Dementia care and the role of guideline adherence in primary care: cross-sectional findings from the DemTab study

Background: General practitioners (GPs) play a key role in the care of people with dementia (PwD). However, the role of the German Dementia Guideline in primary care remains unclear. The main objective of the present study was to examine the role of guideline-based dementia care in general practices. Methods: A cross-sectional analysis of data obtained from the DemTab study was conducted. Descriptive analyses of sociodemographic and clinical characteristics for GPs (N = 28) and PwD (N = 91) were conducted. Adherence to the German Dementia Guideline of GPs was measured at the level of PwD. Linear Mixed Models were used to analyze the associations between adherence to the German Dementia Guideline and GP factors at individual (age, years of experience as a GP, frequency of utilization of guideline, perceived usefulness of guideline) and structural (type of practice, total number of patients seen by a participating GP, and total number of PwD seen by a participating GP) levels as well as between adherence to the German Dementia Guideline and PwD's quality of life. Results: Self-reported overall adherence of GPs was on average 71% (SD = 19.4, range: 25-100). Adherence to specific recommendations varied widely (from 19.2 to 95.3%) and the majority of GPs (79.1%) reported the guideline as only partially or somewhat helpful. Further, we found lower adherence to be significantly associated with higher numbers of patients (gamma 10 = - 5.58, CI = - 10.97, - 0.19, p = .04). No association between adherence to the guideline and PwD's quality of life was found (gamma 10 = -.86, CI = - 4.18, 2.47, p = .61). Conclusion: The present study examined the role of adherence to the German Dementia Guideline recommendations in primary care. Overall, GPs reported high levels of adherence. However, major differences across guideline recommendations were found. Findings highlight the importance of guidelines for the provision of care. Dementia guidelines for GPs need to be better tailored and addressed. Further, structural changes such as more time for PwD may contribute to a sustainable change of dementia care in primary care

Outpatient psychotherapy for home-living vulnerable older adults with depression: study protocol of the PSY-CARE trial

Background: There is a need to improve psychotherapeutic approaches to treatment for vulnerable older adults with depression in terms of both clinical practice and health care supply. Against this background, PSY-CARE is testing the feasibility and effectiveness of outpatient psychotherapy for home-living older adults in need of care with depression in Berlin, Germany, and neighboring suburban areas. Methods: In a two-arm single-center pragmatic randomized controlled trial (RCT), manual-guided outpatient psychotherapy will be compared to brief psychosocial counseling. The study population will be compromised of older adults with clinically significant depressive symptoms who have a long-term care grade, as assessed by the German compulsory state nursing care insurance. In the intervention group, individual cognitive-behavioral psychotherapy tailored to the specific needs of this population will be offered by residential psychotherapists as part of the regular healthcare service. In the active control group, participants will receive individual psychosocial telephone counselling and a self-help guide. The planned sample size is N = 130 (n = 65 participants per group). The reduction of depressive symptoms (primary outcome) as well as the maintaining of activities of daily living, quality of life, and functioning will be assessed with questionnaires provided at baseline, after the end of the intervention and after three months. Feasibility and process evaluation will be conducted qualitatively based on documentation and interviews with psychotherapists, gatekeepers and the participants. Discussion: PSY-CARE investigates the potentials and limitations of providing outpatient psychotherapeutic treatment meeting the demands of vulnerable home-living older adults with depression under the real conditions of the health care system. The study will provide practical implications to improve access to and quality of outpatient psychotherapy for this poorly supplied population. Trial registration: The trial is registered at ISRCTN55646265; February 15, 2019

Recruiting general practitioners and patients with dementia into a cluster randomised controlled trial: strategies, barriers and facilitators

Background: Recruitment of general practitioners (GPs) and their patients is reported as one of the most challenging steps when undertaking primary care research. The present paper describes the recruitment process of a cluster randomised controlled trial (cRCT) aiming to improve dementia care in the primary care setting. Methods: Recruitment data was analysed descriptively using frequency tables to investigate comparisons of recruitment rates and results of different recruitment strategies as well as reasons for participation and non-participation of GPs, patients with dementia (PwD) and their caregivers. Results: Over a period of 23 months, N = 28 GPs were successfully included in the cRCT. This represents an overall recruitment rate of 4.6%. The most efficient strategy in terms of high response and low labour-intensity involved the dissemination of calls for participation in a GP research network. Most frequently reported reasons for GP's participation were Improvement of patient's well-being (n = 22, 79%) followed by Interest in dementia research (n = 18, 64%). The most common reasons for non-participation were Lack of time (n = 71, 34%) followed by Not interested in participation (n = 63, 30%). On a patient level, N = 102 PwD were successfully recruited. On average, each GP referred about n = 7 PwD (range: 1-17; mdn = 6; IQR = 3.5) and successfully recruited about n = 4 PwD (range: 1-11; mdn = 3; IQR = 3.5). Conclusion: First, our findings propose GP research networks as a promising strategy to promote recruitment and participation of GPs and their patients in research. Second, present findings highlight the importance of including GPs and their interests in specific research topics in early stages of research in order to ensure a successful recruitment. Finally, results do not support cold calls as a successful strategy in the recruitment of GPs

Quality of life in people with dementia living in nursing homes: validation of an eight-item version of the QUALIDEM for intensive longitudinal assessment

Purpose: Our aim was to examine whether quality of life which was repeatedly assessed over time is related with the comprehensive assessment of quality of life (QoL) and thereby to validate a brief QoL assessment. Method: This longitudinal study used a comprehensive assessment of quality of life at baseline (QUALIDEM; 37 items) to validate an eight-item version of QUALIDEM to assess momentary quality of life which was repeatedly administered using a tablet device after baseline. In all, 150 people with dementia from 10 long-term facilities participated. Momentary quality of life and comprehensive quality of life, age, gender, activities of daily living (Barthel Index), Functional assessment staging (FAST), and Geriatric Depression (GDS) have been assessed. Results: Comprehensive and momentary quality of life showed good internal consistency with Cronbach’s alpha of .86 and .88 to .93, respectively. For multiple associations of momentary quality of life with the comprehensive quality of life, momentary quality of life was significantly related to comprehensive quality of life (B = .14, CI .08/.20) and GDS (B = − .13, CI − .19/− .06). More specifically, the comprehensive QUALIDEM subscales ‘positive affect’, ‘negative affect’, ‘restlessness’, and ‘social relationships’ showed significant positive associations with momentary quality of life (p < .001). Conclusion: We found that momentary quality of life, reliably assessed by tablet, was associated with comprehensive measures of quality of life and depressive symptoms in people with dementia. Broader use of tablet-based assessments within frequent QoL measurements may enhance time management of nursing staff and may improve the care quality and communication between staff and people with dementia

Concordance of self- and informant-rated depressive symptoms in nursing home residents with Dementia: cross-sectional findings

Background: Depression is highly prevalent in nursing home residents living with moderate to severe dementia. However, assessing depressive symptoms in residents with dementia can be challenging and may vary by rater perspective. We aimed to investigate the concordance of, and factors associated with self- and informant-rated depressive symptoms in nursing home residents with dementia. Methods: Cross-sectional data was collected from N= 162 nursing home residents with dementia (age: 53-100; 74% women). Self-ratings were assessed with the Geriatric Depression Scale, while the depression and anxiety items of the Neuropsychiatric Inventory were used for informant-ratings. Cohen's Kappa was calculated to determine the concordance of both measures and of each with antidepressant medication. Multivariate associations with sociodemographic variables, self- and informant-rated quality of life, dementia stage, neuropsychiatric symptoms, functional status and antidepressant medication were analysed with linear mixed models and generalized estimating equations. Results: Concordance between self- and single item informant-rated depressive symptoms was minimal (Cohen's Kappa = .22, p= .02). No concordance was found for self-reported depressive symptoms and the combined informant-rated depression-anxiety score. Self-reported depression was negatively associated with self-rated quality of life (beta=-.32; 95%CI: -.45 to -.19, p< .001), informant-rated quality of life (beta=-.25; 95%CI: -.43 to -.07, p= .005) and functional status (beta=-.16; 95%CI: -.32 to -.01, p= .04), whilst single item informant-rated depression revealed negative associations with informant-rated quality of life (beta =-.32; 95%CI: -.52 to .13, p=.001) and dementia stage (beta=-.31; 95%CI: -.52 to -.10, p = .004). The combined informant-rated depression-anxiety score showed negative associations with self-rated quality of life (beta=-.12; 95%CI: -.22 to -.03, p = .01) and dementia stage (beta = -.37; 95%CI: -.67 to -.07, p= .02) and a positive association with neuropsychiatric symptoms (beta = .30; 95%CI: .10 to .51, p= .004). No concordance was found with antidepressant medication. Conclusions: In line with our expectations, low agreement and unique association patterns were found for both measures. These findings indicate that both instruments address different aspects of depression and underline the need for comprehensive approaches when it comes to detecting signs of clinically relevant depressive symptoms in dementia

a secondary data analysis based on health insurance routine data

Demenzen stehen unter den psychiatrischen Erkrankungen des Alters an erster Stelle. Sie führen meist in kurzer Zeit zu starken Einschränkungen in Kognition und Alltagskompetenzen und damit zu einem steigenden Versorgungsbedarf. Vor dem Hintergrund der demographischen Entwicklung in Deutschland erscheint es umso dringlicher, die gesundheitliche Versorgung dementer Menschen transparent zu machen und ihre Übereinstimmung mit evidenzbasierten Leitlinien zu überprüfen. Die Dissertation befasst sich mit der gesundheitlichen Versorgung der Demenz und greift dabei auf Krankenkassenroutinedaten einer norddeutschen BKK zurück. Darüber hinaus werden die Leitlinienkonformität der Demenz-Versorgung und Kosten der Versorgung untersucht. Zur Identifizierung demenziell Erkrankter wurden drei Kriterien herangezogen: Antidementiva-Verordnungen, Krankenhaus- und Pflegediagnosen. So ließ sich aus den Routinedaten der Jahre 2000 bis 2002 von rund 73.000 über 60-jährigen gesetzlich Krankenversicherten eine Gruppe von 4.495 Dementen ermitteln. Diese umfasst somit rund 6 % aller älteren Versicherten der untersuchten Krankenkasse und unterscheidet sich in weiteren wesentlichen Charakteristika (höheres Durchschnittsalter, höhere Mortalität, höherer Frauenanteil) von den nicht dementen Älteren. Die meisten Versicherten mit Demenz erhalten zur Pharmakotherapie ihrer Erkrankung Ginkgo-Präparate. AChE-Hemmer bzw. Memantin machen nur 11 % aller Antidementiva-Verordnungen aus. Der überwiegende Teil erhält nur ein bis zwei Verordnungen pro Jahr, was auf mangelnde Kontinuität der pharmakologischen Versorgung schließen lässt. Jeder Zehnte Demente wird mindestens einmal im Untersuchungsverlauf auch antidepressiv behandelt. Weit mehr demenziell erkrankte Versicherte als nicht- demente Versicherte erhalten Antipsychotika. Mehr als einem Viertel aller Dementen werden Benzodiazepine verordnet. Besonders häufig erhalten pflegebedürftige Demente psycholeptische Wirkstoffe. Unter dementen Versicherten ist zu Beginn der Untersuchung der Anteil an Pflegefällen doppelt so hoch wie bei anderen Älteren. Die Inanspruchnahme von Pflegeleistungen verdoppelt sich in der Untersuchungsgruppe innerhalb von drei Jahren. Auch weitere Leistungen (Heil-, Hilfs-, Pflegehilfsmittel) werden durch demenziell Erkrankte häufiger in Anspruch genommen, die darüber hinaus etwas mehr Krankenhausaufenthalte im dreijährigen Untersuchungszeitraum aufweisen als Nicht-Demente. Die Gesamtausgaben für die gesundheitliche Versorgung demenziell Erkrankter liegen mit rund 10.000 Euro pro Kopf 1,5-mal höher als bei Älteren ohne Demenz. Ebenso weisen Demente eine weit stärker ausgeprägte Kostenentwicklung auf. Die verwendete Datengrundlage eignet sich für versorgungsepidemiologische Aussagen zu Prävalenz und Inzidenz der Demenz von hochkonservativem Charakter, da nur die tatsächlich im Gesundheitsversorgungssystem diagnostizierten bzw. behandelten Personen identifiziert wurden. Weiterhin geben die Routinedaten ausreichend Auskunft über die gesundheitliche Versorgungslage dementer Menschen, um in ausgewählten Leistungsbereichen eine leitliniennonkonforme bzw. eine Unter- und Fehlversorgung aufzuzeigen. Die seit einigen Jahren mögliche Verknüpfung von Krankenkassenroutinedaten mit Informationen zur ambulanten Versorgung durch niedergelassene Ärzte ermöglicht in der Zukunft den Ausbau der hier begonnenen Forschung.Dementias are the most common psychiatric diseases in old age. Within a short period of time they lead into severe cognitive impairment, a loss in competences of daily living and therefore to a growing need of health care. Given the demographic development in Germany it has to be considered as essential to clarify health care provided to dementia patients and verify its accordance with dementia guidelines. This study examines the health care provision for people with dementia, based on routine data of a big German health insurance company. Furthermore, the provided care has been compared to applicable therapy guidelines. Three criteria have been used to identify demented people from a cohort of 74,000 insurants aged 60 years and older: 1) Antidementive medication, 2) Dementia diagnosis during a hospital stay, 3) Dementia diagnosis for care services allocation. 4,495 insurants with dementia have been identified via these criteria, which results in a dementia prevalence of 6.1% in the sample. Differences to elderly people without dementia are: higher mean age, higher rate of female insurants, higher mortality. The pharmacotherapy for most of the dementia patients consists in ginkgo biloba compounds. Only 11% of all prescriptions are composed by AChE inhibitors and Memantin. A high percentage of insurants with dementia had only one or two antidementive prescriptions in the three year period examined. Every tenth dementia patient received antidepressive medication during the study period. Antipsychotics were prescribed much more often to insurants with dementia compared to other insurants. Nursing home residents with dementia received the highest amount of psycholeptic substances in the study. Compared to elder people without dementia, nearly twice the number of demented insurants was in need of care. Health care utilization in other sectors, e.g. clinical services, remedies and aids, is also higher in the dementia study group. Study participants with dementia generate total health care costs 1.5 as much as elderly without dementia. In addition, costs for the dementia group increased within 3 years. The data base used in this study allows highly conservative prevalence conclusions. Health insurance routine data can be used to analyse provided health care in a differentiated way and indicates inappropriate or under-supply. The results of this study could be used to brief family practitioners about evidenced-based treatment and potentially inappropriate psychotropic medication of dementia

Testing the stress-buffering hypothesis of social support in couples coping with early-stage dementia.

To test whether the negative relationship between perceived stress and quality of life (Hypothesis 1) can be buffered by perceived social support in patients with dementia as well as in caregivers individually (Hypothesis 2: actor effects) and across partners (Hypothesis 3: partner effects and actor-partner effects).A total of 108 couples (N = 216 individuals) comprised of one individual with early-stage dementia and one caregiving partner were assessed at baseline and one month apart. Moderation effects were investigated by applying linear mixed models and actor-partner interdependence models.Although the stress-quality of life association was more pronounced in caregivers (β = -.63, p<.001) compared to patients (β = -.31, p<.001), this association was equally moderated by social support in patients (β = .14, p<.05) and in the caregivers (β = .13, p<.05). From one partner to his or her counterpart, the partner buffering and actor-partner-buffering effect were not present.The stress-buffering effect has been replicated in individuals with dementia and caregivers but not across partners. Interventions to improve quality of life through perceived social support should not only focus on caregivers, but should incorporate both partners

Actor-partner interdependence model (APIM) of perceived distress-social support interaction (buffering effect) regressed on health-related quality of life.

<p>Actor-partner interdependence model (APIM) of perceived distress-social support interaction (buffering effect) regressed on health-related quality of life.</p