Faculty Bibliography

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.

OBJECTIVES: To evaluate the effect of a multicomponent dementia care management program on primary care provider knowledge, attitudes, and perceptions of quality of dementia care. DESIGN: A clinic-level randomized, controlled trial of a comprehensive care management program for patients with dementia and their nonprofessional caregivers. The program included provider education and protocols for care managers to communicate with patients' medical providers. SETTING: Eighteen clinics (nine intervention, nine [corrected] usual care) in three healthcare systems in San Diego, California. PARTICIPANTS: Two hundred thirty-two medical providers; 129 from nine [corrected] intervention clinics; 103 from nine [corrected] usual-care clinics. MEASUREMENTS: Providers were surveyed 9 months after intervention onset on knowledge (five items on four topics), attitudes about dementia (three items), and perception of quality of dementia care in their practice setting (three items). Multivariable linear and logistic regression models were used to evaluate the differences between intervention and usual-care providers, adjusting for covariate effects across groups and clustering by clinic. RESULTS: One hundred sixty-six of 232 (72%) providers responded. Intervention providers had better knowledge about assessing decision-making capacity than usual-care providers (adjusted difference in percentage correct = 12%; adjusted odds ratio = 2.4, 95% confidence interval = 1.2-4.8). Intervention providers viewed dementia patients as more difficult to manage in primary care than usual-care providers (P = .03). There were no other differences in knowledge, attitudes, or care quality perceptions across intervention and usual-care providers. CONCLUSION: A comprehensive dementia care management model resulted in few differences in provider knowledge or attitudes favorable to dementia care, suggesting that this care model's effects on quality were primarily mediated through other components of the care management program.

Elevated glucocorticoid levels have been associated with cognitive impairment, including dementia. However, few longitudinal studies have examined the association between resting cortisol levels and the incidence of cognitive impairment. We measured overnight urinary excretion of cortisol in 538 high-functioning men and women, 70-79 years of age, in 1988, and assessed their cognitive functioning in 1988, 1991, and 1995 using the short portable mental status questionnaire (SPMSQ). Compared to participants in the bottom quartile of urinary cortisol at baseline, those in the top three quartiles had higher risk of incident cognitive impairment over the 7-year follow up (i.e., decline in SPMSQ score to below six out of nine). This association was not affected by adjustment for age, gender, education level, ethnicity, smoking, prevalent cardiovascular disease, and blood pressure (adjusted odds ratio for the highest quartile 2.34, 95% confidence interval, 1.07-5.14). There was no effect modification by gender; the association was equally strong in men and women. We conclude that urinary excretion of cortisol predicts incident cognitive impairment in older men and women.

BACKGROUND: Although enthusiasm is growing for self-management programs for chronic conditions, there are conflicting data regarding their effectiveness and no agreement on their essential components. PURPOSE: To assess the effectiveness and essential components of self-management programs for hypertension, osteoarthritis, and diabetes mellitus. DATA SOURCES: The authors searched multiple sources dated through September 2004, including the Cochrane Library, MEDLINE, PsycINFO, and Nursing and Allied Health databases, and bibliographies of 87 previous reviews. STUDY SELECTION: Randomized trials that compared outcomes of self-management interventions with a control or with usual care for diabetes mellitus, osteoarthritis, or hypertension; outcomes included hemoglobin A1c level, fasting blood glucose level, weight, blood pressure, pain, or function. DATA EXTRACTION: Two reviewers independently identified trials and extracted data regarding whether the intervention used tailored adjustments to meet individual patient needs, a group setting, feedback, and psychological services, and whether the intervention was provided by the patient's usual physician. DATA SYNTHESIS: Of 780 studies screened, 53 studies contributed data to the random-effects meta-analysis (26 diabetes studies, 14 osteoarthritis studies, and 13 hypertension studies). Self-management interventions led to a statistically and clinically significant pooled effect size of -0.36 (95% CI, -0.52 to -0.21) for hemoglobin A1c, equivalent to a reduction in hemoglobin A1c level of about 0.81%. Self-management interventions decreased systolic blood pressure by 5 mm Hg (effect size, -0.39 [CI, -0.51 to -0.28]) and decreased diastolic blood pressure by 4.3 mm Hg (effect size, -0.51 [CI, -0.73 to -0.30]). Pooled effects of self-management interventions were statistically significant but clinically trivial for pain and function outcomes for osteoarthritis. No consistent results supported any of the 5 characteristics examined as essential for program success. LIMITATIONS: Studies had variable quality, and possible publication bias was evident. CONCLUSIONS: Self-management programs for diabetes mellitus and hypertension probably produce clinically important benefits. The elements of the programs most responsible for benefits cannot be determined from existing data, and this inhibits specification of optimally effective or cost-effective programs. Osteoarthritis self-management programs do not appear to have clinically beneficial effects on pain or function.

OBJECTIVES: To examine hospital use for patients with evidence of cognitive decline indicative of early cognitive impairment. DESIGN: Medicare Part A hospital utilization data were linked to data from the MacArthur Research Network on Successful Aging Community Study to examine the association between baseline cognition and decline in cognitive function over a 3-year period and any hospitalization over that same period. SETTING: New Haven, Connecticut, and East Boston, Massachusetts. PARTICIPANTS: Subjects (N=598) were from two sites of the MacArthur Research Network on Successful Aging Community Study, a 7-year cohort study of community-dwelling older persons with high physical and cognitive functioning. MEASUREMENTS: Multivariate logistic regression was used to determine the association between any hospitalization over 3 years (1988-91) as the outcome variable and baseline cognitive function and decline in cognition over 3 years as primary predictor variables. Decline was based upon repeated (1988 and 1991) measures of delayed verbal recall and the Short Portable Mental Status Questionnaire (SPMSQ). RESULTS: Of 598 subjects, 48 died between 1988 and 1991. No baseline (1988) delayed recall scores or change in recall scores (1988-91) were associated with hospitalization. Although 48.2% declined on verbal memory scores, decline was not associated with risk of hospitalization. Of 494 subjects with complete 3-year data, 31.2% declined at least one point on the SPMSQ, and 4.7% declined more than two points. Among individuals aged 75 and older at baseline, the adjusted odds ratio for hospitalization for those who declined more than 2 points compared with those who declined less was 7.8 (95% confidence interval=2.0-30.8). CONCLUSION: Although specific memory tests were not associated with hospitalization, high-functioning older persons who experienced decline in overall cognitive function were more likely to be hospitalized. Variation in baseline cognitive function in this high-functioning cohort did not affect hospitalization, but additional research is needed to evaluate associations with other healthcare costs.

OBJECTIVES: To assess physician recognition of dementia and cognitive impairment, compare recognition with documentation, and identify physician and patient factors associated with recognition. DESIGN: Survey of physicians and review of medical records. SETTING: Health maintenance organization in southern California. PARTICIPANTS: Seven hundred twenty-nine physicians who provided care for women participating in a cohort study of memory (Women's Memory Study). MEASUREMENTS: Percentage of patients with dementia or cognitive impairment (using the Telephone Interview of Cognitive Status supplemented by the Telephone Dementia Questionnaire) recognized by physicians. Relationship between physician recognition and patient characteristics and physician demographics, practice characteristics, training, knowledge, and attitudes about dementia. RESULTS: Physicians (n=365) correctly identified 81% of patients with dementia and 44% of patients with cognitive impairment without definite dementia. Medical records documented cognitive impairment in 83% of patients with dementia and 26% of patients with cognitive impairment without definite dementia. In a multivariable model, physicians with geriatric credentials (defined as geriatric fellowship experience and/or the certificate of added qualifications) recognized cognitive impairment more often than did those without (risk ratio (RR)=1.56, 95% confidence interval (CI)=1.04-1.66). Physicians were more likely to recognize cognitive impairment in patients with a history of depression treatment (RR=1.3, 95% CI=1.03-1.45) or stroke (RR=1.37, 95% CI=1.04-1.45) and less likely to recognize impairment in patients with cognitive impairment without definite dementia than in those with dementia (RR=0.46, 95% CI=0.23-0.72) and in patients with a prior hospitalization for myocardial infarction (RR=0.37, 95% CI=0.09-0.88) or cancer (RR=0.49, 95% CI=0.18-0.90). CONCLUSION: Medical record documentation reflects physician recognition of dementia, yet physicians are aware of, but have not documented, many patients with milder cognitive impairment. Physicians are unaware of cognitive impairment in more than 40% of their cognitively impaired patients. Additional geriatrics training may promote recognition, but systems solutions are needed to improve recognition critical to provision of emerging therapies for early dementia.

OBJECTIVES: To assess the quality of chronic pain care provided to vulnerable older persons. DESIGN: Observational study evaluating 11 process-of-care quality indicators using medical records and interviews with patients or proxies covering care received from July 1998 through July 1999. SETTING: Two senior managed care plans. PARTICIPANTS: A total of 372 older patients at increased risk of functional decline or death identified by interview of a random sample of community dwellers aged 65 and older enrolled in these managed-care plans. MEASUREMENTS: Percentage of quality indicators satisfied for patients with chronic pain. RESULTS: Fewer than 40% of vulnerable patients reported having been screened for pain over a 2-year period. One hundred twenty-three patients (33%) had medical record documentation of a new episode of chronic pain during a 13-month period, including 18 presentations for headache, 66 for back pain, and 68 for joint pain. Two or more history elements relevant to the presenting pain complaint were documented for 39% of patients, and at least one relevant physical examination element was documented for 68% of patients. Treatment was offered to 86% of patients, but follow-up occurred in only 66%. Eleven of 18 patients prescribed opioids reported being offered a bowel regimen, and 10% of patients prescribed noncyclooxygenase-selective nonsteroidal antiinflammatory medications received appropriate attention to potential gastrointestinal toxicity. CONCLUSION: Chronic pain management in older vulnerable patients is inadequate. Improvement is needed in screening, clinical evaluation, follow-up, and attention to potential toxicities of therapy.

OBJECTIVE: The authors examined whether older adults respond comparably to two standard depression instruments rating symptoms by frequency/duration or degree of severity/"bother." METHODS: Data for this cross sectional analysis of a prospective cohort came from 699 community-dwelling individuals within the communities of Durham, North Carolina, and New Haven, Connecticut. Differences in response between the Center for Epidemiological Studies-Depression (CES-D) survey, emphasizing symptom frequency, were compared with the Hopkins Symptom Checklist (HSCL) subscale, emphasizing bother or discomfort related to those symptoms. Socioeconomic, demographic, and clinical characteristics for subjects with the greatest difference between standardized scale scores were analyzed with multivariable logistic regression. RESULTS: Older persons differed in their responses between the two instruments, despite similar content. Individuals in the highest quartile of difference between the two scales (indicating more bother than symptom frequency) had significantly more education, higher income, and were less often African American, with no differences in health conditions. Moreover, these specific socioeconomic and ethnic characteristics remained significant in multivariable analyses. CONCLUSIONS: Older persons not only differed significantly in their responses between depression instruments based on one dimension or the other, although with similar content, but response was significantly associated with specific subject characteristics. The heterogeneity of older patient populations suggests that recognition of depressive symptoms should include both constructs of symptom-associated discomfort and symptom frequency to achieve more accurate assessment.

OBJECTIVES: To examine whether simple cognitive tests, when applied to cognitively intact older persons, are useful predictors of cognitive impairment 7 years later. DESIGN: Cohort study. SETTING: Durham, North Carolina; East Boston, Massachusetts; and New Haven, Connecticut, areas that are part of the National Institute on Aging Established Populations for Epidemiological Studies of the Elderly. PARTICIPANTS: Participants, aged 70 to 79, from three community-based studies, who were in the top third of this age group, based on physical and cognitive functional status. MEASUREMENTS: New onset of cognitive impairment as defined by a score of less than 7 on the Short Portable Mental Status Questionnaire (SPMSQ) in 1995. RESULTS: At 7 years, 21.8% (149 of 684 subjects) scored lower than 7 on the SPMSQ. Using multivariate logistic regression, three baseline (1988) cognitive tests predicted impairment in 1995. These included two simple tests of delayed recall-the ability to remember up to six items from a short story and up to 18 words from recall of Boston Naming Test items. For each story item missed, the adjusted odds ratio (AOR) for cognitive impairment was 1.44 (95% confidence interval (CI) = 1.16-1.78, P <.001). For each missed item from the word list, the AOR was 1.20 (95% CI = 1.09-1.31, P <.001). The Delayed Recognition Span, which assesses nonverbal memory, also predicted cognitive impairment, albeit less strongly (odds ratio = 1.06 per each missed answer, 95% CI = 1.003-1.13, P =.04). CONCLUSIONS: This study identifies measures of delayed recall and recognition as significant early predictors of subsequent cognitive decline in high-functioning older persons. Future efforts to identify those at greatest risk of cognitive impairment may benefit by including these measures.