Robert Newcomer

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

Unmet care needs and key outcomes in dementia

10,000/per year, compared to >

Misclassification and Selection Bias When Identifying Alzheimer's Disease Solely from Medicare Claims Records

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.

Ethnic differences in the prevalence and pattern of dementia-related behaviors

Objectives: To determine how unmet needs for activity of daily living tasks influenced nursing home placement, death, or loss to follow‐up in dementia.

The longitudinal effects of early behavior problems in the dementia caregiving career

BACKGROUND: Medicare claims as the basis for health condition adjustments is becoming a method of choice in capitation reimbursement. A recent study has found that claims‐based beneficiary classification for Alzheimers disease produces lower prevalence estimates and higher average costs than previous healthcare cost studies in this population. These sets of studies differ in data sources, period length, and in their specification of dementia.

A systematic review of nurse-assisted case management to improve hospital discharge transition outcomes for the elderly.

Objectives: To determine the prevalence of dementia‐related behaviors in a large, multiethnic sample of community‐dwelling patients with moderate to severe dementia and to determine whether differences in patient or caregiver characteristics could explain any differences in prevalence of these behaviors between white and nonwhite patients.

Clinically significant changes in burden and depression among dementia caregivers following nursing home admission

Using multiregional, 3-year data from early career dementia caregivers, this study determines how behavior problems that occur early in the caregiving career influence time to nursing home placement and change in burden and depression over time. A Cox proportional hazards model indicated that caregivers who managed frequent behavior problems earlier are more likely to institutionalize. After controlling for important time-varying covariates in a series of growth-curve models, caregivers who were faced with severe, early behavior problems reported greater increases in burden and depression over the 3-year study period. The findings suggest the need to consider experiences early in the dementia caregiving career when accounting for key longitudinal outcomes and also emphasize the importance of attrition when attempting to model the health implications of informal long-term care over time.

Predictors of Nursing Home Placement in African Americans with Dementia

Purpose This article reviews 15 clinical trials of nurse-assisted case management intended to improve posthospital transitions of elderly patients to other settings. Primary Practice Setting(s) Hospitals. Methodology and Sample The trials were selected after a systematic search of the PubMed database for the period 1996 to 2006. Results Eight of the 15 interventions showed reduced hospital readmission rates and/or fewer hospital days. These findings were observed across patients with “all cause” and heart failure, a variety of hospital types, and variations in the intervention. Reductions in the use of emergency departments were observed in 3 of the 11 studies investigating this. Lower expenditures were reported by all 6 studies reporting such comparisons. Implications for CM Practice Home visits/continuous contact with patients, early postdischarge and frequent contacts, patient education, and the use of specialized nurses who could offer appropriate training and coaching were often credited as program strengths.

S/HMOs, the second generation: building on the experience of the first Social Health Maintenance Organization demonstrations.

BackgroundAlthough extensive research exists on informal long-term care, little work has examined the clinical significance of transitions in family caregiving due to a lack of established clinical cut-points on key measures. The objectives of this study were to determine whether clinically significant changes in symptoms of burden and depression occur among caregivers within 12 months of nursing home admission (NHA) of their relatives with dementia, and to identify key predictors of clinically persistent burden and depression in the first year after institutionalization.MethodsSecondary longitudinal analysis of dementia caregivers were recruited from eight catchment areas in the United States with 6- and 12-month post-placement follow-up data. The sample included data on 1,610 dementia caregivers with pre- and six-month post-placement data and 1,116 with pre-placement, six-month, and 12-month post-placement data. Burden was measured with a modified version of the Zarit Burden Inventory. Depressive symptoms were assessed with the Geriatric Depression Scale.ResultsChi-square analyses found significant (P < .05) reductions in the number of caregivers who reported clinically significant burden and depressive symptoms after NHA compared to pre-placement. Logistic regression models revealed that wives and daughters were most likely to experience clinically persistent burden and husbands were most likely to experience clinically significant depression after NHA.ConclusionsIn addition to suggesting that clinically significant decreases in caregiver burden and depression are likely to occur following institutionalization, the results reveal particular subsets of caregivers who are at continued risk of distress. Such findings can facilitate development of screening processes to identify families at-risk following institutionalization.

The Effects of Incident and Persistent Behavioral Problems on Change in Caregiver Burden and Nursing Home Admission of Persons With Dementia

The objective of the present study was to identify predictors of institutionalization in African Americans who suffer from dementia. Data were derived from the Medicare Alzheimers Disease Demonstration Evaluation (MADDE), which collected information on Alzheimers patients and their family caregivers over a 3‐year period. The baseline MADDE sample included 667 older African Americans suffering from dementia recruited from eight catchment areas in the United States. A Cox proportional hazards model was used to create a predictive model of institutionalization. Subsequent analyses found that care recipient age, sex, Medicaid eligibility, and cognitive impairment; site; and caregiving burden were significant predictors of time to placement. The results, among the first to examine predictors of nursing home placement of cognitively impaired African Americans, emphasize the clinical implications and complex interplay of race, dementia, and caregiving context in the institutionalization process.