Patrick Fox

Patient and Caregiver Characteristics Associated with Depression in Caregivers of Patients with Dementia

OBJECTIVE: Many patients with dementia who live at home would require nursing home care if they did not have the assistance of family caregivers. However, caregiving sometimes has adverse health consequences for caregivers, including very high rates of depression. The goal of this study was to determine the patient and caregiver characteristics associated with depression among caregivers of patients with dementia.DESIGN: Cross-sectional study.PARTICIPANTS AND SETTING: Five thousand six hundred and twenty-seven patients with moderate to advanced dementia and their primary caregivers upon enrollment in the Medicare Alzheimer’s Disease Demonstration (MADDE) at 8 locations in the United States.MEASUREMENTS: Caregiver depression was defined as 6 or more symptoms on the 15-item Geriatric Depression Scale. Patient characteristics measured included ethnicity and other demographic characteristics, income, activities of daily living (ADL) function, Mini-Mental Status Exam (MMSE) score, and behavioral problems. Caregiver characteristics measured included demographic characteristics, relationship to the patient, hours spent caregiving, and ADL and Instrumental Activities of Daily Living (IADL) function. We used x2 and t tests to measure the bivariate relationships between patient and caregiver predictors and caregiver depression. We used logistic regression to determine the independent predictors of caregiver depression.RESULTS: Thirty-two percent of caregivers reported 6 or more symptoms of depression and were classified as depressed. Independent patient predictors of caregiver depression included younger age (odds ratio [OR], 1.91; 95% confidence interval [CI], 1.33 to 2.76 in patients less than 65 years compared to patients over 85 years), white (OR, 1.53; 95% CI, 1.18 to 1.99) and Hispanic ethnicity (OR, 2.50; 95% CI, 1.69 to 3.70) compared to black ethnicity, education (OR, 1.16; 95% CI, 1.01 to 1.33 for those with less than a high school education), ADL dependence (OR, 1.55; 95% CI, 1.26 to 1.90 for patients dependent in 2 or more ADL compared to patients dependent in no ADL), and behavioral disturbance, particularly angry or aggressive behavior (OR, 1.47; 95% CI, 1.27 to 1.69 for patients with angry or aggressive behavior). Independent caregiver predictors of depression included low income (OR, 1.45; 95% CI, 1.18 to 1.77 for less than

Alzheimer's Disease The Unpaid Burden of Caring

10,000/per year, compared to >

Cultural attitudes and caregiver service use: lessons from focus groups with racially and ethnically diverse family caregivers.

20,000 per year), the relationship to the patient (OR, 2.73; 95% CI, 1.31 to 5.72 for wife, compared to son of male patient), hours spent caregiving (OR, 1.89; 95% CI, 1.51 to 2.38 for 40 to 79 hours/week compared to less than 40 hours/week), and functional dependence (OR, 2.53; 95% CI, 2.13 to 3.01 for ADL dependent compared to IADL independent).CONCLUSION: Caregiver depression is a complex process, influenced by ethnicity as well as diverse patient and caregiver characteristics. Efforts to identify and treat caregiver depression will need to be multidisciplinary and focus on multiple risk factors simultaneously.

Correlates of Mini-Mental Status Examination scores among elderly demented patients: the influence of race-ethnicity.

This study presents detailed estimates of the hours and cost of informal care provided to Alzheimers disease patients in Northern California. Data were collected over 12 months from 93 community-residing patients and their caregivers and from 94 institutionalized patients and their caregivers. Patients residing in the community received an average of 286 hours per month of unpaid care, whereas institutionalized patients received 36 hours per month. Alternative methods of imputing informal costs are described. The annual value of informal care (in 1990 dollars) is

Service use and cost outcomes for persons with Alzheimer disease

34,517 for the noninstitutionalized sample and

Improving Asthma-Related Health Outcomes Among Low-Income, Multiethnic, School-aged Children: Results of a Demonstration Project That Combined Continuous Quality Improvement and Community Health Worker Strategies

5,542 for the institutionalized sample. The determinants of informal caregiving were examined and compared in the two settings. The more cognitively impaired the individual, the higher the informal costs no matter what the residental setting. In an institutional setting, the younger the patient and caregiver, the higher the costs. If a caregiver is not a spouse, higher informal care costs were also found.

An examination of differential follow-up rates in breast cancer screening

Abstract Focus groups were conducted with caregivers from eight racial-specific or ethnic-specific populations (African Americans, Chinese, Filipinos, Hispanics, Koreans, Native Americans, Russians, and Vietnamese), to examine cultural variations in caregiving experiences, care-related values and beliefs, care practices, and factors contributing to decisions about the use of caregiver support services. Analysis of focus group transcripts revealed three cross-cutting constructs: familism, group identity, and attitudinal and structural barriers to service use. We discuss these findings in terms of their implications for existing knowledge regarding family responsibility, resource utilization, and program development for racially and ethnically diverse family caregivers.

Mammography Rescreening Among Women of Diverse Ethnicities: Patient, Provider, and Health Care System Factors

Data on 1888 patients seen at Alzheimers Disease Diagnostic and Treatment Centers in California were used to examine possible differences in Mini-Mental State Examination (MMSE) results for different racial-ethnic groups. White patients had scores less indicative of dementia than Black and Hispanic patients using the standard 23 cutting point on the MMSE. However, there were no differences among these groups in the percentages clinically diagnosed as demented. The difference in the percentage of Whites vs Blacks and Hispanics categorized as demented by the MMSE was not accounted for by education, occupation, age, sex, or other variables tested, even though these variables were correlated with MMSE scores. Our data suggest that clinicians should consider MMSE scores for Black and Hispanic patients an underestimate of their cognitive capabilities relative to that of White patients.

Estimating the Costs of Caring for People with Alzheimer Disease in California: 2000–2040

Use of formal services and the associated costs of caring for people with Alzheimer disease and related disorders are expected increase into the next century. This will be driven primarily by general economic inflation, annual increases in health care costs exceeding the inflation rate, increasing numbers of people 85 years of age and older, increases in the expected life span of people at 65 years of age, increasing numbers of people in the nonelderly disabled population receiving Medicare benefits, and changes in the employment structure of the economy. Two sources of data that have been used to estimate formal health and social service utilization and costs are self-report and Medicare claims data. Self-report data are problematic in studies of people with Alzheimer disease because of the demented persons general inability to reliably report on service utilization and the necessary use of proxies to obtain information. Medicare claims are a source for both service utilization and cost data, but limitations in these data result from their use to document reimbursement claims as opposed to accurately reflecting service use histories. Given the lack of reliable and comprehensive service utilization and cost reporting systems, a variety of methods will be required to estimate service use and cost outcome data for people with dementia. These include self-reports of service use and cost, examination of claims records, and service use document abstraction, when feasible.The objective of this study was to determine whether unawareness of cognitive deficit is disease-specific. One hundred thirty-two patients were studied, grouped according to diagnosis of definite or probable Alzheimer disease, vascular dementia, geropsychiatric control, or geriatric control. Diagnosis was the independent variable, and unawareness of cognitive deficit was the dependent variable. The Mini-Mental State Examination score was used as a dementia severity covariate. Analysis of covariance was significant (F = 8.0, p < 0.0001). Follow-up mean comparisons showed the Alzheimer disease group to have significantly greater unawareness of cognitive deficit than all other groups. The vascular dementia group had significantly greater unawareness of cognitive deficit than the two control groups. These results support the premise that, independent of dementia severity, unawareness of cognitive deficit is disease specific.

Timely follow-up among multicultural women with abnormal mammograms

OBJECTIVE. The purpose of this work was to improve asthma-related health outcomes in an ethnically and geographically disparate population of economically disadvantaged school-aged children by using a team-based approach using continuous quality improvement and community health workers. PATIENTS AND METHODS. A demonstration project was conducted with 7 community clinics treating ∼3000 children with asthma 5 to 18 years of age. The overall clinic population with asthma was assessed for care-process changes through random cross-sectional chart reviews at baseline and 24 months (N = 560). A subset of patients with either moderate or severe persistent asthma or poorly controlled asthma (N = 405) was followed longitudinally for specific asthma-related clinical outcomes, satisfaction with care, and confidence managing asthma by family interview at baseline and at 12 or 24 months. Patient-centered and care-process outcomes included patient/parent assessment of quality of care and confidence in self-management, asthma action plan review, and documentation of guideline-based indicators of quality of care. Direct clinical outcomes included daytime and nighttime symptoms, use of rescue medications, acute care and emergency department visits, hospitalizations, and missed school days. Each clinic sites degree of adherence to the intervention model was evaluated and ranked to examine the correlation between model adherence and outcomes. RESULTS. Cross-sectional data showed clinic-wide improvements in the documentation of asthma severity, review of action plans, health services use, and asthma symptoms. At follow-up in the longitudinal sample, fewer patients reported acute visits, emergency department visits, hospitalizations, frequent daytime and nighttime symptoms, and missed school days compared with baseline. More patients reported excellent or very good quality of care and confidence in asthma self-management. Linear regression analysis of the clinical sites’ model adherence ranks against site-level combined scores estimating overall outcomes, clinical outcomes, and improvements in clinical care processes showed significant linear correlations with R2 ≥ 0.60. CONCLUSIONS. The demonstration produced major improvements in asthma-related care processes and clinical outcomes. Closer adherence to the demonstration model was directly associated with better outcomes.