Monica Cepoiu-Martin

Dementia case management and risk of long-term care placement: a systematic review and meta-analysis

The objective of our study is to evaluate the effectiveness of dementia case management compared with usual care on reducing long‐term care placement, hospitalization, and emergency department visits for adult patients with dementia. We also sought to evaluate the effectiveness of this intervention on delaying time to long‐term care placement and hospitalization.

Artificial cervical disc arthroplasty: a systematic review.

Study Design. Systematic Review. Objective. (1) To qualitatively analyze the literature on the efficacy and effectiveness of artificial cervical disc arthroplasty (ACDA). (2) To highlight methodological and reporting issues of randomized controlled trials (RCT) reports on effectiveness of ACDA compared to cervical fusion. Summary of Background Data. ACDA is an alternate surgical procedure that may replace cervical fusion in selected patients suffering from cervical degenerative disc disease. Methods. We searched seven electronic databases, including MEDLINE, Cochrane Library, and EMBASE, unpublished sources, and reference lists for studies on the efficacy and effectiveness of ACDA compared to cervical fusion—the surgical standard of care for patients with cervical degenerative disc disease. Results. A total of 622 studies were retrieved, of which 18 (13 case series, four RCT reports, one nonrandomized comparative study) met the inclusion criteria for this review. The four RCTs and the nonrandomized comparative study concluded that the effectiveness of ACDA is not inferior to that of cervical fusion in the short term (up to 2-yr follow-up). The safety profile of both procedures appears similar. The case series reviewed noted improved clinical outcomes at 1 or 2 years after one or multiple-level ACDA. Conclusion. ACDA is a surgical procedure that may replace cervical fusion in selected patients suffering from cervical degenerative disc disease. Within 2 years of follow-up, the effectiveness of ACDA appears similar to that of cervical fusion. Weak evidence exists that ACDA may be superior to fusion for treating neck and arm pain. Future studies should report change scores and change score variance in accordance with RCT guidelines, in order to strengthen credibility of conclusions and to facilitate meta-analyses of studies.

Predictors of long-term care placement in persons with dementia: a systematic review and meta-analysis

The main objective of this study was to summarize the effects of various individual, caregiver, and system‐related factors on the risk of long‐term care (LTC) placement for persons with dementia.

Elevated Hospitalization Risk of Assisted Living Residents With Dementia in Alberta, Canada

OBJECTIVES Assisted living (AL) is an increasingly used residential option for older adults with dementia; however, lower staffing rates and service availability raise concerns that such residents may be at increased risk for adverse outcomes. Our objectives were to determine the incidence of hospitalization over 1 year for dementia residents of designated AL (DAL) facilities, compared with long-term care (LTC) facilities, and identify resident- and facility-level predictors of hospitalization among DAL residents. METHODS Participants were 609 DAL (mean age 85.7 ± 6.6 years) and 691 LTC (86.4 ± 6.9 years) residents with dementia enrolled in the Alberta Continuing Care Epidemiological Studies. Research nurses completed a standardized comprehensive assessment of residents and interviewed family caregivers at baseline (2006-2008) and 1 year later. Standardized administrator interviews provided facility level data. Hospitalization was determined via linkage with the provincial Inpatient Discharge Abstract Database. Multivariable Cox proportional hazards models were used to identify predictors of hospitalization. RESULTS The cumulative annual incidence of hospitalization was 38.6% (34.5%-42.7%) for DAL and 10.3% (8.0%-12.6%) for LTC residents with dementia. A significantly increased risk for hospitalization was observed for DAL residents aged 90+ years, with poor social relationships, less severe cognitive impairment, greater health instability, fatigue, high medication use (11+ medications), and 2+ hospitalizations in the preceding year. Residents from DAL facilities with a smaller number of spaces, no chain affiliation, and from specific health regions showed a higher risk of hospitalization. CONCLUSIONS DAL residents with dementia had a hospitalization rate almost 4-fold higher than LTC residents with dementia. Our findings raise questions about the ability of some AL facilities to adequately address the needs of cognitively impaired residents and highlight potential clinical, social, and policy areas for targeted interventions to reduce hospitalization risk.

Antipsychotic Prescribing and Safety Monitoring Practices in Children and Youth: A Population-Based Study in Alberta, Canada

Background and ObjectiveAntipsychotic medication use has steadily increased in Canada, with an expansion in the profile of users and the diagnoses for which they are used. The use of antipsychotics is associated with a number of adverse effects for which routine monitoring is recommended. The objectives of this study were to determine the most common diagnoses associated with antipsychotic use in children in Alberta, Canada and the proportion who receive recommended laboratory tests for adverse effects.MethodsData on dispensed antipsychotics, diagnoses, prescribers, and laboratory testing were obtained from provincial data sources. To assess the frequency of metabolic and hormonal laboratory baseline and/or follow-up testing, the sample was divided into an antipsychotic-naïve cohort and an antipsychotic non-naïve cohort.ResultsIn 2014, 6916 children were dispensed at least one second- or third-generation antipsychotic. The most frequently dispensed antipsychotics were risperidone (3908 children), quetiapine (2140 children), and aripiprazole (1302 children). The majority of children prescribed risperidone were diagnosed with Attention Deficit Hyperactivity Disorder (ADHD) or conduct disorder. Quetiapine was mainly prescribed for neurotic disorder or depression, while aripiprazole was prescribed most frequently for conduct disorder or neurotic disorders. Among antipsychotic-naïve patients, 17% had at least one laboratory test done at baseline, and 35% had at least one laboratory test done at follow-up. In the non-naïve patients, 42% had at least one follow-up laboratory test. Lipid and glucose testing were done in less than 5% of the naïve cohort at baseline, and in less than 15% at follow-up. In the non-naïve cohort, less than 22% received lipid or glucose testing during the year 2014.ConclusionsThe majority of antipsychotic use in children in Alberta is off-label and associated with disruptive behavior disorders, depression, and anxiety disorders. The vast majority of children prescribed antipsychotic medications do not undergo recommended laboratory tests.

Policy choices in dementia care—An exploratory analysis of the Alberta continuing care system (ACCS) using system dynamics

BACKGROUND The increase in the incidence of dementia in the aging population and the decrease in the availability of informal caregivers put pressure on continuing care systems to care for a growing number of people with disabilities. Policy changes in the continuing care system need to address this shift in the population structure. One of the most effective tools for assessing policies in complex systems is system dynamics. Nevertheless, this method is underused in continuing care capacity planning. METHODS A system dynamics model of the Alberta Continuing Care System was developed using stylized data. Sensitivity analyses and policy evaluations were conducted to demonstrate the use of system dynamics modelling in this area of public health planning. We focused our policy exploration on introducing staff/resident benchmarks in both supportive living and long-term care (LTC). RESULTS The sensitivity analyses presented in this paper help identify leverage points in the system that need to be acknowledged when policy decisions are made. Our policy explorations showed that the deficits of staff increase dramatically when benchmarks are introduced, as expected, but at the end of the simulation period, the difference in deficits of both nurses and health care aids are similar between the 2 scenarios tested. Modifying the benchmarks in LTC only versus in both supportive living and LTC has similar effects on staff deficits in long term, under the assumptions of this particular model. CONCLUSION The continuing care system dynamics model can be used to test various policy scenarios, allowing decision makers to visualize the effect of a certain policy choice on different system variables and to compare different policy options. Our exploration illustrates the use of system dynamics models for policy making in complex health care systems.

Predictors of institutionalization in dementia: A systematic review and meta-analysis

Information Criteria. All models included baseline age and education as covariates. Results: Performance on attentional control declined over time, and the magnitude of decline did not interact with APOE or family history. Importantly, high baseline levels of tau were associated with significantly increased declines in attentional control. In contrast, levels of Ab42 significantly predicted baseline differences in attention but did not moderate decline over time. Conclusions:Attentional control is a sensitive indicator of preclinical AD pathology. Baseline levels of Ab42 predicted cognitive performance at the baseline assessment and baseline levels of tau significantly predicted the rate of cognitive decline. These findings suggest that attention based tasks can serve as both a screening tool (detect baseline difference due to preclinical amyloid pathology) and also as a cognitive endpoint for treatment outcomes (sensitive to cognitive declines over time associated with tau levels).

Resident and facility predictors of hospitalization among older adults with dementia residing in assisted living facilities

expenditures as a result of their comorbidities. This study assessed the risk of potentially avoidable hospitalizations (PAHs) that might be prevented with good outpatient management among ADRD patients. Methods: We examined the proportions of subjects with PAHs among Medicare beneficiaries with and without ADRD using data from 2007-2008 Medicare claims files. We used logistic regression to calculate propensity scores of having ADRD, matching cases (n1⁄4195,024) and an equal number of controls based on age, sex, race, Medicare-Medicaid dual eligibility, residence in a metropolitan statistical area, and number of comorbidities. We defined PAHs as admissions for: serious short-term complications of diabetes, serious long-term complications of diabetes, COPD or asthma, hypertension, and heart failure, based on the Medicare Ambulatory Care Indicators for the Elderly. We used logistic regression to investigate patient characteristics associated with PAHs. Results: Approximately one in five (20.2%) beneficiaries with ADRD and concurrent COPD/asthma had a PAH directly related to COPD/asthma. Corresponding proportions of patients with PAHs were 11.7% for heart failure, 2.8% for diabetes long-term complications, 1.3% for diabetes short-term complications, and 0.5% for hypertension. Compared to propensity-matched non-ADRD subjects, ADRD beneficiaries were more likely to have PAHs for diabetes shortterm complications (OR1⁄41.43; 95% CI1⁄41.31-1.57), diabetes long-term complications (OR1⁄41.08; 95% CI1⁄41.02-1.14), and hypertension (OR1⁄41.22; 95% CI1⁄41.08-1.38), but less likely to have PAHs for COPD/ asthma (OR1⁄40.85; 95% CI1⁄40.82-0.87) and heart failure (OR1⁄40.89; 95% CI1⁄40.86-0.92). Among ADRD patients, the risk of PAHs increased with comorbidity burden and the presence of medical complications associated with late-stage ADRD (ulcers, feeding disorders and malnutrition, aspiration pneumonia, and incontinence). Conclusions: A substantial proportion of Medicare beneficiaries with ADRD had preventable hospital admissions related to uncontrolled comorbidities. For some conditions, such as diabetes and hypertension, ADRD patients had a higher risk of condition-related PAHs compared to matched controls without dementia. Future ADRD management programs should improve care coordination between ambulatory, inpatient, and post-acute care, and these efforts should target high-risk patients, especially patients with multiple chronic conditions.

The effect of dementia case management in community-dwelling individuals with dementia on resource utilization: A systematic review and meta-analysis

Index, SII). Delirium severity and performance on cognitive test were reviewed daily throughout the GMU stay. Patients with and without dementia were compared for recovery in cognitive scores and functional status. Results: 122 patients with delirium and admitted to GMU were recruited over a one-year period 82 (67.2%) patients with underlying dementia and 40 (32.8%) patients without dementia. There were no significant differences in age, gender, delirium severity or illness severity at admission to GMU between groups, although patients with dementia had significantly higher Charlson’s co-morbidity (2.27 versus 1.75, P1⁄40.05). Patients with and without dementia did not differ in their performance on cognitive testing (CMMSE) at admission to GMU, although delirious patients without underlying dementia demonstrated significantly greater improvement in CMMSE scores at discharge (6.73 points versus 1.99 points, P<0.001). MBI on admission was not significantly different between demented and non-demented groups. The patients in GMU achieved mean MBI improvement of 19.42 points (P<0.001), with both demented and non-demented groups capable of functional recovery (MBI gain of 20.43 versus 17.35 respectively, P1⁄40.35). Illness severity was the only negative predictor of functional recovery. Conclusions: Elderly patients with dementia and recovering from delirium have comparable potential for functional recovery as their cognitively intact counterparts in a delirium management unit focused on geriatric nursing care and rehabilitation. Our findings provide further support that patients with dementia can benefit from rehabilitation in the acute-care setting.