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Background: Research to date has detailed numerous challenges in emergency department (ED) communication with persons living with dementia (PLWD) and their caregivers. However, little is known about communication experiences of individuals belonging to minoritized racial and ethnic groups, who are disproportionately impacted by dementia and less likely to be included in dementia research., Methods: We conducted semi-structured interviews with 29 caregivers of PLWD from two urban academic hospital EDs with distinct patient populations. The first site is an ED in the Northeast serving a majority White, English-speaking, and insured population. The second site is an ED in the South serving a majority Black and/or Hispanic, Spanish-speaking, and underinsured population. Interviews lasted an average of 25 min and were digitally recorded and transcribed. We used an inductive approach to analyze interview transcripts for dominant themes and compared themes between sites., Results: Our sample included caregivers of diverse racial and ethnic backgrounds. Caregivers cared for PLWD who spoke English, Spanish, Arabic, Chinese, and Vietnamese. We identified three themes. First, caregiver advocacy was central to experiences of ED communication, particularly when PLWD primarily spoke a non-English language. Second, routine care plans did not address what mattered most to participants and PLWD. Participants felt that care arose from protocols and did not address what mattered most to them. Third, White English-speaking caregivers in Site 1 more commonly expected ED staff to engage them in care decision-making than Black, Hispanic, Asian, and Middle Eastern caregivers in Site 2., Conclusion: Language barriers amplify the higher intensity care needed by PLWD in the ED. Strategies should be developed for communicating with PLWD and caregivers about what matters most in their ED care., (© 2024 The American Geriatrics Society.)

Background: We investigated the mortality risk associated with the initiation of antipsychotic treatment among patients with dementia and whether comorbidities related to the cardiovascular system and diabetes interact with antipsychotic treatment to increase the mortality risk beyond the risk of death independently associated with antipsychotics and comorbidity alone., Methods: We designed a matched cohort study using nationwide registry data. All Danish residents aged 65-95 years diagnosed with dementia between 2009 and 2014 were included. Dementia was assessed as a first-time registered dementia diagnosis in the Danish National Patient Register or the Danish Psychiatric Central Research Register and/or a first-time prescription for antidementia medication. Patients exposed to antipsychotics were matched with up to three unexposed patients. Cox proportional hazards models were used to compare rates of death within 180 days after the initiation of antipsychotic treatment. The models were adjusted for potential confounders. Analyses were stratified for diabetes, heart disease, and cerebrovascular disease, and we calculated the relative excess risk due to interaction (RERI)., Results: The study cohort included 8244 exposed patients and 24,730 unexposed patients. A total of 5938 patients died during the first 180 days of follow-up. Patients exposed to antipsychotics had a significantly higher adjusted risk of death (hazard ratio: 1.35, 95% confidence interval: 1.27-1.43) than unexposed patients. Crude mortality rates were higher among patients with heart disease and diabetes when antipsychotic treatment was initiated compared with patients without comorbidities. Relative risk estimates did not differ between patients with and without heart disease, cerebrovascular disease, and diabetes, and RERI suggested no positive additive interaction. Risk analysis suggested higher mortality in patients without cerebrovascular disease who initiated antipsychotics., Conclusion: This nationwide study adds to the evidence that antipsychotic treatment is associated with increased mortality and suggests that attention should be paid to all initiators of antipsychotics irrespective of cardiovascular disease and diabetes., (© 2022 The American Geriatrics Society.)

Background: Robust quality indicators (QIs) are essential for monitoring and improving the quality of care and learning from good practice. We aimed to identify and assess QIs for the care of older people and people with dementia who are nearing the end of life and recommend QIs for use with routinely collected electronic data across care settings., Methods: A systematic review was conducted, including five databases and reference chaining. Studies describing the development of QIs for care of older people and those with dementia nearing the end of life were included. QIs were categorized as relating to processes or outcomes, and mapped against six care domains. The psychometric properties (acceptability, evidence base, definition, feasibility, reliability, and validity) of each QI were assessed; QIs were categorized as robust, moderate, or poor., Results: From 12,980 titles and abstracts screened, 37 papers and 976 QIs were included. Process and outcome QIs accounted for 780 (79.7%) and 196 (20.3%) of all QIs, respectively. Many of the QIs concerned physical aspects of care (n = 492, 50.4%), and very few concerned spiritual and cultural aspects of care (n = 19, 1.9%). Three hundred and fifteen (32.3%) QIs were robust and of those 220 were measurable using routinely collected electronic data. The final shortlist of 71 QIs came from seven studies., Conclusions: Of the numerous QIs developed for care of older adults and those with dementia nearing the end of life, most had poor or moderate psychometric properties or were not designed for use with routinely collected electronic datasets. Infrastructure for data availability, combined with use of robust QIs, is important for enhancing understanding of care provided to this population, identifying unmet needs, and improving service provision., (© 2021 The Authors. Journal of the American Geriatrics Society published by Wiley Periodicals LLC on behalf of The American Geriatrics Society.)

Objectives: Coffee, green tea, and caffeine are potential preventive factors for dementia, but the underlying evidence is insufficient. This study aimed to examine associations between the consumption of coffee, green tea, and caffeine and dementia risk in middle-aged and older people., Methods: This was a cohort study with an 8.0-year follow-up. Participants were community-dwelling individuals (n = 13,757) aged 40-74 years. A self-administered questionnaire survey was conducted in 2011-2013. Predictors were the consumption of coffee/green tea, from which caffeine consumption was estimated. The outcome was incident dementia obtained from the long-term care insurance database. Covariates were demographic factors, body mass index, physical activity, energy, smoking, drinking, and disease history. Adjusted hazard ratios (HRs) were calculated using Cox proportional hazards models. HRs were also calculated using a Cox model with delayed entry., Results: The number of dementia cases during the study period was 309. Participants with higher coffee consumption had lower HRs (adjusted p for trend = 0.0014), with the fifth quintile (≥326 ml/day) having a significantly lower HR (0.49, 95% confidence interval [CI]: 0.30-0.79) than the first quintile (<26 ml/day, reference). Similarly, participants with higher caffeine consumption had a significantly lower HR (adjusted p for trend = 0.0004) than the reference. The Cox model with delayed entry yielded similar results. These associations were significant in men, but not in women. Moreover, participants who consumed 2-2.9 cups/day and ≥3 cups/day of coffee had lower HRs (0.69, 95% CI: 0.48-0.98 and 0.53, 95% CI: 0.31-0.89, respectively) than those who consumed 0 cup/day. The association between green tea consumption and reduced dementia risk was significant (adjusted p for trend = 0.0146) only in the 60-69 years age subgroup., Conclusions: High levels of coffee and caffeine consumption were significantly associated with a reduced dementia risk in a dose-dependent manner, especially in men. Moreover, coffee consumption of ≥3 cups/day was associated with a 50% reduction in dementia risk., (© 2021 The American Geriatrics Society.)

Background: The National Institute on Aging (NIA), in conjunction with the Department of Health and Human Services as part of the National Alzheimer's Project Act (NAPA), convened a 2020 Dementia Care, Caregiving, and Services Research Summit Virtual Meeting Series. This review article summarizes three areas of emerging science that are likely to grow in importance given advances in measurement, technologies, and diagnostic tests that were presented at the Summit., Results: Dr. Cassel discussed novel ethical considerations that have resulted from scientific advances that have enabled early diagnosis of pre-clinical dementia. Dr. Monin then summarized issues regarding emotional experiences in persons with dementia and their caregivers and care partners, including the protective impact of positive emotion and heterogeneity of differences in emotion by dementia type and individual characteristics that affect emotional processes with disease progression. Finally, Dr. Jared Benge provided an overview of the role of technologies in buffering the impact of cognitive change on real-world functioning and their utility in safety and monitoring of function and treatment adherence, facilitating communication and transportation, and increasing access to specialists in underserved or remote areas., Conclusions: National policy initiatives, supported by strong advocacy and increased federal investments, have accelerated the pace of scientific inquiry and innovation related to dementia care and services but have raised some new concerns regarding ethics, disparities, and attending to individual needs, capabilities, and preferences., (© 2021 The American Geriatrics Society.)

Objectives: Our aim was to (1) describe the clinical characteristics and symptoms of people diagnosed with dementia at the time of admission to inpatient palliative care; and (2) compare the nature and severity of these palliative care-related problems to patients with other chronic diseases., Design: Descriptive study using assessment data on point of care outcomes (January 1, 2013, to December 31, 2018)., Setting: A total of 129 inpatient palliative care services participating in the Australian Palliative Care Outcomes Collaboration., Participants: A total of 29,971 patients with a primary diagnosis of dementia (n = 1,872), lung cancer (n = 19,499), cardiovascular disease (CVD, n = 5,079), stroke (n = 2,659), or motor neuron disease (MND, n = 862)., Measurements: This study reported the data collected at the time of admission to inpatient palliative care services including patients' self-rated levels of distress from seven common physical symptoms, clinician-rated symptom severity, functional dependency, and performance status. Other data analyzed included number of admissions, length of inpatient stay, and palliative care phases., Results: At the time of admission to inpatient palliative care services, relative to patients with lung cancer, CVD, and MND, people with dementia presented with lower levels of distress from most symptoms (odds ratios [ORs] range from .15 to .80; P < .05 for all) but higher levels of functional impairment (ORs range from 3.02 to 8.62; P < .001 for all), and they needed more assistance with basic activities of daily living (ORs range from 3.83 to 12.24; P < .001 for all). The trends were mostly the opposite direction when compared with stroke patients. Patients with dementia tended to receive inpatient palliative care later than those with lung cancer and MND., Conclusion: The unique pattern of palliative care problems experienced by people with dementia, as well as the skills of the relevant health services, need to be considered when deciding on the best location of care for each individual. Access to appropriately trained palliative care clinicians is important for people with high levels of physical or psychological concerns, irrespective of the care setting or diagnosis. J Am Geriatr Soc 68:1825-1833, 2020., (© 2020 The American Geriatrics Society.)

Objectives: The main objective of the study was to investigate annual changes in the sociodemographic characteristics, morbidity, and functional status of new nursing home residents in Ontario, Canada, between 2000 and 2015. A secondary objective was to develop and assess the quality of an algorithm for ascertaining admissions into publicly funded nursing homes in Ontario using a combination of health administrative data sources that indirectly identifies the residential status of new nursing home residents., Design: Population-based serial cross-sectional study with an accompanying quality assessment study of algorithms., Setting: Publicly funded nursing care homes in Ontario, Canada., Participants: The reference standard for the assessment of algorithm performance was 21 544 newly admitted nursing home residents identified from the Resident Assessment Instrument-Minimum Data Set in 2012. The selected algorithm was then used to identify serial cross-sectional cohorts of newly admitted residents between 2000 and 2015 that ranged in size between 14 651 and 23 630 residents., Measurements: Sociodemographic characteristics, morbidity, and functional status of new residents were determined upon admission to examine patterns in the cohorts' profiles., Results: The proportion of residents aged 85 years and older increased from 45.1% to 53.8% over 16 years. The proportions of individuals with seven or more chronic conditions (from 14.1% to 22.1%) and with nine or more prescription medications (from 44.9% to 64.2%) have also increased in parallel over time. Hypertension, osteoarthritis, and dementia were the most prevalent conditions captured, with the proportion of incoming residents with dementia increasing from 42.3% to 54.1% between 2000 and 2015. Newly admitted residents were more likely to have extensive physical and cognitive impairments upon admission., Conclusion: Admission trends show that new residents were older and had greater multimorbidity and limitations in physical functioning over time. J Am Geriatr Soc 68:1293-1300, 2020., (© 2020 The American Geriatrics Society.)

Presents several articles related to medical care. Sex differences in the relationship between depressive symptoms and dementia incidence; Prevalence, clinical characteristics, and association with cardiovascular risk factors in community-dwelling older persons; Organizational characteristics and restraint use for hospitalized nursing home residents.

Background: The Successful Aging after Elective Surgery (SAGES) II Study was designed to examine the relationship between delirium and Alzheimer's disease and related dementias (AD/ADRD), by capturing novel fluid biomarkers, neuroimaging markers, and neurophysiological measurements. The goal of this paper is to provide the first complete description of the enrolled cohort, which details the baseline characteristics and data completion. We also describe the study modifications necessitated by the COVID‐19 pandemic, and lay the foundation for future work using this cohort. Methods: SAGES II is a prospective observational cohort study of community‐dwelling adults age 65 and older undergoing major non‐cardiac surgery. Participants were assessed preoperatively, throughout hospitalization, and at 1, 2, 6, 12, and 18 months following discharge to assess cognitive and physical functioning. Since participants were enrolled throughout the COVID‐19 pandemic, procedural modifications were designed to reduce missing data and allow for high data quality. Results: About 420 participants were enrolled with a mean (standard deviation) age of 73.4 (5.6) years, including 14% minority participants. Eighty‐eight percent of participants had either total knee or hip replacements; the most common surgery was total knee replacement with 210 participants (50%). Despite the challenges posed by the COVID‐19 pandemic, which required the use of novel procedures such as video assessments, there were minimal missing interviews during hospitalization and up to 1‐month follow‐up; nearly 90% of enrolled participants completed interviews through 6‐month follow‐up. Conclusion: While there are many longitudinal studies of older adults, this study is unique in measuring health outcomes following surgery, along with risk factors for delirium through the application of novel biomarkers—including fluid (plasma and cerebrospinal fluid), imaging, and electrophysiological markers. This paper is the first to describe the characteristics of this unique cohort and the data collected, enabling future work using this novel and important resource. [ABSTRACT FROM AUTHOR]

Background: Residential care/assisted living (RC/AL) is an increasingly common place of end‐of‐life care for persons with Alzheimer's disease and related dementia (ADRD), who have unique care needs as their health declines. Approximately 22% of RC/ALs provide specialized memory care (memory‐care RC/AL). Understanding how end‐of‐life outcomes differ by memory care among residents with ADRD could facilitate aging/dying in place for this population. The objective of this paper is to examine if end‐of‐life outcomes (i.e., mortality, hospice use, and number of days receiving hospice in the last month of life) differ between residents with ADRD who moved to memory‐care RC/AL, compared with residents with ADRD who moved to RC/AL without memory care (general RC/AL). Methods: Prospective cohort of 15,152 fee‐for‐service Medicare beneficiaries with ADRD who moved to large RC/AL (> = 25 beds) between 2016 and 2018. We used inverse probability treatment weighting to account for observable differences between memory‐care and general RC/AL residents. Two‐part models estimated the difference by memory care in the number of days receiving hospice care in the last months of life among RC/AL decedents. Results: The unadjusted mortality rates were 13.4% in general RC/AL and 15.8% in memory‐care RC/AL with an adjusted difference of 1.3 percentage points higher mortality among memory‐care RC/AL residents (p = 0.04). Hospice use was 8% and 10.6% among general and memory‐care RC/AL residents, respectively, with an adjusted difference of 1.4 percentage points (p = 0.01) higher in memory care. Two‐part models showed that decedents in memory‐care RC/AL spent about 1.4 more days receiving hospice care in the last month of life (p = 0.02). Conclusion: We find a higher mortality rate and higher rate of hospice use among memory‐care RC/AL residents. These findings suggest that memory care may attract residents closer to the end of life and/or promote hospice use at the end of life. [ABSTRACT FROM AUTHOR]

Background: Dementia can impede the relationship and connection between the person with dementia (PWD) and their caregiver. Yet, caregiving in dementia also offers opportunities for connection, which has implications for caregiver and PWD well-being. In this qualitative study, we describe and characterize ways caregivers felt connected to the person with dementia they care for., Methods: We conducted a telephone-based survey with caregivers of people with dementia. For this paper, we analyzed responses to an open-ended question focused on when caregivers feel most connected to the person they are caring for. Responses were analyzed and coded and themes were identified through an iterative process involving a multidisciplinary team of researchers and clinicians., Results: 437 caregivers participated in this study. We identified two domains of connection: activity-based and emotion-based connections. Within activity-based connections, the following themes emerged: everyday activities; reminiscing; activities of caregiving; novel experiences; and time with family and friends. Within emotional connections, the following themes emerged: expressions of love, appreciation, and gratitude; physical affection; sharing an emotion or emotional experience; and times when the PWD seems like "themself" again., Conclusions: Findings provide insights into ways caregivers experience a sense of connection with the person they care for. There is a call to shift away from focusing on reducing stress and toward optimizing positive experiences as a way to better support caregivers' health and well-being. Interventions that leverage these insights to foster caregiver - PWD connection could lead to better health and well-being for both members of the dyad. The amplification of a positive experience may be particularly important for caregivers who are struggling with limited support or respite. Clinicians may be interested in using a question about connection as a way to more fully understand a caregiver's current experience., (© 2023 The American Geriatrics Society.)

Background: Although advance care planning (ACP) for persons with dementia (PWD) can promote patient-centered care by aligning future healthcare with patient values, few PWD have documented ACPs for reasons incompletely understood. The objective of this paper is to characterize the perceived value of, barriers to, and successful strategies for completing ACP for PWD as reported by frontline clinicians., Methods: Qualitative study using semi-structured interviews (August 2018-December 2019) with clinicians (physicians, nurse practitioners, nurses, social workers) at 11 US health systems. Interviews asked clinicians about their approaches to ACP with PWDs, including how ACP was initiated, what was discussed, how carepartners were involved, how decision-making was approached, and how decision-making capacity was assessed., Results: Of 75 participating generalist and specialty clinicians from across the United States, 61% reported conducting ACP with PWD, of whom 19% conducted ACP as early as possible with PWD. Three themes emerged: value of early ACP preserves PWD's autonomy in cases of differing PWD carepartner values, acute medical crises, and clinician paternalism; barriers to ACP with PWD including the dynamic and subjective assessment of patient decision-making capacity, inconsistent awareness of cognitive impairment by clinicians, and the need to balance patient and family carepartner involvement; and strategies to support ACP include clarifying clinicians' roles in ACP, standardizing clinicians' approach to PWD and their carepartners, and making time for ACP and decision-making assessments that allow PWD and carepartner involvement regardless of the patients' capacity., Conclusions: Clinicians found early ACP for PWD valuable in promoting patient-centered care among an at-risk population. In sharing their perspectives on conducting ACP for PWD, clinicians described challenges that are amenable to changes in training, workflow, and material support for clinician time. Clinical practices need sustainable scheduling and financial support models., (© 2022 The American Geriatrics Society.)

The concept of trauma and traumatic stress and its impact on health and mental health has been studied for nearly half a century. Trauma‐informed care (TIC) is person‐centered care designed and delivered based on knowledge of the ubiquity of trauma. It requires building an understanding of the role that trauma plays in the lives and health outcomes of survivors. In doing so, it helps promote physical, psychological, and emotional safety for both clinicians and patients. Trauma and traumatic events are cumulative over the lifespan, and individuals who have experienced trauma are at higher risk for re‐traumatization and poorer health outcomes. TIC approaches have been applied in many healthcare settings successfully; however, to date, there have not been any recommendations made about applying these approaches to care of homebound older adults, even though it may be surmised that this population is at an especially high risk for prior trauma and entering a person's safe space could be especially sensitive for trauma survivors. This paper serves to provide specific recommendations for applying a trauma‐informed approach to a home visit and provides recommendations to home‐based primary care groups and health systems about implementing universal trauma‐informed care to homebound older adults. [ABSTRACT FROM AUTHOR]

The coronavirus disease 19 (COVID-19) pandemic has created significant and new challenges for the conduct of clinical research involving older adults with Alzheimer's disease and related dementias (ADRD). It has also stimulated positive adaptations in methods for engaging older adults with ADRD in research, particularly through the increased availability of virtual platforms. In this paper, we describe how we adapted standard in-person participant recruitment and qualitative data collection methods for virtual use in a study of decision-making experiences in older adults with ADRD. We describe key considerations for the use of technology and virtual platforms and discuss our experience with using recommended strategies to recruit a diverse sample of older adults. We highlight the need for research funding that supports the community-based organizations on which improving equity in ADRD research participation often depends., (© 2022 The American Geriatrics Society.)

Background: The Successful Aging after Elective Surgery (SAGES) II study was designed to increase knowledge of the pathophysiology and linkages between delirium and dementia. We examine novel biomarkers potentially associated with delirium, including inflammation, Alzheimer's disease (AD) pathology and neurodegeneration, neuroimaging markers, and neurophysiologic markers. The goal of this paper is to describe the study design and methods for the SAGES II study. Methods: The SAGES II study is a 5‐year prospective observational study of 400–420 community dwelling persons, aged 65 years and older, assessed prior to scheduled surgery and followed daily throughout hospitalization to observe for development of delirium and other clinical outcomes. Delirium is measured with the Confusion Assessment Method (CAM), long form, after cognitive testing. Cognitive function is measured with a detailed neuropsychologic test battery, summarized as a weighted composite, the General Cognitive Performance (GCP) score. Other key measures include magnetic resonance imaging (MRI), transcranial magnetic stimulation (TMS)/electroencephalography (EEG), and Amyloid positron emission tomography (PET) imaging. We describe the eligibility criteria, enrollment flow, timing of assessments, and variables collected at baseline and during repeated assessments at 1, 2, 6, 12, and 18 months. Results: This study describes the hospital and surgery‐related variables, delirium, long‐term cognitive decline, clinical outcomes, and novel biomarkers. In inter‐rater reliability assessments, the CAM ratings (weighted kappa = 0.91, 95% confidence interval, CI = 0.74–1.0) in 50 paired assessments and GCP ratings (weighted kappa = 0.99, 95% CI 0.94–1.0) in 25 paired assessments. We describe procedures for data quality assurance and Covid‐19 adaptations. Conclusions: This complex study presents an innovative effort to advance our understanding of the inter‐relationship between delirium and dementia via novel biomarkers, collected in the context of major surgery in older adults. Strengths include the integration of MRI, TMS/EEG, PET modalities, and high‐quality longitudinal data. [ABSTRACT FROM AUTHOR]

Background: The primary objective of this paper was to examine perspectives and experiences of individuals with cognitive impairment who received an amyloid PET scan and their care partners, with regard to the process, logistics, and decision‐making associated with receiving an amyloid PET scan and its results. Methods: Structured telephone interviews were conducted with 200 randomly sampled scan recipient/care partner dyads from the CARE IDEAS study. The audio‐recorded, transcribed responses were analyzed using an inductive qualitative content analytic approach. Results: Participating individuals and care partners described their experiences in seeking a diagnosis for memory issues, including decision‐making and logistics involved with receiving an amyloid PET scan. Participants discussed the factors contributing to their decision to seek a diagnosis for their memory issues and their hopes and expectations in completing the scan. Participants also described the trajectory of this process, and although some described relatively straightforward trajectories, others described problems associated with identifying appropriate providers and coordinating care across numerous providers to obtain a diagnosis for their memory issues. Participants described an additional challenge of physicians attributing cognitive decline to normal aging, rather than signs of a neurodegenerative disorder. Conclusions: Findings shed light on the barriers and delays that individuals and care partners experience in connecting with physicians and obtaining a comprehensive evaluation for cognitive problems. Results from this study have implications for physicians who provide care to older adults, and specifically highlight the need for greater care coordination and clearer communication with and systems of referral for patients. [ABSTRACT FROM AUTHOR]

Background: Alzheimer's disease and related dementias (ADRD) affect 5.7 million Americans, and are expensive despite the lack of a cure or even treatments effective in managing the disease. The literature thus far has tended to focus on the costs to Medicare, even though one of the main characteristics of ADRD (the loss of independence and ability to care for oneself) incurs costs not covered by Medicare. Methods: In this paper, we use survey data for 2002–2016 from the Health and Retirement Study to estimate the out‐of‐pocket costs of ADRD for the patient and their family through the first 8 years after the onset of symptoms, as defined by a standardized 27‐point scale of cognitive ability. A two‐part model developed by Basu and Manning (2010) allows us to separate the costs attributable to ADRD into two components, one driven by differences in longevity and one driven by differences in utilization. Results: We identified a cohort of 3619 incident dementia cases, 38.9% were male, and 66.9% were non‐Hispanic White. Dementia onset was 77.7 years of age, on average. OOP costs attributable to dementia are $8751 over the first 8 years after the onset. These incremental costs are driven by nursing home expenditures, which are largely uninsured in the US. OOP spending is highest for whites and women. Conclusion: The financial burden of ADRD is significant, and largely attributable to the lack of wide‐spread long‐term care insurance. [ABSTRACT FROM AUTHOR]

Objectives: To investigate the association between baseline sleep apnea and risk of incident dementia in the Prevention of Alzheimer's Disease with Vitamin E and Selenium (PREADViSE) study and to explore whether the association depends on apolipoprotein E (APOE) ɛ4 allele status., Design: Secondary analysis based on data collected during PREADViSE., Setting: Participants were assessed at 128 local clinical study sites during the clinical trial phase and later were followed by telephone from a centralized location., Participants: Men enrolled in PREADViSE (without dementia or other active neurological conditions that affect cognition such as major psychiatric disorders, including depression; N = 7,547)., Measurements: Participants were interviewed at baseline for sleep apnea. The Memory Impairment Screen (MIS) was administered to each participant annually. Subjects who failed this initial screen were tested with secondary screening tests. Medical history and medication use were determined, and the AD8 dementia screening instrument was used., Results: The effect of self-reported sleep apnea on dementia risk depended on APOE ɛ4 status. When the allele was absent, baseline self-reported sleep apnea was associated with a 66% higher risk of developing dementia (95% confidence interval = 2-170%), whereas self-reported sleep apnea conferred no additional risk for participants with an ɛ4 allele., Conclusion: Sleep apnea may increase risk of dementia in the absence of APOE ɛ4. This may help inform prevention strategies for dementia or AD in older men with sleep apnea. Registration: PREADViSE is registered at ClinicalTrials.gov: NCT00040378., Competing Interests: The editor in chief has reviewed the conflict of interest checklist provided by the authors and has determined that the authors have no financial or any other kind of personal conflicts with this paper., (© 2016, Copyright the Authors Journal compilation © 2016, The American Geriatrics Society.)

Background: To demonstrate feasibility and utility of the iPad version of the NIH Toolbox Cognition Battery (NIHTB‐CB) in a clinical trial of older adults. Methods: Fifty‐one adults, aged 55 and older without dementia were tested twice on NIHTB‐CB and more traditional paper‐and‐pencil neuropsychological measures after meal ingestion, with approximately a 4‐week interval. We also compared performances at Time 1 and Time 2 for significant change. We also extracted the response times and errors for available NIHTB‐CB subtests to determine subtle changes in performance. Results: Over the interval, improvement in fluid cognitive measures was noted at Time 2 (t = −3.07, p = 0.004), whereas crystallized measures were unchanged. Tests of fluid cognition negatively correlated with age, particularly for the second visit. Analysis of the average speed per item showed that, for two of the tests, speed increased at Time 2. Traditional neuropsychological tests correlated with many of the NIHTB‐CB measures. Response times for all five timed tests decreased at Time 2, although only statistically significant for Picture Sequence and Picture Vocabulary. Conclusions: The iPad version of the NIH Toolbox Cognition Battery appears to be an adequate measure to assess cognitive functioning in a clinical trial of older adults. Psychometric analyses suggest stability in measures of crystallized functioning, whereas measures of fluid abilities revealed improvements over the short time frame of the study. Response times and errors for individual tests revealed intriguing relationships that should be further evaluated to determine the utility in clinical sample analysis, as this could aid identification of subtle cognitive change over short periods. Additional studies with larger sample sizes will be helpful to understanding the reliability, sensitivity, and specificity of the NIHTB‐CB sub‐scores in older adults. In addition, further evaluations with clinical populations, including individuals with cognitive impairment, are warranted. [ABSTRACT FROM AUTHOR]

The Northern California Chronic Care Network for Dementia brings together Northern California's major providers of managed care, community-based care, consumer education, and advocacy in new partnerships to improve the care of persons with dementia enrolled in managed care plans and their family caregivers. These partnerships are part of a national initiative entitled the Chronic Care Network for Alzheimer's Disease (CCN/AD) sponsored by the National Chronic Care Consortium and the Alzheimer's Association. This initiative selected eight promising provider-consumer partnerships across the country to implement and evaluate a new model of coordinated care for people with dementia and their families. This paper describes the Northern California network's partnerships and its intervention and challenges. The intervention is grounded in the key components of the CCN/AD model: "identification of patients with possible dementia, diagnostic assessment, care management and family caregiver information and support." These components, in turn, are translated into protocols and pathways designed to create timely, comprehensive, appropriate, and effective systems of care services that address the unique needs of dementia patients and their caregivers over the course of the disease.

Delirium in a patient with preexisting dementia is a common problem that may have serious complications and poor prognostic implications. The purpose of this paper was to conduct a systematic review of the medical literature on delirium superimposed on dementia, specifically to review studies on prevalence, associated features, outcomes, and management. Areas of controversy and gaps in our knowledge of this problem are highlighted. Finally, an agenda for future research is proposed. Fourteen studies were reviewed, including seven prospective studies, three retrospective studies, two cross-sectional studies, and two clinical trials. For the review of the literature on delirium superimposed on dementia, we searched MEDLINE from January 1966 through February 2002 for research studies with primary sources of data. Selection criteria for inclusion of articles in this study were inclusion of data on subjects with delirium superimposed on dementia, inclusion of a validated operational definition/measures of dementia and delirium, actual data on persons with delirium and dementia reported in the paper, and reporting of primary data. MEDLINE was searched using the following key search terms: delirium, acute confusion, cognitive impairment, Alzheimer's disease, dementia, delirium superimposed on dementia, and elderly. The prevalence of delirium superimposed on dementia ranged from 22% to 89% of hospitalized and community populations aged 65 and older with dementia. To date, only one reported study systematically identified associated factors and interventions for delirium superimposed on dementia, but several studies examining outcomes have found that adverse events are associated with delirium in persons with dementia, including accelerated and long-term cognitive and functional decline, need for institutionalization, rehospitalization, and increased mortality. This paper highlights the dearth of research on delirium superimposed on dementia and stresses the importance of early recognition and prevention of delirium in persons with dementia.

Objectives: Family caregiving is an integral part of the care system for persons with dementing disorders, such as Alzheimer's disease. This study tested role-training intervention as a way to help family caregivers appreciate and assume a more clinical belief set about caregiving and thereby ameliorate the adverse outcomes associated with caregiving., Design: Training effectiveness was tested in a trial in which family care receiver dyads were randomly assigned to training beginning immediately or were placed in a wait-list control group and assigned to receive training in 5 to 6 months, following completion of data collection., Setting: A community-based 14-hour training program provided in seven weekly 2-hour sessions. The training program curriculum was built on a stress and coping theory base. Recruitment and randomization were ongoing. Programs were begun every 2 months over a two and one half-year period for a total of 16 programs., Participants: Community health and social service agencies referred primary caregivers and at least one other family member of community-dwelling persons with dementia to participate., Measurements: Data reported in this paper were gathered from each participating family at entry to the study and 5 months later. Standard measures of beliefs about caregiving, burden, depression, and reaction to care receiver behavior were administered to caregivers. A standard measure of mental status was administered to the person with dementia and standardized instruments were used to gather information from caregivers concerning care receivers' behavior and abilities to perform activities of daily living (ADLs)., Results: Data were analyzed from 94 caregiver/care receiver dyads with complete sets of data. Treatment and control caregivers and care receivers were similar at baseline, and care receivers in both groups declined similarly over the 5-month period. Significant within-group improvements occurred with treatment group caregivers on measures of beliefs about caregiving (P = .044) and reaction to behavior (P = .001). When outcomes were compared, treatment group caregivers were significantly different (in the expected direction) from those in the control group on measures of the stress mediator, beliefs (P = .025), and key outcomes, response to behavior (P = .019), depression (P = .040), and burden (P = .051). There was a significant positive association between the strengthened mediator, the caregivers' having less-emotionally enmeshed beliefs about caregiving roles and responsibilities, and the outcome, namely improvements in burden (P = .019) and depression (P = .007)., Conclusion: A caregiver training intervention focused on the work of caregiving and targeted at knowledge, skills, and beliefs benefits caregivers in important outcome dimensions. The results suggest the benefits of providing information, linkage, and role coaching to dementia family caregivers.

Objective: Dementia is a serious public health problem. General medical comorbidity is common in dementia patients and critical to their care. However, little is known about medical comorbidity in these patients, and there are no straightforward bedside global rating scales for the seriousness of comorbid medical illness. This paper describes the development and measurement properties of the General Medical Health Rating (GHMR), a rapid global rating scale of medical comorbidity in dementia patients., Design: Interrater reliability, concurrent validity, and predictive validity of the GMHR are reported., Setting: An outpatient dementia clinic, assisted living, and nursing home., Participants: A total of 819 consecutive dementia clinic outpatients and 180 consecutive admissions to Copper Ridge, a long-term care residence for people with dementia, were included in the study., Results: GMHR was found to be highly reliable (weighted kappa = .91). Across all stages and types of dementia, GMHR ratings were correlated with number of comorbid medical conditions, number of medications being taken for comorbid conditions, and with activity of daily living impairment, even after adjustment for severity of dementia. GMHR ratings were also a strong predictor of falls and of mortality in long-term care residents after adjustment for age and severity of dementia., Conclusion: GMHR is a reliable, valid, global bedside measure of severity of general medical comorbidity for patients with dementia that can be used for clinical and research purposes.

Rehabilitative behavioral interventions that are documented in clinical trials to improve nursing home resident outcomes and are recommended by practice guidelines are often not adapted for daily use in nursing homes and other long-term care (LTC) facilities. Failure to evaluate issues other than clinical efficacy when developing interventions contributes to this gap between efficacy and effectiveness in practice. A potential solution is a research model that supplements traditional clinical intervention research with methodology designed specifically to evaluate the ability of LTC facilities to implement the interventions. This paper discusses several critical issues of intervention and implementation that should be addressed, including targeting interventions, advocacy, cost-effectiveness, training, and quality control. We also describe how clinical trials could be designed and staged to increase the probability that effective interventions will be implemented in the day-to-day care of frail older patients in LTC facilities.

There are distinct qualitative differences between the dementias that present with and without posterior cortical features. These can be utilized in dementia assessment. This paper reviews the validity and potential utility of a dichotomy based on generalized cortical (Type 1) versus isolated frontal system pathology (Type 2). These syndromes are associated with distinct differentials and problem behaviors. They may also result in different caregiving burdens or treatment responses. Alzheimer's disease (AD) is by far the most common cause of the Type 1 syndrome. Type 2 presentations select for potentially reversible non-AD conditions. Common cognitive screening instruments are insensitive to Type 2 cases. However, the Type 1/Type 2 distinction can be made reliably using qualitative clinical rating scales. We will review these instruments and discuss their application in clinical settings.

Despite the many complications and minimal benefits associated with long-term enteral nutrition in patients with advanced dementia, it is, nevertheless, a widespread practice in nursing homes throughout the United States. This paper presents a review of the literature on dementia, geriatric nutrition, and enteral feeding. There appears to be limited research to support the long-term benefits and safety of enteral nutrition in advanced dementia. Additionally, it is not yet clear that long-term enteral nutrition in advanced dementia results in an improved quality of life.

An ongoing debate in gerontology concerns the relationship between aging and disease. Goodwin, as part of a discussion on the importance of geriatric ideology, argues that age-related disorders like senile dementia of the Alzheimer's type (SDAT) should be regarded as an aging process, while others suggest it is more appropriate to consider it as a disease. This paper comments on the arguments presented by Goodwin and develops these by providing a review of the underlying assumptions concerning aging and disease. The policy relevance and implications for future research are also outlined.

The majority of research on "caregiver burden" focuses on mental health consequences. These stresses are associated with psychotropic drug use among some caregivers. The purposes of this paper are to identify the correlates of psychotropic drug use among caregivers of demented older adults and to determine whether or not certain types of psychotropics (ie, antianxiety, antidepressant, and sedative/hypnotic agents) have common or unique correlates. The prevalence of psychotropic drug use among caregivers in the sample (n = 510) is substantially higher than previously reported prevalence rates in the general population and among community-dwelling elderly. Using logistic regression techniques, caregiver characteristics (eg, gender, health, relationship to the patient) rather than severity of the patient's condition emerge as predictors of antianxiety, antidepressant, and sedative/hypnotic use. The caregiver's perception of how well he or she is supported in the caregiving role emerges as an important correlate of psychotropic drug use in general and especially of antidepressant consumption. Results suggest that caregivers are a high-risk group for the development of emotional symptoms such as nervousness, exhaustion, decreased appetite, and difficulty sleeping, symptoms that may or may not constitute a psychiatric disorder. Characteristics of the caregiver, especially aspects of the support system, should be important considerations in decisions to prescribe psychotropic drugs.

Objectives: To explore global changes in the prescription of analgesic drugs over time in the international long‐term care (LTC) population. Design: Systematic review. Setting: We included original research articles in English, published and unpublished, that included number of participants, country and year(s) of data collection, and prescription of analgesics (analgesics not otherwise specified, opioids, acetaminophen; scheduled only, or scheduled plus as needed (PRN)). Participants: LTC residents. Measurements: We searched PubMed, EMBASE, CINAHL, International Pharmaceutical Abstracts, PsycINFO, Cochrane, Web of Science, Google Scholar, using keywords for LTC facilities and analgesic medication; hand‐searched references of eligible papers; correspondence. Studies were quality rated using an adapted Newcastle‐Ottawa scale. Pearson correlation coefficients were generated between percentage of residents prescribed an analgesic and year of data collection. If available, we investigated changes in acetaminophen and opioid prescriptions. Results: Forty studies met inclusion criteria. A moderate correlation (0.59) suggested that scheduled prescription rates for analgesics have increased over time. Similar findings were reflected in scheduled prescriptions for acetaminophen and opioids. No increase was seen when analyzing scheduled plus PRN analgesics. Use of opioids (scheduled plus PRN) appears to have increased over time. Conclusion: Worldwide, use of opioids and acetaminophen has increased in LTC residents. Research is needed to explore whether this reflects appropriate pain management for LTC residents and if PRN medication is used effectively. [ABSTRACT FROM AUTHOR]

Objectives To describe the frequency and nature of deaths from resident-to-resident aggression ( RRA) in nursing homes in Australia. Design National population-based retrospective cohort study. Setting Accredited nursing homes in Australia. Participants Residents whose deaths resulted from RRA and were reported to the coroner between July 1, 2000, and December 31, 2013. Measurements Cases were identified using the National Coronial Information System, and data on individual, interpersonal, organizational, and societal factors were collected through review of the paper-based coroners' files. Results This research identified 28 deaths from RRA over a 14-year study period (0.004 per 100,000 bed days). Most exhibitors of aggression were male (n = 24, 85.7%), and risk of death from RRA was twice as high for male as for female nursing home residents (relative risk ( RR) = 2.13, 95% confidence interval ( CI) = 0.93-4.80, P = .05). Almost 90% of residents involved in RRA had a diagnosis of dementia, and three-quarters had a history of behavioral problems, including wandering and aggression. Dyad analysis showed that exhibitors of aggression were often younger and more recently admitted to the nursing home than targets. RRA incidents commonly occurred in communal areas and during the afternoon and involved a 'push and fall.' Seven (25%) RRA deaths had a coronial inquest; criminal charges were rarely filed. Conclusion This is the first national study in Australia, and the largest internationally, to examine RRA deaths using medicolegal data. This generates hypotheses for future research on the effect of environmental and organizational factors on the frequency and preventability of RRA. [ABSTRACT FROM AUTHOR]

In reviewing the literature on treatment approaches with the psychiatric elderly, a large number of studies were found which espouse comprehensive rehabilitation programs that usually require supplementation of existing personnel and expansion of facilities. Although some agencies and institutions are fortunate in securing the needed funds for such program implementation, most others face the reality of limited personnel and funding cutbacks. This paper briefly reviews modalities which do not demand additional expenditures for specialized facilities in the treatment of chronically ill geropsychiatric patients.

It has been recognized that AIDS can present initially as dementia without other neurological or clinical manifestations. In addition, HIV-contaminated blood transfusions in the elderly seem to be underreported. Because of these findings, dementia in the elderly may be misdiagnosed as Alzheimer's disease or other causes of senile dementia. This paper reports on one patient who presented with a diagnosis of Alzheimer's disease and was later found to have AIDS.

The interdisciplinary aspects of the psychogeriatric assessments described in three previous papers are discussed on the basis of factor-analysis findings and their significance in diagnosis, treatment, planning and theory. The difference between basic biopsychologic dysfunctions (including pathohistologic changes and various counter-regulations) and psychosocial dysfunctions (lifestyle) becomes clear statistically as well as clinically. This difference probably is fundamental, in the sense that intact biopsychologic functions are elementary tools for the psychosocial functions.

Few papers have been published concerning the efficacy of community-based memory and dementia screening programs. This article examines the descriptive, clinical, and outcome characteristics of participants attending the Memory Screening Outreach Program (MSOP). The program provided free screenings of participants' short-term memory processes, neurocognitive complaints, and depressive and psychiatric symptomatology. Screening results were subsequently forwarded to participants and their designated healthcare providers (HCPs), and approximately 8 weeks later, participants who received follow-up recommendations were mailed a survey assessing screening-related outcomes. One thousand community-based persons aged 44 to 91 participated in the program at 16 screening sites. Results indicated that 44.3% of the MSOP participants received follow-up recommendations secondary to age-inappropriate memory impairments, depressive or psychiatric symptomatology, significant neurocognitive complaints, need for respite, or a combination thereof. Memory impairments and depressive or psychiatric symptomatology contributed, at least in part, to the recommendations of 24.0% and 30.9% of the sample, respectively. The prevalence of impaired Wechsler Memory Scale-III subtest performances ranged from 20.5% to 5.4%, and 28.7% of the participants exhibited elevated depression inventory scores. Of the participants who returned follow-up surveys, 49.5% visited their primary HCPs regarding their screening results; of the participants who had not followed up, 36.8% indicated plans to do so. Of the participants who followed up, contributing conditions and diagnoses were identified in 50.9%, medication or supplement recommendations or regimen changes were provided to 47.1%, and 17.0% were referred to healthcare specialists. Overall, the MSOP proved efficacious in identifying age-inappropriate memory impairments, notable depressive and psychiatric symptomatology, and significant neurocognitive complaints in an appreciable portion of a large, community-based, sample of middle-aged and older adults, which, in turn, contributed to the identification and treatment of a diversity of conditions at follow-up. [ABSTRACT FROM AUTHOR]