These programs offer a flexible and comprehensive framework to modify the primary care delivery systems in accordance with the local resources and demands. The models recognize that communities will vary greatly in the available resources and that these resources will change over time. Moreover, these models emphasize the importance of collaboration and coordination of care across different health care providers, family, and community organizations and agencies. n n nThe content of the ideal collaborative dementia care program would include the following (see Fig.xa01): n n nA feasible dementia identification and diagnosis process including a reliable tool for periodic needs assessment and evaluation of ongoing therapy. n n nPharmacological and psychosocial interventions that prevent or reduce the family caregiver’s psychological and physical burden. n n nSelf-management tools to enhance the patient and the caregiver skills in managing dementia disability and navigating the health care system. n n nPharmacological interventions for care-recipients that target the cognitive, functional, and behavioral and psychological symptoms of dementia such as n nEnhancement of the patient’s cholinergic system via prescribing cholinesterase inhibitors and decreasing exposure to medication with anticholinergic activities n n nImprovement in medication adherence n n nReduction in cerebrovascular risk factors such hypertension, diabetes, and hyperlipidemia n n nPrevention and management of delirium, depression, and psychosis superimposed on dementia n n n n n nCase management and coordination with community resources including adult day care, respite care, and support groups. n n nModification of the patient’s physical home environment to accommodate dementia disability. n n nAn increasing focus on palliative care needs as the illness progresses, including advance care planning, attentive management of pain and other symptoms, avoidance of burdensome and undesired medical treatments, and eventual discussion of referral to hospice. n n n n n n nFig.xa01 n nThe ideal collaborative dementia care program n n n nDelivering the right dose and the right combination of the above critical components of dementia care program to the right dementia patient and the right caregiver at the right time is crucial. The typical primary care practice is not currently prepared to deliver this care. Primary care needs much greater support and integration with community services and access to dementia support teams if primary care is to succeed in caring for the growing population of older adults with dementia. As shown in the figure, finding efficiency and quality in this system will likely require a stepped-care approach where the intensity of specialty care varies according to the level of patient disability. Based on the complexity of the patient and the caregiver needs, the dementia support team could operate in a periodic consultancy model, ongoing co-management mode or as the putative primary care provider (see Fig.xa01). For older adults with advanced dementia, we need to begin a dialogue about the limits of primary care approaches. Such a dialogue must include both the strengths of a generalist approach and its weaknesses.

Palliative Care for Patients with Dementia: A National Survey

Best-practice models of dementia care have evolved from strategies focused on family caregivers to guidelines predicated on supporting the patient-caregiver dyad along the care continuum. These models have grown in complexity to encompass medical and team-based care that is designed to coordinate dementia care across settings and providers for a defined population of patients. Although there is evidence that the models can improve outcomes, they have not been widely adopted. Barriers to the models increased adoption include workforce limitations, the cost of necessary practice redesign, and limited evidence of their potential cost-effectiveness. We summarize the origins, evidence base, and common components of best-practice models of dementia care, and we discuss barriers to their implementation. We conclude by describing two current efforts to implement such models on a broad scale, supported by the Center for Medicare and Medicaid Innovation. Taken together, these models seek to demonstrate improved dementia care quality and outcomes, accompanied by cost savings, in both community-based and institutional care settings.

The Optimizing Patient Transfers, Impacting Medical Quality, and Improving Symptoms: Transforming Institutional Care Approach: Preliminary Data from the Implementation of a Centers for Medicare and Medicaid Services Nursing Facility Demonstration Project

OBJECTIVES: To determine the extent to which hospice and nonhospice palliative care (PC) programs provide services to patients with dementia and to describe barriers and facilitators to providing nonhospice PC.