Faculty Bibliography

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.

OBJECTIVES: To describe the quality of dementia care within one U.S. metropolitan area and to investigate associations between variations in quality and patient, caregiver, and health system characteristics. DESIGN: Observational, cross-sectional. SETTING AND PARTICIPANTS: Three hundred eighty-seven patient-caregiver pairs from three healthcare organizations MEASUREMENTS: Using caregiver surveys and medical record abstraction to assess 18 dementia care processes drawn from existing guidelines, the proportion adherent to each care process was calculated, as well as mean percentages of adherence aggregated within four care dimensions: assessment (6 processes), treatment (6 processes), education and support (3 processes), and safety (3 processes). For each dimension, associations between adherence and patient, caregiver, and health system characteristics were investigated using multivariable models. RESULTS: Adherence ranged from 9% to 79% for the 18 individual care processes; 11 processes had less than 40% adherence. Mean percentage adherence across the four care dimensions was 37% for assessment, 33% for treatment, 52% for education and support, and 21% for safety. Higher comorbidity was associated with greater adherence across all four dimensions, whereas greater caregiver knowledge (in particular, one item) was associated with higher care quality in three of four care dimensions. For selected dimensions, greater adherence was also associated with greater dementia severity and with more geriatrics or neurologist visits. CONCLUSION: In general, dementia care quality has considerable room for improvement. Although greater comorbidity and dementia severity were associated with better quality, caregiver knowledge was the most consistent caregiver characteristic associated with better adherence. These findings offer opportunities for targeting low quality and suggest potential focused interventions.

Memory impairment is the most frequent cognitive dysfunction for older patients. Though studies have shown that dementia is often overlooked in primary care settings, there has been minimal focus specifically on memory impairment, on patients' concerns about memory, or their desire to address these concerns. The objectives of this study were to (1) investigate the prevalence of memory impairment among patients without dementia diagnoses, (2) determine the degree of patients' concern about memory impairment and (3) identify other patient characteristics associated with memory impairment among older primary care patients. Using telephone versions of a four-item memory test and proxy-reported cognitive decline for patients unable to complete interviews, we performed memory assessment of randomly selected patients, 75 years and older, without dementia diagnoses who see primary care physicians at least twice every six months. Among 260 patients and 20 proxies, 19.8% had memory impairment at a level indicative of probable dementia. Adjusting for age, ethnicity, and education, subjects who were more concerned about memory impairment were more likely to be impaired. (Adjusted odds ratio [AOR]: 1.4 (for each additional level of concern); 95% confidence interval [CI]: (1.0-2.0)). Similarly, subjects wanting their physician to discuss with them their memory concerns were more likely to be impaired (AOR: 1.4; 95% CI: 1.0-1.9). Memory impairment is common among older primary care patients without diagnosed dementia. Knowing patients' concerns about memory impairment and their desire to discuss these concerns may facilitate cognitive screening in this setting.

OBJECTIVE: The prevalence of dementia continues to rise, and yet, there are few known modifiable risk factors. Depression, as a treatable condition, may be important in the development of dementia. Our objective was to examine the association between depressive symptoms and longitudinal cognitive changes in older adults who were high-functioning at baseline. METHODS: The authors analyzed data from a community-based cohort (aged 70-79 at baseline), who, at study entry, scored 7 or more (out of 9) on the Short Portable Mental Status Questionnaire (SPMSQ). Depressive symptoms were assessed at baseline using the depression subscale of the Hopkins Symptom Check List. Cognitive performance was measured at baseline and at seven-year follow up by the SPMSQ and by summary scores from standard tests of naming, construction, spatial recognition, abstraction, and delayed recall. RESULTS: After adjusting for potential confounders, including age, education, and chronic health conditions such as diabetes, heart attack, stroke, and hypertension, a higher number of baseline depressive symptoms were strongly associated with greater seven-year decline in cognitive performance and with higher odds of incident cognitive impairment, i.e., decline in SPMSQ score to < or = 6 (adjusted odds ratio per quartile of depressive symptoms score: 1.34, 95% confidence interval: 1.10-1.68). CONCLUSIONS: Depressive symptomatology independently predicts cognitive decline and incident cognitive impairment in previously high-functioning older persons.

BACKGROUND: Adherence to dementia guidelines is poor despite evidence that some guideline recommendations can improve symptoms and delay institutionalization of patients. OBJECTIVE: To test the effectiveness of a dementia guideline-based disease management program on quality of care and outcomes for patients with dementia. DESIGN: Clinic-level, cluster randomized, controlled trial. SETTING: 3 health care organizations collaborating with 3 community agencies in southern California. PARTICIPANTS: 18 primary care clinics and 408 patients with dementia age 65 years or older paired with 408 informal caregivers. INTERVENTION: Disease management program led by care managers and provided to 238 patient-caregiver pairs at 9 intervention clinics for more than 12 months. MEASUREMENTS: Adherence to 23 guideline recommendations (primary outcome) and receipt of community resources and patient and caregiver health and quality-of-care measures (secondary outcomes). RESULTS: The mean percentage of per-patient guideline recommendations to which care was adherent was significantly higher in the intervention group than in the usual care group (63.9% vs. 32.9%, respectively; adjusted difference, 30.1% [95% CI, 25.2% to 34.9%]; P < 0.001). Participants who received the intervention had higher care quality on 21 of 23 guidelines (P < or = 0.013 for all), and higher proportions received community agency assistance (P < or = 0.03) than those who received usual care. Patient health-related quality of life, overall quality of patient care, caregiving quality, social support, and level of unmet caregiving assistance needs were better for participants in the intervention group than for those in the usual care group (P < 0.05 for all). Caregiver health-related quality of life did not differ between the 2 groups. LIMITATIONS: Participants were well-educated, were predominantly white, had a usual source of care, and were not institutionalized. Generalizability to other patients and geographic regions is unknown. Also, costs of a care management program under fee-for-service reimbursement may impede adoption. CONCLUSIONS: A dementia guideline-based disease management program led to substantial improvements in quality of care for patients with dementia. Current Controlled Trials identifier: ISRCTN72577751.