Faculty Bibliography

OBJECTIVE: Implement a memory impairment screening procedure for elderly Hispanic primary care patients, and analyze its yield and challenges to further triage and diagnostic evaluation. METHODS: Three hundred twenty nine Hispanic patients aged >/=60 years or proxy informants were enrolled from outpatient primary care clinics at an urban safety-net medical center. Patients were screened for memory impairment using the WHO-UCLA AVLT; for those without consent capacity, proxies were given the IQCODE. Bilingual research assistants conducted in-person or telephone screening. Age, gender, education, comorbidities, acculturation, overall health, access to care, and memory concerns were assessed as potential predictors of memory impairment. Based on identified implementation challenges, a multi-disciplinary stakeholder committee proposed revised approaches to increase diagnostic evaluation and sustainability. RESULTS: Of 677 eligible patients approached, 329 (49%) were screened, and 77 (23%) met criteria for memory impairment using the WHO-UCLA AVLT (N=60) or the IQCODE (N=17). Only male gender and higher comorbidity uniquely predicted memory impairment (ps<0.05). Few screen-positive patients declined further triage and evaluation, but a substantial proportion could not be subsequently contacted. Challenges to implementing a memory screening program included staff time and adequate clinic space for in-person screening; challenges to follow-up of positive screening results included inability to contact patients and lack of primary care continuity to facilitate further triage and referral. CONCLUSIONS: Nearly one-fourth of primary care Hispanic elders screened as memory-impaired, but few factors predicted positive screening. Stakeholder-guided adaptations are needed-particularly in resource-constrained settings-to overcome challenges to further diagnostic evaluation and referral.

OBJECTIVES: To determine the concurrent influence of depressive symptoms, medical conditions, and disabilities in activities of daily living (ADLs) on rates of decline in cognitive function of older Americans. DESIGN: Prospective cohort. SETTING: National population based. PARTICIPANTS: A national sample of 6,476 adults born before 1924. MEASUREMENTS: Differences in cognitive function trajectories were determined according to prevalence and incidence of depressive symptoms, chronic diseases, and ADL disabilities. Cognitive performance was tested five times between 1993 and 2002 using a multifaceted inventory examined as a global measure (range 0-35, standard deviation (SD) 6.0) and word recall (range 0-20, SD 3.8) analyzed separately. RESULTS: Baseline prevalence of depressive symptoms, stroke, and ADL limitations were independently and strongly associated with lower baseline cognition scores but did not predict future cognitive decline. Each incident depressive symptom was independently associated with a 0.06-point lower (95% confidence interval (CI)=0.02-0.10) recall score, incident stroke with a 0.59-point lower total score (95% CI=0.20-0.98), each new basic ADL limitation with a 0.07-point lower recall score (95% CI=0.01-0.14) and a 0.16-point lower total score (95% CI=0.07-0.25), and each incident instrumental ADL limitation with a 0.20-point lower recall score (95% CI=0.10-0.30) and a 0.52-point lower total score (95% CI=0.37-0.67). CONCLUSION: Prevalent and incident depressive symptoms, stroke, and ADL disabilities contribute independently to poorer cognitive functioning in older Americans but do not appear to influence rates of future cognitive decline. Prevention, early identification, and aggressive treatment of these conditions may ameliorate the burdens of cognitive impairment.

OBJECTIVES: To compare primary care providers' (PCPs') perceptions about dementia and its care within their healthcare organization with perceptions of other common chronic conditions and to explore factors associated with differences. DESIGN: Cross-sectional survey. SETTING: Three California healthcare organizations. PARTICIPANTS: One hundred sixty-four PCPs. MEASUREMENTS: PCPs' views about primary care for dementia were analyzed and compared with views about care for heart disease, diabetes mellitus, and selected other conditions. Differences in views about conditions according to PCP type (internists, family physicians) were assessed. Multivariate analysis examined relationships between provider and practice characteristics and views about dementia care. RESULTS: More PCPs strongly agreed that older patients with dementia are difficult to manage (23.8%) than for heart disease (5.0%) or diabetes mellitus (6.3%); PCPs can improve quality of life for heart disease (58.9%) and diabetes mellitus (61.6%) than for dementia (30.9%); older patients should be routinely screened for heart disease (63.8%) and diabetes mellitus (67.7%) than dementia (55.5%); and their organizations have expertise/referral resources to manage diabetes mellitus (49.4%) and heart disease (51.8%) than dementia (21.1%). More PCPs reported almost effortless organizational care coordination for heart disease (13.0%) or diabetes mellitus (13.7%) than for dementia (5.6%), and a great deal or many opportunities for improvement in their ability to manage dementia (50.6%) than incontinence, depression, or hypertension (7.4-34.0%; all P<.05). Internists' views regarding dementia care were less optimistic than those of family physicians, but PCP type was unrelated to views on diabetes mellitus or heart disease. CONCLUSION: Improving primary care management of dementia should directly address PCP concerns about expertise and referral resources, difficulty of care provision, and PCP views about prospects for patient improvement.

BACKGROUND: Dementia is a common geriatric syndrome. It is unclear how best to predict survival among dementia patients, which leaves clinicians, patients, and families uncertain as to how to proceed with medical decisions and reassessing goals. METHODS: We performed a MEDLINE systematic review of studies that evaluated dementia prognosis and survival; 48 studies (cohort, cross-sectional, retrospective, and case-control studies) were included. RESULTS: Increased age, male gender, decreased functional status, and medical comorbidities such as diabetes, cardiovascular disease, and malignancy were associated with a higher mortality rate in dementia patients. Patients' baseline education level showed no influence on survival. There was no consensus regarding the association among dementia type, baseline cognitive function, and neuropsychiatric symptoms with dementia prognosis. CONCLUSION: Despite much data, we lack a unifying guideline for dementia prognostication. Moving forward, the creation of a risk score for dementia could be helpful for patients and families in reassessing goals of care and possible enrollment in services such as hospice or palliative care.

This study used mixed-effects modeling of data from a national sample of 6,476 US adults born before 1924, who were tested 5 times between 1993 and 2002 on word recall, serial 7's, and other mental status items to determine demographic and socioeconomic predictors of trajectories of cognitive function in older Americans. Mean decline with aging in total cognition score (range, 0-35; standard deviation, 6.00) was 4.1 (0.68 standard deviations) per decade (95% confidence interval: 3.8, 4.4) and in recall score (range, 0-20; standard deviation, 3.84) was 2.3 (0.60 standard deviations) per decade (95% confidence interval: 2.1, 2.5). Older cohorts (compared with younger cohorts), women (compared with men), widows/widowers, and those never married (both compared with married individuals) declined faster, and non-Hispanic blacks (compared with non-Hispanic whites) and those in the bottom income quintile (compared with the top quintile) declined slower. Race and income differences in rates of decline were not sufficient to offset larger differences in baseline cognition scores. Educational level was not associated with rate of decline in cognition scores. The authors concluded that ethnic and socioeconomic disparities in cognitive function in older Americans arise primarily from differences in peak cognitive performance achieved earlier in the life course and less from declines in later life.

OBJECTIVE: To calculate intervention costs and the potential cost offset of a care management intervention that substantially improved the quality of dementia care. STUDY DESIGN: From both a payer perspective and a social planner perspective, we analyzed data from a cluster randomized controlled trial (RCT) evaluating this intervention versus usual care. The RCT included 408 pairs of older adults with dementia and their caregivers. Caregivers were surveyed at baseline, at 12 months, and at 18 months to assess patient healthcare utilization and out-of-pocket costs. METHODS: We calculated fixed and per-patient intervention costs from RCT records. We combined the monthly per-patient costs of healthcare services, informal caregiving, and out-of-pocket costs, and we conducted multivariate analyses comparing this sum (potential cost offset) for intervention versus usual care patients. Covariates included patient age, sex, and baseline costs. We limited the main analysis to patients who survived until the 12-month survey or the 18-month survey. RESULTS: The intervention required a start-up cost of $70,256 and mean intervention per-patient per month costs of $118. There were no significant differences in the mean monthly cost of healthcare and caregiving services for intervention versus usual care patients using the societal perspective (difference of -$555 per month, P = .28) or the payer perspective (difference of -$219 per month [including nursing home costs], P = .55; difference of -$256 per month [excluding nursing home costs], P = .47). CONCLUSION: Although this analysis of a dementia care management intervention did not demonstrate a significant cost offset, the intervention may represent a worthwhile approach to improving the quality of care and health outcomes for patients with dementia and their caregivers.

OBJECTIVES: To test the accuracy of a brief cognitive assessment of nursing home (NH) residents and to determine whether facility nurses can reliably perform this assessment. DESIGN: Cross-sectional, independent cognitive screening tests with NH residents. SETTING: Six Department of Veteran Affairs nursing facilities. PARTICIPANTS: Three hundred seventy-four residents from six regionally distributed Veteran Affairs NHs. MEASUREMENTS: Three cognitive assessment instruments: the Brief Interview of Mental Status (BIMS), created for this study; the Minimum Data Set (MDS) 2.0 Cognitive Performance Scale (CPS), and the Modified Mini-Mental State Examination (3MS) as the criterion standard. The 15-point BIMS tests memory and orientation and includes free and cued recall items. Research assistants administered the 3MS and BIMS to all subjects. Facility nurses administered the same BIMS to a subsample. RESULTS: Three hundred seventy-four of 417 (89.7%) residents approached completed the 3MS and research assistant-administered BIMS (BIMS-R); 212 residents also received a facility nurse-administered BIMS (BIMS-N). The BIMS-R was more highly correlated with the 3MS than was the CPS (Pearson correlation coefficient (r)=0.79 vs 0.62; P<.01 for difference). For the subset who received facility assessments, the BIMS-N was also more highly correlated with the 3MS (Pearson r=0.74 vs 0.65; P<.01 for difference). For any impairment (3MS<78), the area under the receiver operator characteristic curve (AUC) was 0.86 for the BIMS, versus 0.77 for the CPS. For severe impairment (3MS<48) the AUC was 0.94, versus 0.85 for the CPS. CONCLUSION: In this population, a brief cognitive test is a more accurate approach to cognitive assessment than the current observational methods employed using the MDS 2.0.

OBJECTIVES: To identify specific care management activities within a dementia care management intervention that are associated with 18-month change in caregiver mastery and relationship strain. DESIGN: Exploratory analysis, using secondary data (care management processes and caregiver outcomes) from the intervention arm of a clinic-level randomized, controlled trial of a dementia care management quality improvement program. SETTING: Nine primary care clinics in three managed care and fee-for-service southern California healthcare organizations. PARTICIPANTS: Two hundred thirty-eight pairs: individuals with dementia and their informal, nonprofessional caregivers. MEASUREMENTS: Care management activity types extracted from an electronic database were used as predictors of caregiver mastery and relationship strain, which were measured through mailed surveys. Multivariable linear regression models were used to predict caregiver mastery and relationship strain. RESULTS: For each care manager home environment assessment, caregiver mastery increased 4 points (range 0-100, mean+/-standard deviation 57.1+/-26.6, 95% confidence interval (CI)=2.4-5.7; P=.001) between baseline and 18 months. For every action linking caregivers to community agencies for nonspecific needs, caregiver mastery decreased 6.2 points (95% CI=-8.5 to -3.9; P<.001). No other care management activities were significantly associated with this outcome, and no specific activities were associated with a change in caregiver relationship strain. CONCLUSION: Home assessments for specific needs of caregivers and persons with dementia are associated with improvements in caregivers' sense of mastery. Future work is needed to determine whether this increase is sustained over time and decreases the need for institutionalization.

OBJECTIVES: To describe end-of-life advance care planning among the oldest-old (those >/= 85 years) and to identify patient characteristics and healthcare utilization patterns associated with likelihood of care planning documentation. DESIGN: Medical charts were abstracted for evidence of advance care planning documentation (including surrogate for health care decisions) and linked to patient demographic, clinical, and health utilization characteristics. SETTING: Veterans Affairs Greater Los Angeles Healthcare System (VA GLAHS). PARTICIPANTS: All Veterans (n = 175) aged >/= 85 who died between September 1999 and October 2000 and used services at the VA GLAHS in the last year of life. MEASUREMENTS: The association of patient demographic, clinical, and health care utilization characteristics with documentation of advance care planning and surrogates was modeled using multivariate logistic regression. RESULTS: Among veterans (mean age at death, 89.4 +/- 3.8 years), 50 of 149 (34%) electronic available records had documented care preferences whereas 68 (46%) had documentation of surrogates. Considering demographic, clinical, and service use characteristics, only age (adjusted odds ratio [AOR]: 1.1 per year; 95% confidence interval [CI]: 1.0-1.2) and outpatient visits (AOR: 1.6 per quartile of general and geriatric medicine visit frequency; 95% CI: 1.1-;2.3) were associated with advance directive completion. A multivariable regression model using the same predictors to predict documentation of surrogates found similar associations with total outpatient visits (AOR: 1.5; 95% CI: 1.0-2.0) and general and geriatric medicine utilization. (AOR: 1.4; 95% CI: 1.0-2.0). CONCLUSION: Even in a health care system known for high-quality chronic illness care, documentation of advance care planning and selected proxies for health care decisions at the end of life was infrequent. Outpatient primary care and geriatric providers' visits were more frequent among those who had documented advance care planning, suggesting that involvement of these practitioners may improve end-of-life care.