Specific Cognitive/Behavioral Domains Predict Neuropsychiatric Symptoms in Severe Dementia

Background: Neuropsychiatric symptoms (NPS) have high prevalence in Alzheimer’s disease and related disorders (ADRD), with nearly 100% of individuals experiencing some type of symptom over the course of dementia (Tschanz et al, 2011). The occurrence of NPS is highly variable and fluctuates in severity (Tschanz et al., 2016). Their occurrence differs by type of dementia and increases over time (Kazui et al., 2016). Although risk factors for NPS in ADRD have been studied (e.g., Steinberg et al., 2014; Treiber et al, 2008), greater understanding of the nature of NPS and their triggers is needed to inform care management strategies (Gauthier et al., 2010). While much research has examined NPS in mild-to-moderate dementia, fewer studies have examined NPS in severe dementia. We investigated the cognitive correlates of NPS in patients with severe dementia in a community-based sample, examining whether impairments in specific cognitive or behavioral domains were more predictive of specific NPS. We hypothesized that poorer cognitive abilities would be associated with more severe NPS (e.g., agitation) and higher cognitive scores with affective symptoms in severe dementia. Methods: Eighty-nine (27%) out of 328 total participants of a longitudinal study of dementia progression (the Cache County Dementia Progression Study) met criteria for severe dementia: Mini-Mental State Exam (MMSE) score of ≤10 or Clinical Dementia Rating of 3 (severe). Forty-eight (54%) of these individuals completed the Severe Cognitive Impairment Profile (SCIP), which assessed the following domains: Comportment, Attention, Language, Memory, Motor, Conceptualization, Arithmetic, and Visuospatial abilities. NPS were assessed by caregiver report using the Neuropsychiatric Inventory (NPI). The NPI assesses delusions, hallucinations, depression, anxiety, irritability, apathy, agitation/aggression, judgement, aberrant motor behaviors, euphoria, sleep and appetite. Demographic information, overall health, place of residence (private home, assisted living facility and nursing home), and dementia duration were also assessed. NPI severity scores (intensity x frequency) were summed across domains to yield a total NPI score (Total NPI-12) and domain clusters of psychotic symptoms (hallucinations and delusions), affective symptoms (depression, anxiety, and irritability), apathy, and agitation/aggression were examined. Bivariate correlations between SCIP domain scores and Total NPI-12 and the domain clusters were examined. SCIP domain scores that were significantly correlated with NPI scores in bivariate analyses were entered into multiple regression models. Covariates tested included the age at which severe dementia criteria was met, the duration of dementia from age of onset, gender, place of residence, overall health and years of education. Results: Mean (SD) age and education were 86.23 (6.12) and 13.13 (3.13), respectively. Total NPI-12 scores showed significant correlations with the SCIP sub scores of comportment ( r = -0.36, p = 0.017) and memory (r = - 0.31, p = 0.047). Apathy significantly correlated with comportment (r = -0.38, p = 0.010) while agitation/aggression correlated with conceptualization (r = -0.41, p = 0.007), language (r = -0.36, p = 0.017), memory (r = -0.48, p = 0.001), and visuospatial ability (r = -0.31, p = 0.045). In multiple regression models (with inclusion of significant covariates), total NPI-12 scores were significantly associated with comportment (β = -1.32, SE = 0.56, p = 0.02); apathy was significantly associated with comportment (β = -0.01, SE = 0.02, p = 0.003); and agitation/aggression was significantly associated with memory (β = -0.43, SE = 0.12, p = 0.001). NPI affective and psychotic scores were not associated with any SCIP domains. Conclusion: In this sample of individuals with severe dementia, we found several cognitive or behavioral domains were associated with NPS. Poorer abilities in Comportment, which consisted of responses to social questions (e.g., greetings) were associated with more severe apathy, and poorer abilities in conceptualization, language, memory and visuospatial skills were associated with more severe agitation/aggression. With the latter, multiple regression models found only memory scores to independently predict agitation/aggression, reflecting moderate correlation between cognitive domains. Our results suggest that poor cognitive abilities may increase vulnerability to NPS, possibly as a result of impaired comprehension of activities and events in the environment. Cognitive testing may be useful to identify those at greatest risk for NPS. Furthermore, environmental manipulations that aim to decrease the complexity and therefore degree of stimulation for persons with dementia to a level more appropriate to their level of cognitive function may help reduce the occurrence of NPS in severe dementia

A framework for scaling up health interventions: lessons from large-scale improvement initiatives in Africa

BACKGROUND: Scaling up complex health interventions to large populations is not a straightforward task. Without intentional, guided efforts to scale up, it can take many years for a new evidence-based intervention to be broadly implemented. For the past decade, researchers and implementers have developed models of scale-up that move beyond earlier paradigms that assumed ideas and practices would successfully spread through a combination of publication, policy, training, and example. Drawing from the previously reported frameworks for scaling up health interventions and our experience in the USA and abroad, we describe a framework for taking health interventions to full scale, and we use two large-scale improvement initiatives in Africa to illustrate the framework in action. We first identified other scale-up approaches for comparison and analysis of common constructs by searching for systematic reviews of scale-up in health care, reviewing those bibliographies, speaking with experts, and reviewing common research databases (PubMed, Google Scholar) for papers in English from peer-reviewed and “gray” sources that discussed models, frameworks, or theories for scale-up from 2000 to 2014. We then analyzed the results of this external review in the context of the models and frameworks developed over the past 20 years by Associates in Process Improvement (API) and the Institute for Healthcare improvement (IHI). Finally, we reflected on two national-scale improvement initiatives that IHI had undertaken in Ghana and South Africa that were testing grounds for early iterations of the framework presented in this paper. RESULTS: The framework describes three core components: a sequence of activities that are required to get a program of work to full scale, the mechanisms that are required to facilitate the adoption of interventions, and the underlying factors and support systems required for successful scale-up. The four steps in the sequence include (1) Set-up, which prepares the ground for introduction and testing of the intervention that will be taken to full scale; (2) Develop the Scalable Unit, which is an early testing phase; (3) Test of Scale-up, which then tests the intervention in a variety of settings that are likely to represent different contexts that will be encountered at full scale; and (4) Go to Full Scale, which unfolds rapidly to enable a larger number of sites or divisions to adopt and/or replicate the intervention. CONCLUSIONS: Our framework echoes, amplifies, and systematizes the three dominant themes that occur to varying extents in a number of existing scale-up frameworks. We call out the crucial importance of defining a scalable unit of organization. If a scalable unit can be defined, and successful results achieved by implementing an intervention in this unit without major addition of resources, it is more likely that the intervention can be fully and rapidly scaled. When tying this framework to quality improvement (QI) methods, we describe a range of methodological options that can be applied to each of the four steps in the framework’s sequence