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Background/objectives: Briefer measures of symptoms and functional limitations may reduce assessment burden and facilitate monitoring populations of persons with dementia (PWD)., Design: Prospective follow-up study., Setting: University-based dementia care management program., Participants: 1,091 PWD., Measurements: We assessed cognition (Mini Mental State Examination (MMSE)-11 tasks), neuropsychiatric symptom severity (Neuropsychiatric Inventory Questionnaire Severity Scale (NPIQ-S)-12 items), and functional ability (Activities of Daily Living (ADL)-6 items; Functional Activities Questionnaire (FAQ)-10 items). Item response theory was used to select subsets of items by identifying low item discrimination (<1.50), poor item fit (χ 2 ), local dependence (LD), and with difficulty similar to other items. We estimated correlations between original and shorter scales and compared their associations with mortality. We added two symptoms (trouble swallowing, coughing when eating) reflecting late-stage dementia complications, created a multi-dimensional dementia assessment composite, and examined its association with mortality., Results: Five MMSE tasks were eliminated: two with low discrimination, two with difficulty similar to other items, and one with poor fit. The remaining tasks were correlated with the full MMSE at r = 0.82. We retained three ADLs that were correlated with the total ADL set at r = 0.95 and kept five FAQ items that were not LD (correlation with full FAQ, r = 0.97). Associations with mortality were similar between the longer and shorter scales. A higher score on the composite (range 0-100) indicates worse dementia impact and was associated with mortality (hazard ratio (HR) per scale point: 1.03 (1.02-1.04))., Conclusion: These brief assessments and dementia composite may reduce administration time while preserving validity., (© 2020 The American Geriatrics Society.)

Background/objectives: Although nurse practitioner dementia care co-management has been shown to reduce total cost of care for fee-for-service (FFS) Medicare beneficiaries, the reasons for cost savings are unknown. To further understand the impact of dementia co-management on costs, we examined acute care utilization, long-term care admissions, and hospice use of program enrollees as compared with persons with dementia not in the program using FFS and managed Medicare claims data., Design: Quasi-experimental controlled before-and-after comparison., Setting: Urban academic medical center., Participants: A total of 856 University of California, Los Angeles (UCLA) Alzheimer's and Dementia Care program patients were enrolled between July 1, 2012, and December 31, 2015, and 3,139 similar UCLA patients with dementia not in the program. Comparison patients were identified as having dementia using International Classification of Diseases-9 codes and natural language processing of clinical notes. Coarsened exact matching was used to reduce covariate imbalance between intervention and comparison patients., Intervention: Dementia co-management model using nurse practitioners partnered with primary care providers and community organizations., Measurements: Average difference-in-differences per quarter over the 2.5-year intervention period for all-cause hospitalization, emergency department (ED) visits, intensive care unit (ICU) stays, and number of inpatient hospitalization days; admissions to long-term care facilities; and hospice use in the last 6 months of life., Results: Intervention patients had fewer ED visits (odds ratio [OR] = .80; 95% confidence interval [CI] = .66-.97) and shorter hospital length of stay (incident rate ratio = .74; 95% CI = .55-.99). There were no significant differences between groups for hospitalizations or ICU stays. Program participants were less likely to be admitted to a long-term care facility (hazard ratio = .65; 95% CI = .47-.89) and more likely to receive hospice services in the last 6 months of life (adjusted OR = 1.64; 95% CI = 1.13-2.37)., Conclusion: Comprehensive nurse practitioner dementia care co-management reduced ED visits, shortened hospital length of stay, increased hospice use, and delayed admission to long-term care., (© 2020 The American Geriatrics Society.)

Background/objectives: Persons with Alzheimer disease and related dementias (ADRDs) require comprehensive care that spans health systems and community-based organizations. This study examined the clinical outcomes of a comprehensive dementia care program and identified subgroups who were more likely to benefit., Design: Observational, baseline and 1 year after intervention., Setting: Urban, academic medical center., Participants: A total of 554 persons with dementia and their caregivers who had 1-year follow-up evaluations and data on clinical outcomes., Intervention: Health system-based comprehensive dementia care management program using nurse practitioner dementia care managers., Measurements: Patient measures included the Mini-Mental State Examination (MMSE), the Functional Activities Questionnaire, Basic and Instrumental Activities of Daily Living scales, the Cornell Scale for Depression in Dementia, and the Neuropsychiatric Inventory Questionnaire (NPI-Q) Severity. Caregiver measures included the Modified Caregiver Strain Index, the Patient Health Questionnaire-9, NPI-Q Distress, and the Dementia Burden Scale-Caregiver). We used established minimal clinically important differences and lowest tertiles of baseline symptoms to define improving symptoms and maintaining low symptoms as clinical benefit for patients and caregivers., Results: At year 1, persons with ADRD improved on all scales, except MMSE and functional status measures; caregivers improved on all scales. Using validated instruments, 314/543 (58%) of patients, 282/447 (63%) of caregivers, and 376/501 (75%) of patients or caregivers demonstrated clinical benefit. In adjusted multivariate models, at year 1, more behavioral symptoms and fewer depression symptoms at baseline were associated with patient improvement; and fewer baseline depression symptoms were associated with maintaining low behavioral symptoms. Male caregiver sex, higher baseline caregiver burden, and caring for patients with fewer baseline depression symptoms were associated with caregiver improvement. Male caregiver sex and patients with fewer depression symptoms, fewer behavioral symptoms, and more functional impairment at baseline were associated with caregivers maintaining low burden at 1 year., Conclusions: Health system-based comprehensive dementia care management is a promising approach to improving clinical outcomes, with benefits for both patients and caregivers. J Am Geriatr Soc 67:2267-2273, 2019., (© 2019 The American Geriatrics Society.)

Objectives: To better capture the scope of caregiver burden by creating a composite of 3 existing measures that assess different health domains., Design: Prospective follow-up study., Setting: University-based dementia care management program., Participants: Caregivers of persons with dementia (PWD) (N=1,091)., Measurements: The composite measure (the Dementia Burden Scale-Caregiver (DBS-CG)) was based on the Modified Caregiver Strain Index, Neuropsychiatric Inventory Questionnaire Distress Scale, and Patient Health Questionnaire (PHQ-9). Alternative factor structures were evaluated using 2 confirmatory factor analysis (CFA) models: a bifactor model and a 3 correlated factors model. Good model fit was defined as a root mean square error of approximation (RMSEA) of less than 0.06 and comparative fit index (CFI) value greater than 0.95. Coefficient omega was used to estimate scale reliability. Minimally important differences (MIDs) were estimated by anchoring the magnitude of DBS-CG change to change in caregiver self-efficacy and functional ability of PWD., Results: The bifactor CFA model fit best (RMSEA = 0.04, CFI = 0.95). Based on this model, a DBS-CG scale was created wherein all items were transformed to a possible range of 0 to 100 and then averaged. Higher scores indicate higher burden. Mean DBS-CG score was 27.3. The reliability was excellent (coefficient omega=0.93). MID estimates ranged from 4 to 5 points (effect sizes: 0.20-0.49)., Conclusion: This study provides support for the reliability and validity of the DBS-CG. It can be used as an outcome measure to assess the effect of interventions to reduce dementia caregiver burden., (© 2018, Copyright the Authors Journal compilation © 2018, The American Geriatrics Society.)

Objectives: To determine the effect and cost-effectiveness of training nonnursing staff to provide feeding assistance for nutritionally at-risk nursing home (NH) residents., Design: Randomized, controlled trial., Setting: Five community NHs., Participants: Long-stay NH residents with an order for caloric supplementation (N = 122)., Intervention: Research staff provided an 8-hour training curriculum to nonnursing staff. Trained staff were assigned to between-meal supplement or snack delivery for the intervention group; the control group received usual care., Measurements: Research staff used standardized observations and weighed-intake methods to measure frequency of between-meal delivery, staff assistance time, and resident caloric intake., Results: Fifty staff (mean 10 per site) completed training. The intervention had a significant effect on between-meal caloric intake (F = 56.29, P < .001), with the intervention group consuming, on average, 163.33 (95% CI = 120.19-206.47) calories per person per day more than the usual care control group. The intervention costs were $1.27 per person per day higher than usual care (P < .001). The incremental cost-effectiveness ratio for the intervention was 134 kcal per dollar. The increase in cost was due to the higher frequency and number of snack items given per person per day and the associated staff time to provide assistance., Conclusion: It is cost effective to train nonnursing staff to provide caloric supplementation, and this practice has a positive effect on residents' between-meal intake., (© 2016, Copyright the Authors Journal compilation © 2016, The American Geriatrics Society.)

Objectives: To determine the cost-effectiveness of two nutrition interventions on food, beverage, and supplement intake and body weight., Design: Randomized, controlled trial., Setting: Five skilled nursing home facilities., Participants: Long-stay residents with orders for nutrition supplementation (N = 154)., Intervention: Participants were randomized into a usual care control group, an oral liquid nutrition supplement (ONS) intervention group, or a snack intervention group. Research staff provided ONS, according to orders or a variety of snack foods and beverages twice per day between meals, 5 days per week for 24 weeks and assistance to promote consumption., Measurements: Research staff independently weighed residents at baseline and monthly during the 24-week intervention. Resident food, beverage and supplement intake and the amount of staff time spent providing assistance were assessed for 2 days at baseline and 2 days per month during the intervention using standardized observation and weighed intake procedures., Results: The ONS intervention group took in an average of 265 calories more per day and the snack intervention group an average of 303 calories more per day than the control group. Staff time required to provide each intervention averaged 11 and 14 minutes per person per offer for ONS and snacks, respectively, and 3 minutes for usual care. Both interventions were cost-effective in increasing caloric intake, but neither intervention had a significant effect on body weight, despite positive trends., Conclusion: Oral liquid nutrition supplements and snack offers were efficacious in promoting caloric intake when coupled with assistance to promote consumption and a variety of options, but neither intervention resulted in significant weight gain., 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., (© 2015, Copyright the Authors Journal compilation © 2015, The American Geriatrics Society.)

Objectives: To evaluate effects of a multicomponent intervention on fecal incontinence (FI) and urinary incontinence (UI) outcomes., Design: Randomized controlled trial., Setting: Six nursing homes (NHs)., Participants: One hundred twelve NH residents., Intervention: Intervention subjects were offered toileting assistance, exercise, and choice of food and fluid snacks every 2 hours for 8 hours per day over 3 months., Measurements: Frequency of UI and FI and rate of appropriate toileting as determined by direct checks from research staff. Anorectal assessments were completed on a subset of 29 residents., Results: The intervention significantly increased physical activity, frequency of toileting, and food and fluid intake. UI improved (P=.049), as did frequency of bowel movements (P<.001) and percentage of bowel movements (P<.001) in the toilet. The frequency of FI did not change. Eighty-nine percent of subjects who underwent anorectal testing showed a dyssynergic voiding pattern, which could explain the lack of efficacy of this intervention program alone on FI., Conclusion: This multicomponent intervention significantly changed multiple risk factors associated with FI and increased bowel movements without decreasing FI. The dyssynergic voiding pattern and rectal hyposensitivity suggest that future interventions may have to be supplemented with bulking agents (fiber), biofeedback therapy, or both to improve bowel function., (© 2010, Copyright the Authors. Journal compilation © 2010, The American Geriatrics Society.)

Objectives: Many elderly persons have drug benefits with coverage gaps, such as in Medicare Part D. Because beneficiaries who have such gaps must pay all drug costs, an accurate knowledge of gap thresholds and communication with providers about exceeding caps is important for elderly persons to manage out-of-pocket drug costs., Design: Cross-sectional survey., Setting: Health plan., Participants: One thousand three hundred eight health plan members aged 65 and older. The study was a 2002 cross-sectional survey of elderly persons with capped drug benefits in a managed care plan in one state. Participants were sampled so that half reached coverage caps and half did not., Methods: Participants reported cap levels, communication with providers about exceeding caps, and decreased medication use due to cost., Results: Of the 1,308 participants (65.4%response rate), 68.6%did not know their correct cap level. Rates were similar in those who exceeded caps (66.2%), reported difficulty paying for medications (63.9%), or decreased medication use (66%). For participants who exceeded caps, 59.1% did not know beforehand that they were close to exceeding caps and 50.2% did not tell providers afterward. In multivariate analyses accounting for demographics and health, the oldest participants (> or =85 vs 65-74) were at greater risk for not knowing cap levels (odds ratio (OR)=2.0, 95% confidence interval (CI)=1.2-3.4) and not telling providers about exceeding caps (OR=2.2, 95% CI=1.1-4.5)., Conclusions: Elderly patients often did not know correct cap levels and did not tell providers about exceeding caps. Providers, plans, and policymakers should actively assess and improve Medicare beneficiaries' knowledge of Part D coverage gaps.

Objectives: To compare the costs of mobile and stationary mammography and examine the incremental cost-effectiveness of using mobile mammography to increase screening rates., Design: A cost-effectiveness analysis was performed using effectiveness data from a randomized clinical trial and modeling of costs associated with the mobile mammography intervention., Setting: The trial involved 60 community-based meal sites, senior centers, and clubs., Participants: Four hundred ninety-nine individuals were enrolled in the study, of whom 463 had outcome data available for analysis., Measurements: Costs were calculated for stationary and mobile mammography, as well as costs due to differences in technology and film versus digital. Incremental cost-effectiveness (cost per additional screen) was modeled, and sensitivity analysis was performed by altering efficiency (throughput) and effectiveness based on subgroup data from the randomized trial., Results: The estimated annual costs were $435,162 for a stationary unit, $539,052 for a mobile film unit, and $456, 392 for a mobile digital unit. Assuming mobile units are less efficient (50% annual volume), the cost per screen was $41 for a stationary unit, $86 for a mobile film unit, and $102 for a mobile digital unit. The incremental cost per additional screen were $207 for a mobile film unit and $264 for a mobile digital unit over a stationary unit., Conclusion: Although mobile mammography is a more effective way to screen older women, the absolute cost per screen of mobile units is higher, whereas the reimbursement is no different. Financial barriers may impede the widespread use of this approach.

Objectives: To determine the effects of a feeding assistance intervention on food and fluid intake and body weight., Design: Crossover controlled trial., Setting: Four skilled nursing homes (NHs)., Participants: Seventy-six long-stay NH residents at risk for unintentional weight loss., Intervention: Research staff provided feeding assistance twice per day during or between meals, 5 days per week for 24 weeks., Measurements: Research staff independently weighed residents at baseline and monthly during a 24-week intervention and 24-week control period. Residents' food and fluid intake and the amount of staff time spent providing assistance to eat was assessed for 2 days at baseline and 3 and 6 months during each 24-week period., Results: The intervention group showed a significant increase in estimated total daily caloric intake and maintained or gained weight, whereas the control group showed no change in estimated total daily caloric intake and lost weight over 24 weeks. The average amount of staff time required to provide the interventions was 42 minutes per person per meal and 13 minutes per person per between-meal snack, versus usual care, during which residents received, on average, 5 minutes of assistance per person per meal and less than 1 minute per person per snack., Conclusion: Two feeding assistance interventions are efficacious in promoting food and fluid intake and weight gain in residents at risk for weight loss. Both interventions require more staff time than usual NH care. The delivery of snacks between meals requires less time than mealtime assistance and thus may be more practical to implement in daily NH care practice.

Objectives: To determine whether elderly patients with high drug expenditures want and receive providers' help in managing drug costs., Design: Cross-sectional survey., Setting: A Medicare managed care plan (>400,000 members) in one state in 2002., Participants: One thousand one hundred six seniors (62% response rate) sampled so that half exceeded caps on their drug benefits the previous year, and all had total drug expenditures in the top quartile of members in their cap level., Measurements: Participants' preferences and experiences with providers discussing costs and participation in choosing medications., Results: Two-thirds reported difficulty paying for medications, and one-fourth decreased medication use because of cost. Most wanted providers to ask about medication affordability (81%), consider cost (86%), offer choices (70%), and to persuade them or decide for them which medication to use (88%), but few said providers asked about affordability (17%), usually or always discussed prices (19%), or offered choices (45%), although nearly all said providers chose their medications (93%). Sixty-two percent had asked providers for help with drug costs, although 34% who used less medication because of cost or had difficulty paying for medications had not asked for help., Conclusion: Providers should be aware that elderly patients want their help in managing drug costs but do not always receive it or ask for help when they need it. Providers could improve communication by initiating conversations about cost and by asking patients about preferences when prescribing.

Objectives: To evaluate the benefit of eyeglasses and magnifiers in elderly patients with uncorrected refractive errors., Design: A single-center, randomized, prospective, controlled trial (September 2001 to August 2003)., Setting: Los Angeles County, California., Participants: One hundred thirty-one community-dwelling persons aged 65 and older who had habitual distance visual acuity of 20/32 or worse and whose distant visual acuity, near visual acuity, or both could be improved with eyeglasses, a magnifier, or both by two lines of acuity or more., Intervention: Sixty-six were randomized to receive a prescription and voucher for free eyeglasses, a magnifier, or both immediately, and 65 were randomized to receive a prescription and voucher after the 3-month follow-up visit (the control group)., Measurements: Primary outcome was vision-specific functioning as measured using the 25-item National Eye Institute-Visual Functioning Questionnaire (NEI-VFQ). Secondary outcomes were distance and near visual acuity and overall functioning as measured using the Rosow-Breslau function questionnaire., Results: In the intention-to-treat analysis of 3-month follow-up data, participants who received the eyeglasses prescription and voucher immediately had greater improvement in NEI-VFQ composite scores than the control group (P<.01). They also had greater improvement in perceptions of their general vision (P<.01), distance visual acuity (P=.03), near visual acuity (P=.04), and mental health (P=.02)., Conclusion: Correction of uncorrected refractive error, one of the leading causes of visual impairment in older people, improved the vision-specific quality of life of community-dwelling older persons.

Objectives: To examine hospital use for patients with evidence of cognitive decline indicative of early cognitive impairment., Design: Medicare Part A hospital utilization data were linked to data from the MacArthur Research Network on Successful Aging Community Study to examine the association between baseline cognition and decline in cognitive function over a 3-year period and any hospitalization over that same period., Setting: New Haven, Connecticut, and East Boston, Massachusetts., Participants: Subjects (N=598) were from two sites of the MacArthur Research Network on Successful Aging Community Study, a 7-year cohort study of community-dwelling older persons with high physical and cognitive functioning., Measurements: Multivariate logistic regression was used to determine the association between any hospitalization over 3 years (1988-91) as the outcome variable and baseline cognitive function and decline in cognition over 3 years as primary predictor variables. Decline was based upon repeated (1988 and 1991) measures of delayed verbal recall and the Short Portable Mental Status Questionnaire (SPMSQ)., Results: Of 598 subjects, 48 died between 1988 and 1991. No baseline (1988) delayed recall scores or change in recall scores (1988-91) were associated with hospitalization. Although 48.2% declined on verbal memory scores, decline was not associated with risk of hospitalization. Of 494 subjects with complete 3-year data, 31.2% declined at least one point on the SPMSQ, and 4.7% declined more than two points. Among individuals aged 75 and older at baseline, the adjusted odds ratio for hospitalization for those who declined more than 2 points compared with those who declined less was 7.8 (95% confidence interval=2.0-30.8)., Conclusion: Although specific memory tests were not associated with hospitalization, high-functioning older persons who experienced decline in overall cognitive function were more likely to be hospitalized. Variation in baseline cognitive function in this high-functioning cohort did not affect hospitalization, but additional research is needed to evaluate associations with other healthcare costs., (Copyright 2004 American Geriatrics Society)

Objectives: To determine the relative costs of four risk-identification strategies and compare their performance in predicting hospital use by different subgroups of older persons based on age, sex, and prior hospital use., Design: Prospective validation study and cost-comparison analysis., Setting: Community-based., Participants: Five thousand one hundred thirty-eight participants of the sixth wave of three sites of the Established Populations for Epidemiologic Studies of the Elderly., Measurements: Four strategies (prior hospitalization data only, a 10-item self-report screen alone, self-report combined with two laboratory tests, and sequential self-report plus as-needed use of laboratory tests when the self-report screen is inconclusive) and 3-year Medicare Part A hospital cost data., Results: Assuming that interventions based on screening would yield a total benefit of $1,000 per true-positive case and a cost of $400 for each false-positive case, the sequential strategy was slightly less expensive than the self-report only strategy; both were considerably less expensive than the combined or hospitalization-only strategies. Accuracy as measured by the area under the receiver operating characteristic curve for the sequential strategy was comparable for all subgroups (between 0.62 and 0.70) but was least accurate for those who had high prior use and for those aged 85 and older., Conclusion: A sequential screening strategy that administers laboratory tests selectively is slightly less expensive than one that uses only self-report items. This strategy is also accurate in both sexes, in those with various degrees of prior use, and in the oldest old.

Objective: More than half of nursing home residents suffer from urinary incontinence. These residents typically have long stays and, because of comorbid cognitive and physical impairments, have little hope of living again in a noninstitutional environment The value of interventions to change functional status of this chronically institutionalized population is often questioned. This paper explores this value issue in the context of two incontinence management interventions that have been shown to improve functional status: (1) Functional Incidental Training (FIT), and (2) Prompted Voiding (PV). The relative value of the different interventions for the nursing home population was estimated using paired preferences., Design: The cost of two interventions (FIT and PV) that target incontinent nursing home residents was related to the value of these interventions as perceived by consumers of nursing home services. Both interventions decrease incontinence frequency, and one intervention also improves mobility endurance., Participants: Ninety incontinent nursing home residents received the intervention; 37 older nondemented board and care residents and 31 family members of the nursing home residents provided estimates of the intervention's value., Measurement: The staff-time allocations involved in implementing both interventions were documented in more than 85 resident care episodes. These time data were converted to labor cost based on the cost of nursing aides who would actually implement the intervention. The value of each intervention was assessed by asking consumers to make choices between the intervention and its associated outcomes (such as increased dryness) and other nursing home services of known cost (e.g., moving to a private room)., Results: Both interventions had labor costs that were greater than "usual care" costs. The additional cost was estimated to be $4.31 per resident per day for PV and $6.42 per resident per day for FIT if these programs were implemented from 7 AM to 7 AM. Consumer preference data indicated that consumers preferred the FIT and PV outcomes to more expensive alternative services, calculated to cost $10.00 per day, often marketed to consumers,, Conclusion: Consumers may prefer the FIT and PV interventions relative to the typical services often marketed to the nursing home consumer. The analysis completed in this paper suggests that both interventions have value for frail residents likely to live out their lives in a nursing home.