A Systematic Review of Interventions to Improve the Communication of Advanced Directives and Medication Administration Records for Elderly Patients Transferring Between Nursing Homes and Acute Care Hospitals

Objectives: To conduct a systematic review of the literature to identify interventions that can improve the communication of advanced care directives and accurate and appropriate medication lists for elderly patients transferring between nursing homes and acute care hospitals. Methods: The MEDLINE, ISI, and EBSCO Host databases were searched from inception to February 17, 2008 for appropriate articles. All abstracts identified by a prespecified strategy were reviewed. Studies met inclusion criteria if their design was of a randomized control trial, pre/post observational trial, or post-intervention observational study. Data regarding each study were abstracted from the manuscript by the reviewer to a standardized collection instrument and details regarding type of study, study population, intervention, and results were recorded in evidence tables. Results: Six hundred ninety-six titles were identified by the pre-specified search strategies. Eighteen articles were submitted for full review. Thirteen articles did not meet inclusion/exclusion criteria and five articles were determined to describe interventions that resulted in the enhanced transition of appropriate medication lists or advanced directives between skilled nursing facilities and acute care hospital settings, whether to the emergency department or inpatient units. Of these articles, two articles described interventions that resulted in the enhanced transmission of advanced directives, two articles described interventions that resulted in the better transmission of medication lists, and one article described an intervention that accomplished both of these goals. Conclusions: The accurate communication of key patient information is integral to providing high quality health care to elderly, skilled nursing facility patients transferring to and from acute care hospitals. A standardized patient transfer document may assist with the successful communication of advanced care directives and medication lists, while a pharmacist-developed review of medication lists may help identify omitted or indicated medications on patient transfer. Randomized controlled trials with large number of patients in varied health care systems may be needed to determine the ideal design and medium for a patient transfer document. Further work will be needed to coordinate research efforts and adopt standardized definitions of high quality transitional care.Master of Public Healt

Ongoing Medical Management to Maximize Health and Well-being for Persons Living With Dementia

Background and Objectives: Persons living with dementia have complex care needs including memory loss that should be taken into account by providers and family caregivers involved with their care. The prevalence of comorbid conditions in people with dementia is high and, thus, how primary care, community providers and family caregivers provide best practice care, person-centered care is important. Research Design and Methods: Care providers should understand the ongoing medical management needs of persons living with dementia in order to maximize their quality of life, proactively plan for their anticipated needs, and be as well prepared as possible for health crises that may occur. Results: This article provides eight practice recommendations intended to promote understanding and support of the role of nonphysician care providers in educating family caregivers about ongoing medical management to improve the wellbeing of persons living with dementia. Discussion and Implications: Key among these are recommendations to use nonpharmacological interventions to manage behavioral and psychological symptoms of dementia as the first line of treatment and recommendations on how to best support the use and discontinuation of pharmacological interventions as necessary

Acceptability and Results of Dementia Screening Among Older Adults in the United States

OBJECTIVES: To measure older adults acceptability of dementia screening and assess screening test results of a racially diverse sample of older primary care patients in the United States. DESIGN: Cross-sectional study of primary care patients aged 65 and older. SETTING: Urban and suburban primary care clinics in Indianapolis, Indiana, in 2008 to 2009. PARTICIPANTS: Nine hundred fifty-four primary care patients without a documented diagnosis of dementia. MEASUREMENTS: Community Screening Instrument for Dementia, the Mini-Mental State Examination, and the Telephone Instrument for Cognitive Screening. RESULTS: Of the 954 study participants who consented to participate, 748 agreed to be screened for dementia and 206 refused screening. The overall response rate was 78.4%. The positive screen rate of the sample who agreed to screening was 10.2%. After adjusting for demographic differences the following characteristics were still associated with increased likelihood of screening positive for dementia: age, male sex, and lower education. Patients who believed that they had more memory problems than other people of their age were also more likely to screen positive for dementia. CONCLUSION: Age and perceived problems with memory are associated with screening positive for dementia in primary care

Interaction between cognitive impairment and discharge destination and its effect on rehospitalization

OBJECTIVES: To evaluate the effect of cognitive impairment on rehospitalization in older adults. DESIGN: One-year longitudinal study. SETTING: Medical service of an urban, 340-bed public hospital in Indianapolis between July 2006 and March 2008. PARTICIPANTS: Individuals aged 65 and older admitted to the medical service (N = 976). MEASUREMENTS: Rehospitalization was defined as any hospital admission after the index admission. Participant demographics, discharge destination, Charlson Comorbidity Index, Acute Physiology Score, and prior hospitalizations were measured as the confounders. Participants were considered to have cognitive impairment if they had two or more errors on the Short Portable Mental Status Questionnaire. RESULTS: After adjusting for confounders, a significant interaction between cognitive impairment and discharge location was found to predict rehospitalization rate (P = .008) and time to 1-year rehospitalization (P = .03). Participants with cognitive impairment discharged to a facility had a longer time to rehospitalization (median 142 days) than participants with no cognitive impairment (median 98 days) (hazard ratio (HR) = 0.77, 95% confidence interval (CI) = 0.58-1.02, P = .07), whereas participants with cognitive impairment discharged to home had a slightly shorter time to rehospitalization (median 182 days) than those without cognitive impairment (median 224 days) (HR = 1.15, 95% CI = 0.92-1.43, P = .23). These two nonsignificant HRs in opposite directions were significantly different from each other (P = .03). CONCLUSION: Discharge destination modifies the association between cognitive impairment and rehospitalization. Of participants discharged to a facility, those without cognitive impairment had higher rehospitalization rates, whereas the rates were similar between cognitively impaired and intact participants discharged to the community

Risk factors for the progression of mild cognitive impairment to dementia

The increasing prevalence of cognitive impairment among the older adult population warrants attention to the identification of practices that may minimize the progression of early forms of cognitive impairment, including the transitional stage of mild cognitive impairment (MCI), to permanent stages of dementia. This article identifies both markers of disease progress and risk factors linked to the progression of MCI to dementia. Potentially modifiable risk factors may offer researchers a point of intervention to modify the effect of the risk factor and to minimize the future burden of dementia

Workforce development to provide person-centered care

OBJECTIVES: Describe the development of a competent workforce committed to providing patient-centered care to persons with dementia and/or depression and their caregivers; to report on qualitative analyses of our workforce's case reports about their experiences; and to present lessons learned about developing and implementing a collaborative care community-based model using our new workforce that we call care coordinator assistants (CCAs). METHOD: Sixteen CCAs were recruited and trained in person-centered care, use of mobile office, electronic medical record system, community resources, and team member support. CCAs wrote case reports quarterly that were analyzed for patient-centered care themes. RESULTS: Qualitative analysis of 73 cases using NVivo software identified six patient-centered care themes: (1) patient familiarity/understanding; (2) patient interest/engagement encouraged; (3) flexibility and continuity of care; (4) caregiver support/engagement; (5) effective utilization/integration of training; and (6) teamwork. Most frequently reported themes were patient familiarity - 91.8% of case reports included reference to patient familiarity, 67.1% included references to teamwork and 61.6% of case reports included the theme flexibility/continuity of care. CCAs made a mean number of 15.7 (SD = 15.6) visits, with most visits for coordination of care services, followed by home visits and phone visits to over 1200 patients in 12 months. DISCUSSION: Person-centered care can be effectively implemented by well-trained CCAs in the community

Emergency Department Use Among Older Adults With Dementia

Although persons with dementia are frequently hospitalized, relatively little is known about the health profile, patterns of health care use, and mortality rates for patients with dementia who access care in the emergency department (ED). We linked data from our hospital system with Medicare and Medicaid claims, Minimum Data Set, and Outcome and Assessment Information Set data to evaluate 175,652 ED visits made by 10,354 individuals with dementia and 15,020 individuals without dementia over 11 years. Survival rates after ED visits and associated charges were examined. Patients with dementia visited the ED more frequently, were hospitalized more often than patients without dementia, and had an increased odds of returning to the ED within 30 days of an index ED visit compared with persons who never had a dementia diagnosis (odds ratio, 2.29; P<0.001). Survival rates differed significantly between patients by dementia status (P<0.001). Mean Medicare payments for ED services were significantly higher among patients with dementia. These results show that older adults with dementia are frequent ED visitors who have greater comorbidity, incur higher charges, are admitted to hospitals at higher rates, return to EDs at higher rates, and have higher mortality after an ED visit than patients without dementia

Patterns of Emergency Department Use Among Long-Stay Nursing Home Residents With Differing Levels of Dementia Severity

OBJECTIVES: To describe emergency department (ED) utilization among long-stay nursing home residents with different levels of dementia severity. DESIGN: Retrospective cohort study. SETTING: Public Health System. PARTICIPANTS: A total of 4491 older adults (age 65 years and older) who were long-stay nursing home residents. MEASUREMENTS: Patient demographics, dementia severity, comorbidities, ED visits, ED disposition decisions, and discharge diagnoses. RESULTS: Forty-seven percent of all long-stay nursing home residents experienced at least 1 transfer to the ED over the course of a year. At their first ED transfer, 36.4% of the participants were admitted to the hospital, whereas 63.1% of those who visited the ED were not. The median time to first ED visit for the participants with advanced stage dementia was 258 days, whereas it was 250 days for the participants with early to moderate stage dementia and 202 days for the participants with no dementia (P = .0034). Multivariate proportional hazard modeling showed that age, race, number of comorbidities, number of hospitalizations in the year prior, and do not resuscitate status all significantly influenced participants' time to first ED visit (P < .05 for all). After accounting for these effects, dementia severity (P = .66), years in nursing home before qualification (P = .46), and gender (P = .36) lost their significance. CONCLUSIONS: This study confirms high rates of transfer of long-stay nursing home residents, with nearly one-half of the participants experiencing at least 1 ED visit over the course of a year. Although dementia severity is not a predictor of time to ED use in our analyses, other factors that influence ED use are readily identifiable. Nursing home providers should be aware of these factors when developing strategies that meet patient care goals and avoid transfer from the nursing home to the ED

Transitions in Care in a Nationally Representative Sample of Older Americans with Dementia

OBJECTIVES: To describe transitions in care for older adults with dementia identified from a nationally representative cohort and to describe transition rates in those with more-severe levels of cognitive and functional impairment. DESIGN: Longitudinal cohort study. SETTING: Health and Retirement Study (HRS). PARTICIPANTS: HRS respondents aged 65 and older whose survey data were linked with Medicare claims from 1999 to 2008 (N = 16,186). MEASUREMENTS: Transitions in care between home, home with formal services, hospital, and nursing facility care; cognitive function; activities of daily living; and mortality. RESULTS: The 3,447 (21.3%) HRS subjects who were ever diagnosed with dementia experienced frequent transitions. Of subjects transitioning from a hospital stay, 52.2% returned home without home care services, and 33.8% transitioned to a nursing facility. Of subjects transitioning from a nursing facility, 59.2% transitioned to the hospital, and 25.3% returned home without services. There were 2,139 transitions to death, and 58.7% of HRS subjects with dementia died at home. Even in persons with moderate to severe dementia, multiple transitions in care were documented, including transitions from the hospital to home and back to the hospital. CONCLUSION: In this nationally representative sample of older adults, subjects diagnosed with dementia experience frequent transitions. Persons with dementia who are cared for at home and who transition back to home often have moderate to severe impairments in function and cognition

Redesigning Systems of Care for Older Adults with Alzheimer' Disease

Best-practice models of dementia care have evolved from strategies focused on family caregivers to guidelines predicated on supporting the patient-caregiver dyad along the care continuum. These models have grown in complexity to encompass medical and team-based care that is designed to coordinate dementia care across settings and providers for a defined population of patients. Although there is evidence that the models can improve outcomes, they have not been widely adopted. Barriers to the models' increased adoption include workforce limitations, the cost of necessary practice redesign, and limited evidence of their potential cost-effectiveness. We summarize the origins, evidence base, and common components of best-practice models of dementia care, and we discuss barriers to their implementation. We conclude by describing two current efforts to implement such models on a broad scale, supported by the Center for Medicare and Medicaid Innovation. Taken together, these models seek to demonstrate improved dementia care quality and outcomes, accompanied by cost savings, in both community-based and institutional care settings