Karikoita dementoituvien henkilöiden hoidossa

Pitfalls in the treatment of persons with dementia Persons with dementia require high-quality health care, rehabilitation and sufficient social services to support their autonomy and to postpone permanent institutionalization. This study sought to investigate possible pitfalls in the care of patients with dementia: hip fracture rehabilitation, use of inappropriate or antipsychotic medication, social and medicolegal services offered to dementia caregiving families. Three different Finnish samples were used from years 1999-2005, mean age 78 to 86 years. After hip fracture operation, the weight-bearing restriction especially in group of patients with dementia, was associated with a longer rehabilitation period (73.5 days vs. 45.5 days, p=0.03) and the inability to learn to walk after six weeks (p<0.001). Almost half (44%) of the pre-surgery home-dwellers with dementia in our sample required permanent hospitalization after hip fracture. Potentially inappropriate medication was used among 36.2% of nursing home and hospital patients. The most common PIDs in Finland were temazepam over 15 mg/day, oxybutynin, and dipyridamole. However, PID use failed to predict mortality or the use of health services. Nearly half (48.4%) of the nursing home and hospital patients with dementia used antipsychotic medication. The two-year mortality did not differ among the users of conventional or atypical antipsychotics or the non-users (45.3% vs.32.1% vs.49.6%, p=0.195). The mean number of hospital admissions was highest among non-users (p=0.029). A high number of medications (HR 1.12, p<0.001) and the use of physical restraints (HR 1.72, p=0.034) predicted higher mortality at two years, while the use of atypical antipsychotics (HR 0.49, p=0.047) showed a protective effect, if any. The services most often offered to caregiving families of persons with Alzheimer s disease (AD) included financial support from the community (36%), technical devices (33%), physiotherapy (32%), and respite care in nursing homes (31%). Those services most often needed included physiotherapy for the spouse with dementia (56%), financial support (50%), house cleaning (41%), and home respite (40%). Only a third of the caregivers were satisfied with these services, and 69% felt unable to influence the range of services offered. The use of legal guardians was quite rare (only 4.3%), while the use of financial powers of attorney was 37.8%. Almost half (47.9%) of the couples expressed an unmet need for discussion with their doctor about medico-legal issues, while only 9.9% stated that their doctor had informed them of such matters. Although we already have many practical methods to develop the medical and social care of persons with AD, these patients and their families require better planning and tailoring of such services. In this way, society could offer these elderly persons better quality of life while economizing on its financial resources. This study was supported by Social Insurance Institution of Finland and part of it made in cooperation with the The Central Union of the Welfare for the Aged, Finland.Dementoituvien henkilöiden hoitoa ja palveluja on mahdollista parantaa monin käytännöllisin keinoin Dementiaa sairastavat henkilöt tarvitsevat erityisen haavoittuvuutensa vuoksi asianmukaista terveydenhoitoa, kuntoutusta ja riittäviä sosiaalisia palveluja, jotta heidän autonomiaansa voidaan tukea ja laitoshoidon tarvetta myöhentää. Tässä väitöstyössä kartoitettiin mahdollisia karikoita dementiaa sairastavien henkilöiden hoidossa: lonkkamurtuman jälkeistä kuntoutumista, sopimattomia lääkkeitä, psykoosilääkkeitä ja sosiaalisia, juridisia ja taloudellisia palveluja. Tutkimuksessa käytettiin kolmea suomalaista potilasaineistoa vuosilta 1999 - 2005. Potilaiden keski-ikä oli 78 - 86 vuotta. Melkein puolet aiemmin kotona asuneista dementiaa sairastavista potilaista joutui pysyvään laitoshoitoon lonkkamurtuman jälkeen. Lonkkamurtumaleikkauksen jälkeinen usein käytetty varausrajoitus eli leikatun jalan käyttämiskielto liittyi erityisesti dementiaa sairastavien pidempään kuntoutusaikaan (73,5 pv vs. 45,5 pv) ja siihen, ettei potilas oppinut itsenäistä kävelyä kuuden viikon aikana. Sopimattomaksi arvioituja lääkkeitä käytti 36.2 % hoitokoti- ja sairaalapotilaista, mutta tämä ei lisännyt kuolleisuutta tai terveyspalveluiden käyttöä. Lähes puolella (48,4 %) dementiaa sairastavista potilaista oli käytössä psykoosilääke. Eroa kahden vuoden kuolleisuudessa ei havaittu, kun verrattiin vanhan ja uuden polven psykoosilääkkeiden käyttäjiä ja niitä, joilla ei ollut psykoosilääkettä käytössä. Sairaalahoitojen määrä oli suurin niillä, jotka eivät käyttäneet mitään psykoosilääkettä. Runsas lääkkeiden määrä (HR 1,12) ja lepositeiden käyttö (HR 1,72) ennustivat lisääntynyttä kuolleisuutta kahden vuoden kuluttua, kun taas uuden polven psykoosilääkkeiden käyttö oli pikemminkin suojaava tekijä tässä aineistossa (HR 0.49). Omaishoitajaperheiden palvelujen tarve ja todellisuus eivät kohtaa tällä hetkellä. Alzheimerin tautia sairastavan omaishoitajille tarjottiin eniten omaishoidontukea (36 %), teknisiä apuvälineitä (33 %), fysioterapiaa lähinnä sotaveteraaneille (32 %) ja lyhytaikaista lomapaikkaa sairastuneelle laitoksessa (31 %). Perheet toivoivat kuitenkin eniten fysioterapiaa Alzheimerin tautia sairastavalle (56 %), omaishoidontukea (50 %), kodin siivousta (41 %) ja kotiin tulevaa hoitajaa pariksi tunniksi kerrallaan (40 %). Vain kolmasosa omaishoitajista oli tyytyväisiä palveluihin, ja 69 prosenttia heistä koki, ettei heillä itsellään ole mahdollisuutta vaikuttaa palvelutarjontaan. Edunvalvonta oli käytössä 4,3 prosentilla, pankkivaltuutus 37,8 prosentilla. Lähes puolet pariskunnista toivoi keskustelua lääkärin kanssa Alzheimerin tautia sairastavan taloudellisten asioiden hoitoon liittyvistä seikoista, mutta tämä oli toteutunut vain 9,9 prosentilla perheistä. Dementiaa sairastavien hoidossa tarvitaan uudenlaista suunnittelua ja palvelujen räätälöintiä omaishoitajaperheiden omien tarpeiden mukaisesti. Tämä voisi paitsi parantaa näiden iäkkäiden ihmisten elämänlaatua, myös tuoda taloudellisia säästöjä yhteiskunnalle. Tutkimus tehtiin Kansaneläkelaitoksen tuella ja osa siitä toteutettiin yhteistyössä Vanhustyön Keskusliiton kanssa

Alzheimer’s Patients’ Spouses Critiques of the Support Services

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Cognitive Performance at Time of AD Diagnosis : A Clinically Augmented Register-Based Study

We aimed to evaluate the feasibility of using real-world register data for identifying persons with mild Alzheimer's disease (AD) and to describe their cognitive performance at the time of diagnosis. Patients diagnosed with AD during 2010-2013 (aged 60-81 years) were identified from the Finnish national health registers and enlarged with a smaller private sector sample (total n = 1,268). Patients with other disorders impacting cognition were excluded. Detailed clinical and cognitive screening data (the Consortium to Establish a Registry for Alzheimer's Disease neuropsychological battery [CERAD-nb]) were obtained from local health records. Adequate cognitive data were available for 389 patients with mild AD (31%) of the entire AD group. The main reasons for not including patients in analyses of cognitive performance were AD diagnosis at a moderate/severe stage (n = 266, 21%), AD diagnosis given before full register coverage (n = 152, 12%), and missing CERAD-nb data (n = 139, 11%). The cognitive performance of persons with late-onset AD (n = 284), mixed cerebrovascular disease and AD (n = 51), and other AD subtypes (n = 54) was compared with that of a non-demented sample (n = 1980) from the general population. Compared with the other AD groups, patients with late-onset AD performed the worst in word list recognition, while patients with mixed cerebrovascular disease and AD performed the worst in constructional praxis and clock drawing tests. A combination of national registers and local health records can be used to collect data relevant for cognitive screening; today, the process is laborious, but it could be improved in the future with refined search algorithms and electronic data.Peer reviewe

Education-Based Cutoffs for Cognitive Screening of Alzheimer’s Disease

Introduction: The educational background and size of the elderly population are undergoing significant changes in Finland during the 2020s. A similar process is likely to occur also in several European countries. For cognitive screening of early Alzheimer’s disease (AD), using outdated norms and cutoff scores may negatively affect clinical accuracy. The aim of the present study was to examine the effects of education, age, and gender on the Consortium to Establish a Registry for Alzheimer’s Disease neuropsychological battery (CERAD-nb) in a large register-based, clinical sample of patients with mild AD and nondemented at-risk persons from the general population (controls) and to examine whether corrected cutoff scores would increase the accuracy of differentiation between the 2 groups. Methods: CERAD-nb scores were obtained from AD patients (n = 389, 58% women, mean age 74.0 years) and from controls (n = 1,980, 52% women, mean age 68.5 years). The differences in CERAD-nb performance were evaluated by univariate GLM. Differentiation between the 2 groups was evaluated using a receiver operating characteristic (ROC) curve, where a larger area under the ROC curve represents better discrimination. Youden’s J was calculated for the overall performance and accuracy of each of the measures. Results: Of the demographic factors, education was the strongest predictor of CERAD-nb performance, explaining more variation than age or gender in both the AD patients and the controls. Education corrected cutoff scores had better diagnostic accuracy in discriminating between the AD patients and controls than existing uncorrected scores. The highest level of discrimination between the 2 groups overall was found for two CERAD-nb total scores. Conclusions: Education-corrected cutoff scores were superior to uncorrected scores in differentiating between controls and AD patients especially for the highest level of education and should therefore be used in clinical cognitive screening, also as the proportion of the educated elderly is increasing substantially during the 2020s. Our results also indicate that total scores of the CERAD-nb are better at discriminating AD patients from controls than any single subtest score. A digital tool for calculating the total scores and comparing education-based cutoffs would increase the efficiency and usability of the test.Peer reviewe

Relationship of Neuropsychiatric Symptoms with Falls in Alzheimer's Disease : Does Exercise Modify the Risk?

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Monetary value of informal caregiving in dementia from a societal perspective

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Effect of Exercise on Drug-Related Falls Among Persons with Alzheimer's Disease : A Secondary Analysis of the FINALEX Study

Introduction No study has investigated how exercise modifies the effect of fall-related drugs (FRDs) on falls among people with Alzheimer's disease (AD). Objective The aim of this study was to investigate how exercise intervention and FRDs interact with fall risk among patients with AD. Methods In the FINALEX trial, community-dwelling persons with AD received either home-based or group-based exercise twice weekly for 1 year (n = 129); the control group received normal care (n = 65). The number of falls was based on spouses' fall diaries. We examined the incidence rate ratios (IRRs) for falls among both non-users and users of various FRDs (antihypertensives, psychotropics, drugs with anticholinergic properties [DAPs]) in both control and combined intervention groups. Results Between the intervention and control groups, there was no difference in the number of falls among those without antihypertensives or psychotropics. In the intervention group taking antihypertensives, the IRR was 0.5 falls/person-year (95% confidence interval [CI] 0.4-0.6), while in the control group, the IRR was 1.5 falls/person-year (95% CI 1.2-1.8) [p <0.001 for group, p = 0.067 for medication, p <0.001 for interaction]. Among patients using psychotropics, the intervention group had an IRR of 0.7 falls/person-year (95% CI 0.6-0.9), while the control group had an IRR of 2.0 falls/person-year (95% CI 1.6-2.5) [p <0.001 for group, p = 0.071 for medication, p <0.001 for interaction]. There was a significant difference in falls between the intervention and control groups not using DAPs (0.6, 95% CI 0.5-0.7; 1.2, 95% CI 1.0-1.4), and between the intervention and control groups using DAPs (1.1, 95% CI 0.8-1.3; 1.5, 95% CI 1.0-2.1) [p <0.001 for group, p = 0.014 for medication, p = 0.97 for interaction]. Conclusion Exercise has the potential to decrease the risk for falls among people with AD using antihypertensives and psychotropics.Peer reviewe

How Do Community-Dwelling Persons with Alzheimer Disease Fall? Falls in the FINALEX Study

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Potentially severe drug-drug interactions among older people and associations in assisted living facilities in Finland : a cross-sectional study

Objective: This study aims to assess potentially severe class D drug-drug interactions (DDDIs) in residents 65 years or older in assisted living facilities with the use of a Swedish and Finnish drug-drug interaction database (SFINX). Design: A cross-sectional study of residents in assisted living facilities in Helsinki, Finland. Setting: A total of 1327 residents were assessed in this study. Drugs were classified according to the Anatomical Therapeutic Chemical (ATC) classification system and DDDIs were coded according to the SFINX. Main outcome measures: Prevalence of DDDIs, associated factors and 3-year mortality among residents. Results: Of the participants (mean age was 82.7 years, 78.3% were females), 5.9% (N=78) are at risk for DDDIs, with a total of 86 interactions. Participants with DDDIs had been prescribed a higher number of drugs (10.8 (SD 3.8) vs. 7.9 (SD 3.7), p Conclusions: Of the residents in assisted living, 5.9% were exposed to DDDIs associated with the use of a higher number of drugs. Physicians should be trained to find safer alternatives to drugs associated with DDDIs.Peer reviewe

Exercise rehabilitation on home-dwelling patients with Alzheimer's disease - a randomized, controlled trial. Study protocol

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