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The care of over 5 million Americans living with dementia represents a growing challenge to the health care system (Bynum 2014; Alzheimer's Association 2015). The estimated formal and informal care [...], Objective. To investigate effects of a novel dementia care coordination program on health services utilization. Data Sources/Study Setting. A total of 303 community-dwelling adults aged [greater than or equal to]70 with a cognitive disorder in Baltimore, Maryland (2008-2011). Study Design. Single-blind RCT evaluating efficacy of an 18-month care coordination intervention delivered through community-based nonclinical care coordinators, supported by an interdisciplinary clinical team. Data Collection/Extraction Methods. Study partners reported acute care/inpatient, outpatient, and home- and community-based service utilization at baseline, 9, and 18 months. Principal Findings. From baseline to 18 months, there were no significant group differences in acute care/inpatient or total outpatient services use, although intervention participants had significantly increased outpatient dementia/mental health visits from 9 to 18 months (p = .04) relative to controls. Home and community-based support service use significantly increased from baseline to 18 months in the intervention compared to control (p = .005). Conclusions. While this dementia care coordination program did not impact acute care/inpatient services utilization, it increased use of dementia-related outpatient medical care and nonmedical supportive community services, a combination that may have helped participants remain at home longer. Future care model modifications that emphasize delirium, falls prevention, and behavior management may be needed to influence inpatient service use. Key Words. Dementia, care coordination

New research from the Aberdeen Group underscores the criticality of spend analysis to overall spend management. The findings also show, however, that many companies struggle with putting together an effective [...]

Objective: The second-generation antipsychotics are associated with metabolic abnormalities in patients with schizophrenia. Elderly patients with Alzheimer's disease are frequently treated with these antipsychotics, but limited data are available on their metabolic effects. Method: The authors assessed 186 male and 235 female Alzheimer's disease outpatients from the Clinical Antipsychotic Trials of Intervention Effectiveness-Alzheimer's Disease (CATIE-AD) for changes in weight, waist circumference, blood pressure, fasting glucose, and lipids in relation to duration of second-generation antipsychotic use (i.e., olanzapine, quetiapine, and risperidone) throughout the 36-week trial, using logistic regression and mixed-effects models. Results-Women showed significant weight gain (0.14 lb/week of use) while change was nonsignificant in men. Clinically significant weight gain (i.e., [greater than or equal to] 7% of body weight) was seen among patients with antipsychotic use [less than or equal to] 12 weeks (odds ratio [OR]=1.56, 95% Cl=0.53 to 4.58), between 12 and 24 weeks (OR=2.89, 95% Cl=0.97 to 8.64), and >24 weeks (OR= 3.38, 95% Cl=1.24 to 9.23) relative to patients who did not use antipsychotics during the trial. Olanzapine and quetiapine treatments were significantly associated with weight gain (0.12 and 0.14 lb/week, respectively). In addition, olanzapine was significantly associated with decreases in HDL cholesterol (-0.19 mg/dl/week) and increased girth (0.07 inches/week) relative to the placebo group. No treatment effects were noted for changes in blood pressure, glucose, and triglycerides. Conclusion: Second-generation antipsychotic use was associated with weight gain in women, with olanzapine and quetiapine in particular, and with unfavorable change in HDL cholesterol and girth with olanzapine. The potential consequences of these effects suggest that patients with Alzheimer's disease treated with second-generation antipsychotics should be monitored closely.

Objective: The study measured the effects of atypical antipsychotics on psychiatric and behavioral symptoms in patients with Alzheimer's disease and psychosis or agitated behavior. Method: The Clinical Antipsychotic Trials of Intervention Effectiveness--Alzheimer's Disease (CATIE-AD) Alzheimer's disease effectiveness study included 421 outpatients with Alzheimer's disease and psychosis or agitated/aggressive behavior. Patients were assigned randomly to masked, flexible-dose treatment with olanzapine, quetiapine, risperidone, or placebo for up to 36 weeks. Patients could be randomly reassigned to a different medication at the clinician's discretion, which ended phase 1. Psychiatric and behavioral symptoms, functioning, cognition, care needs, and quality of life were measured at regular intervals. Results: In relation to placebo, the last observation in phase 1 showed greater improvement with olanzapine or risperi-done on the Neuropsychiatric Inventory total score, risperidone on the Clinical Global Impression of Changes, olanzapine and risperidone on the Brief Psychiatric Rating Scale (BPRS) hostile suspiciousness factor, and risperidone on the BPRS psychosis factor. There was worsening with olanzapine on the BPRS withdrawn depression factor. Among patients continuing phase 1 treatment at 12 weeks, there were no significant differences between antipsychotics and placebo on cognition, functioning, care needs, or quality of life, except for worsened functioning with olanzapine compared to placebo. Conclusion: In this descriptive analysis of outpatients with Alzheimer's disease in usual care settings, some clinical symptoms improved with atypical antipsychotics. Antipsychotics may be more effective for particular symptoms, such as anger, aggression, and paranoid ideas. They do not appear to improve functioning, care needs, or quality of life.

Objective: The authors systematically reviewed the literature on psychological approaches to treating the neuropsychiatric symptoms of dementia. Method: Reports of studies that examined effects of any therapy derived from a psychological approach that satisfied pre-specified criteria were reviewed. Data were extracted, the quality of each study was rated, and an overall rating was given to each study by using the Oxford Centre for Evidence-Based Medicine criteria. Results: A total of 1,632 studies were identified, and 162 satisfied the inclusion criteria for the review. Specific types of psycho-education for caregivers about managing neuropsychiatric symptoms were effective treatments whose benefits lasted for months, but other caregiver interventions were not. Behavioral management techniques that are centered on individual patients' behavior or on caregiver behavior had similar benefits, as did cognitive stimulation. Music therapy and Snoezelen, and possibly sensory stimulation, were useful during the treatment session but had no longer-term effects; interventions that changed the visual environment looked promising, but more research is needed. Conclusions: Only behavior management therapies, specific types of caregiver and residential care staff education, and possibly cognitive stimulation appear to have lasting effectiveness for the management of dementia-associated neuropsychiatric symptoms. Lack of evidence regarding other therapies is not evidence of lack of efficacy. Conclusions are limited because of the paucity of high-quality research (only nine level-1 studies were identified). More high-quality investigation is needed.

Background and Objectives: Psychiatric disorders could limit the success of behavioral counseling strategies. We evaluated the prevalence of psychiatric disorders among sexually transmitted disease (STD) clinic patients and their association with STD risk. Methods: A systematic sample of 201 patients presenting to a public STD clinic in Baltimore, Maryland, participated in the structured clinical interview for the Diagnostic and Statistical Manual of Mental Disorders, 4th edition. Results: Overall, 45% of 201 STD clinic patients interviewed had a current axis I disorder and 29% had an axis II personality disorder. Substance use disorders predominated among axis I diagnoses; antisocial personality disorder (ASPD) predominated among axis II diagnoses, with an ASPD prevalence of 29.4% in men. ASPD was associated with a diagnosis of an STD (odds ratio, 3.67; 95% confidence interval, 1.63-8.30; P = 0.002). Substance use was not associated with an STD diagnosis. Conclusions: STD clinic patients have complex psychopathology that could increase HIV risk and compromise prevention interventions. Specialized counseling strategies, particularly targeting personality traits of ASPD, could improve prevention outcomes.

The licit consumption of psychostimulants, dexamphetamine and methylphenidate, in Australia is examined in this paper. These drugs are use to treat attention deficit hyperactivity disorder.

Objective: This study estimated the psychiatric morbidity of patients with degenerative cerebellar diseases. Method: The study included a series of 31 patients with degenerative cerebellar diseases, compared with 21 patients with Huntington's disease and 29 neurologically healthy comparison subjects. Comprehensive psychiatric evaluations, including the Structured Clinical Interview for DSM-IV and psychopathology rating scales, were administered. Results: The overall rate of noncognitive psychiatric disorders was 77% in the patients with degenerative cerebellar diseases, nearly identical to that in the patients with Huntington's disease (81%) and about double that seen in the neurologically healthy subjects (41%). There were high rates of all mood disorders in both the degenerative cerebellar diseases group (68%) and the Huntington's disease group (43%); the rate in the degenerative cerebellar diseases group was significantly higher than that in the neurologically healthy subjects (31%). The frequency of personality change in the three groups was striking: change was present in 26% of the degenerative cerebellar diseases patients, 48% of the Huntington's disease patients, and none of the neurologically healthy comparison subjects. A total of 19% of the degenerative cerebellar diseases subjects and 71% of the Huntington's disease subjects met DSM-IV criteria for either cognitive disorder or dementia. Conclusions: The high rate of psychiatric and cognitive disorders in the patients with degenerative cerebellar diseases suggests that many, if not most, patients with degenerative cerebellar diseases may benefit from psychiatric interventions. These results also support previous findings that the cerebellum may have a role in modulating emotion and cognition.

Objective: The authors report findings from a study of 5,092 community residents who constituted 90% of the elderly resident population of Cache County, Utah. Method: The 5,092 participants, who were 65 years old or older, were screened for dementia. Based on the results of this screen, 1,002 participants (329 with dementia and 673 without dementia) underwent comprehensive neuropsychiatric examinations and were rated on the Neuropsychiatric Inventory, a widely used method for ascertainment and classification of dementia-associated mental and behavioral disturbances. Results: Of the 329 participants with dementia, 214 (65%) had Alzheimer's disease, 62 (19%) had vascular dementia, and 53 (16%) had another DSM-IV dementia diagnosis; 201 (61%) had exhibited one or more mental or behavioral disturbances in the past month. Apathy (27%), depression (24%), and agitation/aggression (24%) were the most common in participants with dementia. These disturbances were almost four times more common in participants with dementia than in those without. Only modest differences were observed in the prevalence of mental or behavioral disturbances in different types of dementia or at different stages of illness: participants with Alzheimer's disease were more likely to have delusions and less likely to have depression. Agitation/aggression and aberrant motor behavior were more common in participants with advanced dementia. Conclusions: On the basis of their findings in this large community population of elderly people, the authors conclude that a wide range of dementia-associated mental and behavioral disturbances afflict the majority of individuals with dementia. Because of their frequency and their adverse effects on patients and their caregivers, these disturbances should be ascertained and treated in all cases of dementia.

Objective: This study investigated the prevalence of dementia in a general hospital, reasons for which patients with dementia were admitted, and the relationship between dementia and length of stay, cost, and in-hospital mortality rate. Method: The study focused on data from the hospital database on 21,251 patients aged 60 and older who were discharged in 1996 and 1997. Patients were grouped as with or without a discharge diagnosis of dementia by ICD-9-CM criteria. The groups were compared on sociodemographic characteristics, principal discharge diagnoses, lengths of stay, costs, and in-hospital mortality rates. Results: The prevalence of dementia among discharged patients was 3.9% (N = 823); it was dependent on age (age 60-64, prevalence = 2.6%; age 85 and older, prevalence = 8.9%). The primary discharge diagnoses of the groups were different. The mean length of stay was 10.4 days for patients with dementia and 6.5 days for patients without dementia. Per capita hospital costs were $4,000 higher for patients with dementia. Differences in lengths of stay and per capita costs were statistically significant after adjusting for age, race, and sex. Lengths of stay and hospital costs for patients with dementia were significantly higher for eight primary discharge diagnoses after adjusting for age, race, and sex. Conclusions: Dementia is present in a significant proportion of patients admitted to general inpatient units. Patients with dementia are admitted for different reasons than patients without dementia and appear to have longer stays, which are associated with higher costs. Efforts to identify dementia early during hospitalization could improve patient care and reduce costs.

Objective: The goal of this study was to determine the frequency of physically aggressive behavior in community-residing patients with dementia and its relationship to depression. Method: A consecutive series of 541 patients with DSM-IV-defined dementia underwent comprehensive neuropsychiatric evaluation and were rated on the Cornell Scale for Depression in Dementia, the Mini-Mental State, the Psychogeriatric Dependency Rating Scale, and the General Medical Health Rating. Results: Physically aggressive behavior was exhibited by 79 patients in the 2 weeks before evaluation. Aggressive behavior was closely associated with moderate to severe depression, male gender, and greater impairment in activities of daily living, even after adjustment for delusions, hallucinations, sleep disturbance, and severity of cognitive impairment. After adjustment for depression, gender, and impairment in activities of daily living, there was no association between physically aggressive behavior and the presence of either delusions or hallucinations. Conclusions: A substantial minority of patients with dementia exhibit physically aggressive behavior, and this aggression is strongly linked with the presence of depressive symptoms. It is possible that the identification and treatment of depression in dementia may be a means of preventing and managing physically aggressive behavior.

Objective: The epidemiology of cognitive decline over 11.5 years was investigated in a large community-residing population, with a special emphasis on the relationship between education and cognitive decline. Method: The study was an 11.5-year follow-up of a probability sample of the adult household residents of east Baltimore. From the Baltimore cohort of the Epidemiologic Catchment Area study, 1,488 participants completed the Mini-Mental State during three study waves in 1981, 1982, and 1993-1996. For each study participant, the difference in scores on the Mini-Mental State between waves 2 and 3 was calculated. Results: Over a median interval of 11.5 years, the study participants' scores on the Mini-Mental State declined a mean of 1.41 points, and the scores of 68% of the participants declined by at least 1 Mini-Mental State point. With and without adjustment for age, greater declines were associated with having 8 years or less of formal education and with being African American. Conclusions: Over a long time period, cognitive decline occurred in all age groups. Having more than 8 years of formal education was associated with less decline. However, beyond 9 years, additional education was not associated with a further reduction in cognitive decline. This suggests that a minimal amount of education during early critical periods might confer protection against cognitive decline later in life.

Objective: The authors sought to determine whether rates of depressive symptoms change from early- to late-stage HIV-1 infection and to determine the predictors of depressive symptoms as AIDS develops. Method: The data for this study were from 911 HIV-seropositive men - community volunteers from four U.S. cities - who entered the 10-year Multicenter AIDS Cohort Study without a diagnosis of AIDS and subsequently developed AIDS. The subjects underwent semiannual follow-ups during the study period. The outcome measures - overall depressive symptoms, nonsomatic depressive symptoms, syndromal depression, and severe depression - were assessed over the 5 years before and the 2 years after AIDS diagnosis from responses on the Center for Epidemiologic Studies Depression Scale (CES-D Scale). Results: Depressive symptoms were stable over time from month 60 to month 18 before AIDS developed. However, beginning 12-18 months before AIDS diagnosis, there was a significant rise in all measures of depression, which reached a plateau within 6 months before AIDS developed. At this plateau, there was a 45% increase in mean CES-D Scale scores above baseline. An elevated CES-D Scale score in the earlier stages of infection, a self-report of AIDS-related symptoms (such as rash and lymphadenopathy), concurrent unemployment, cigarette smoking, and limited social supports were consistent predictors of higher rates of depression as AIDS developed. Conclusions: There is a dramatic, sustained rise in depressive symptoms as AIDS develops, beginning as early as 18 months before clinical AIDS is diagnosed. Prior depression, HIV-disease-related factors, and psychological stressors contribute to this rise. This robust phenomenon invites further characterization.

Founded in 1924, the Curtis Institute of Music is a full-scholarship music school located on Philadelphia's historic Rittenhouse Square. Its new 105,000-square foot education and residence building, named for H. [...]