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Most innovations developed to reduce the burden of Alzheimer disease and other related dementias (ADRD) are difficult to implement, diffuse, and scale. The consequences of such challenges in design, implementation, and diffusion are suboptimal care and resulting harm for people living with ADRD and their caregivers. National experts identified four factors that contribute to our limited ability to implement and diffuse of evidence‐based services and interventions for people living with ADRD: (1) limited market demand for the implementation and diffusion of effective ADRD interventions; (2) insufficient engagement of persons living with ADRD and those caring for them in the development of potential ADRD services and interventions; (3) limited evidence and experience regarding scalability and sustainability of evidence‐based ADRD care services; and (4) difficulties in taking innovations that work in one context and successfully implementing them in other contexts. New investments in the science of human‐centered design, implementation, and diffusion are crucial for meeting the goals of the National Plan to Address Alzheimer's Disease under the auspices of the National Alzheimer's Project Act. [ABSTRACT FROM AUTHOR]

Function and the independent performance of daily activities are of critical importance to older adults. Although function was once a domain of interest primarily limited to geriatricians, transdisciplinary research has demonstrated its value across the spectrum of medical and surgical care. Nonetheless, integrating a functional perspective into medical and surgical therapeutics has yet to be implemented consistently into clinical practice. This article summarizes the presentations and discussions from a workshop, "Embedding/Sustaining a Focus on Function in Specialty Research and Care," held on January 31 to February 1, 2019. The third in a series supported by the National Institute on Aging and the John A. Hartford Foundation, the workshop aimed to identify scientific gaps and recommend research strategies to advance the implementation of function in care of older adults. Transdisciplinary leaders discussed implementation of mobility programs and functional assessments, including comprehensive geriatric assessment; integrating cognitive and sensory functional assessments; the role of culture, environment, and community in incorporating function into research; innovative methods to better identify functional limitations, techniques, and interventions to facilitate functional gains; and the role of the health system in fostering integration of function. Workshop participants emphasized the importance of aligning goals and assessments and adopting a team science approach that includes clinicians and frontline staff in the planning, development, testing, and implementation of tools and initiatives. This article summarizes those discussions. See related editorial by Ling et al. [ABSTRACT FROM AUTHOR]

OBJECTIVES: Developing scalable strategies for the early identification of Alzheimer's disease and related dementia (ADRD) is important. We aimed to develop a passive digital signature for early identification of ADRD using electronic medical record (EMR) data. DESIGN: A case‐control study. SETTING: The Indiana Network for Patient Care (INPC), a regional health information exchange in Indiana. PARTICIPANTS: Patients identified with ADRD and matched controls. MEASUREMENTS: We used data from the INPC that includes structured and unstructured (visit notes, progress notes, medication notes) EMR data. Cases and controls were matched on age, race, and sex. The derivation sample consisted of 10 504 cases and 39 510 controls; the validation sample included 4500 cases and 16 952 controls. We constructed models to identify early 1‐ to 10‐year, 3‐ to 10‐year, and 5‐ to 10‐year ADRD signatures. The analyses included 14 diagnostic risk variables and 10 drug classes in addition to new variables produced from unstructured data (eg, disorientation, confusion, wandering, apraxia, etc). The area under the receiver operating characteristics (AUROC) curve was used to determine the best models. RESULTS: The AUROC curves for the validation samples for the 1‐ to 10‐year, 3‐ to 10‐year, and 5‐ to 10‐year models that used only structured data were.689,.649, and.633, respectively. For the same samples and years, models that used both structured and unstructured data produced AUROC curves of.798,.748, and.704, respectively. Using a cutoff to maximize sensitivity and specificity, the 1‐ to 10‐year, 3‐ to 10‐year, and 5‐ to 10‐year models had sensitivity that ranged from 51% to 62% and specificity that ranged from 80% to 89%. CONCLUSION: EMR‐based data provide a targeted and scalable process for early identification of risk of ADRD as an alternative to traditional population screening. J Am Geriatr Soc 68:511–518, 2020 [ABSTRACT FROM AUTHOR]

This article describes how key aspects of the Sandra Eskenazi Center for Brain Care Innovation's (SECBCI) care model can inform other entities on the development of new models of population health management, through a framework that emphasizes social, behavioral, and environmental determinants of health, as well as biomedical aspects. The SECBCI is a collaboration with Eskenazi Health and community-based organizations such as the Central Indiana Council on Aging Area Agency on Aging and the Greater Indianapolis Chapter of the Alzheimer's Association in Central Indiana. [ABSTRACT FROM AUTHOR]

The current US system of reimbursement for dementia care does not support the complex biospychosocial needs of families living with Alzheimer disease and related dementias. We propose an alternative payment system for dementia care that would provide insurance coverage for evidence-based, collaborative dementia care models. This payment model involves a per member per month payment for care management services that would target community-dwelling beneficiaries living with dementia and evidence-based education and support programs for unpaid caregivers. This payment model has the potential to align the incentives of payers and providers and create market demand for the implementation of collaborative dementia care models across the nation. [ABSTRACT FROM AUTHOR]

Objectives: To describe the essential components of an Agile Implementation (AI) process, which rapidly and effectively implements evidence‐based healthcare solutions, and present a case study demonstrating its utility. Design: Case demonstration study. Setting: Integrated, safety net healthcare delivery system in Indianapolis. Participants: Interdisciplinary team of clinicians and administrators. Measurements: Reduction in dementia symptoms and caregiver burden; inpatient and outpatient care expenditures. Results: Implementation scientists were able to implement a collaborative care model for dementia care and sustain it for more than 9 years. The model was implemented and sustained by using the elements of the AI process: proactive surveillance and confirmation of clinical opportunities, selection of the right evidence‐based healthcare solution, localization (i.e., tailoring to the local environment) of the selected solution, development of an evaluation plan and performance feedback loop, development of a minimally standardized operation manual, and updating such manual annually. Conclusion: The AI process provides an effective model to implement and sustain evidence‐based healthcare solutions. [ABSTRACT FROM AUTHOR]

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

Background: The timely detection of Alzheimer's disease and other related dementias (ADRD) is suboptimal. Digital data already stored in electronic health records (EHR) offer opportunities for enhancing the timely detection of ADRD by facilitating the development of passive digital markers (PDMs). We conducted a systematic evidence review to identify studies that describe the development, performance, and validity of EHR‐based PDMs for ADRD. Methods: We searched the literature published from January 2000 to August 2022 and reviewed cross‐sectional, retrospective, or prospective observational studies with a patient population of 18 years or older, published in English that collected and interpreted original data, included EHR as a source of digital data, and had the primary purpose of supporting ADRD care. We extracted relevant data from the included studies with guidance from the Critical Appraisal and Data Extraction for Systematic Reviews of Prediction Modelling Studies checklist and used the US Preventive Services Task Force criteria to appraise each study. Results: We included and appraised 19 studies. Four studies were considered to have a fair quality, and none was considered to have a good quality. The functionality of the PDMs varied from detecting mild cognitive impairment, Alzheimer's disease or ADRD, to forecasting stages of ADRD. Only seven studies used a valid reference diagnostic method. Nine PDMs used only structured EHR data, and five studies provided complete information on the race and ethnicity of its population. The number of features included in the PDMs ranges from 10 to 853, and the PMDs used a variety of statistical and machine learning algorithms with various time‐at‐risk windows. The area under the curve (AUC) for the PDMs varied from 0.67 to 0.97. Conclusion: Although we noted heterogeneity in the PDMs development and performance, there is evidence that these PDMs have the potential to detect ADRD at earlier stages. [ABSTRACT FROM AUTHOR]

Background: Alzheimer disease results in progressive functional decline, leading to loss of independence.Objective: To determine whether collaborative care plus 2 years of home-based occupational therapy delays functional decline.Design: Randomized, controlled clinical trial. (ClinicalTrials.gov: NCT01314950).Setting: Urban public health system.Patients: 180 community-dwelling participants with Alzheimer disease and their informal caregivers.Intervention: All participants received collaborative care for dementia. Patients in the intervention group also received in-home occupational therapy delivered in 24 sessions over 2 years.Measurements: The primary outcome measure was the Alzheimer's Disease Cooperative Study Group Activities of Daily Living Scale (ADCS ADL); performance-based measures included the Short Physical Performance Battery (SPPB) and Short Portable Sarcopenia Measure (SPSM).Results: At baseline, clinical characteristics did not differ significantly between groups; the mean Mini-Mental State Examination score for both groups was 19 (SD, 7). The intervention group received a median of 18 home visits from the study occupational therapists. In both groups, ADCS ADL scores declined over 24 months. At the primary end point of 24 months, ADCS ADL scores did not differ between groups (mean difference, 2.34 [95% CI, -5.27 to 9.96]). We also could not definitively demonstrate between-group differences in mean SPPB or SPSM values.Limitation: The results of this trial are indeterminate and do not rule out potential clinically important effects of the intervention.Conclusion: The authors could not definitively demonstrate whether the addition of 2 years of in-home occupational therapy to a collaborative care management model slowed the rate of functional decline among persons with Alzheimer disease. This trial underscores the burden undertaken by caregivers as they provide care for family members with Alzheimer disease and the difficulty in slowing functional decline.Primary Funding Source: National Institute on Aging. [ABSTRACT FROM AUTHOR]

An editorial is presented which addresses the authors' views about the historical evolution of geriatric medicine as of 2017, and it mentions the authors' careers as Geriatricians, as well as the labeling of geriatric medicine as a metadiscipline. The use of medical innovations to increase patient safety and the quality of medical care for an aging population in America is examined, along with the teaching of geriatrics, patience, and fellowship programs.

Objectives To determine individuals' perceptions concerning dementia screening and to evaluate the possibility of an association between their perceptions and their willingness to undergo screening. Design Cross-sectional study of primary care patients aged 65 and older. Setting Urban primary care clinics in Indianapolis, Indiana, in 2008 to 2009. Participants Five hundred fifty-four primary care patients without a documented diagnosis of dementia. Measurements The Perceptions Regarding Investigational Screening for Memory in Primary Care Questionnaire ( PRISM- PC) and agreement or refusal to undergo dementia screening. Results Of the 554 study participants who completed the PRISM- PC, 65.5% were aged 70 and older, 70.0% were female, and 56.5% were African American; 57 (10.3%) refused screening for dementia. Of the 497 (89.7%) who agreed to screening, 63 (12.7%) screened positive. After adjusting for age, perception of depression screening, perception of colon cancer screening, and belief that no treatment is currently available for Alzheimer's disease, the odds of refusing screening were significantly lower in participants who had higher PRISM- PC domain scores for benefits of dementia screening (odds ratio ( OR) = 0.85, 95% confidence interval ( CI) = 0.75-0.97; P = .02). In the same regression model, the odds of refusing screening were significantly higher in participants aged 70 to 74 ( OR = 5.65, 95% CI = 2.27-14.09; P < .001) and those aged 75 to 79 ( OR = 3.63, 95% CI = 1.32-9.99; P = .01) than in the reference group of patients aged 65 to 69. Conclusion Age and perceived benefit of screening are associated with acceptance of dementia screening in primary care. [ABSTRACT FROM AUTHOR]

Background: Approximately 40% of hospitalized older adults have cognitive impairment (CI) and are more prone to hospital-acquired complications. The Institute of Medicine suggests using health information technology to improve the overall safety and quality of the health care system. Objective: Evaluate the efficacy of a clinical decision support system (CDSS) to improve the quality of care for hospitalized older adults with CI. Design: A randomized controlled clinical trial. Setting: A public hospital in Indianapolis. Population: A total of 998 hospitalized older adults were screened for CI, and 424 patients (225 intervention, 199 control) with CI were enrolled in the trial with a mean age of 74.8, 59% African Americans, and 68% female. Intervention: A CDSS alerts the physicians of the presence of CI, recommends early referral into a geriatric consult, and suggests discontinuation of the use of Foley catheterization, physical restraints, and anticholinergic drugs. Measurements: Orders of a geriatric consult and discontinuation orders of Foley catheterization, physical restraints, or anticholinergic drugs. Results: Using intent-to-treat analyses, there were no differences between the intervention and the control groups in geriatric consult orders (56% vs 49%, P = 0.21); discontinuation orders for Foley catheterization (61.7% vs 64.6%, P = 0.86); physical restraints (4.8% vs 0%, P = 0.86), or anticholinergic drugs (48.9% vs 31.2%, P = 0.11). Conclusion: A simple screening program for CI followed by a CDSS did not change physician prescribing behaviors or improve the process of care for hospitalized older adults with CI. [ABSTRACT FROM AUTHOR]

Background: Given the current lack of disease-modifying therapies, it is important to explore new models of longitudinal care for older adults with dementia that focus on improving quality of life and delaying functional decline. In a previous clinical trial, we demonstrated that collaborative care for Alzheimer's disease reduces patients' neuropsychiatric symptoms as well as caregiver stress. However, these improvements in quality of life were not associated with delays in subjects' functional decline. Trial design: Parallel randomized controlled clinical trial with 1:1 allocation. Participants: A total of 180 community-dwelling patients aged ≥45 years who are diagnosed with possible or probable Alzheimer's disease; subjects must also have a caregiver willing to participate in the study and be willing to accept home visits. Subjects and their caregivers are enrolled from the primary care and geriatric medicine practices of an urban public health system serving Indianapolis, Indiana, USA. Interventions: All patients receive best practices primary care including collaborative care by a dementia care manager over two years; this best practices primary care program represents the local adaptation and implementation of our prior collaborative care intervention in the urban public health system. Intervention patients also receive in-home occupational therapy delivered in twenty-four sessions over two years in addition to best practices primary care. The focus of the occupational therapy intervention is delaying functional decline and helping both subjects and caregivers adapt to functional impairments. The in-home sessions are tailored to the specific needs and goals of each patient-caregiver dyad; these needs are expected to change over the course of the study. Objective: To determine whether best practices primary care plus home-based occupational therapy delays functional decline among patients with Alzheimer's disease compared to subjects treated in the control group. Outcomes: The primary outcome is the Alzheimer's Disease Cooperative Studies Group Activities of Daily Living Scale; secondary outcome measures are two performance-based measures including the Short Physical Performance Battery and Short Portable Sarcopenia Measure. Outcome assessments for both the caregiver-reported scale and subjects' physical performance scales are completed in the subject's home. Randomization: Eligible patient-care giver dyads will be stratified by clinic type and block randomized with a computer developed randomization scheme using a 1:1 allocation ratio. Blinding: Single blinded. Research assistants completing the outcome assessments were blinded to the subjects' treatment group. Trial status: Ongoing ClinicalTrial.Gov identifier: NCT01314950; date of completed registration 10 March 2011; date first patient randomized 9 March 2011 [ABSTRACT FROM AUTHOR]

The article reports on a global increase which has been seen in the number of older people who have developed age related cognition disorders such as Alzheimer's disease and discusses the annual costs to the U.S. health care system that are attributed to diseases which feature cognitive impairment in older people. In the article the authors offer their opinions on a framework which could be used to improve the care of individuals with age related cognition disorders.

The article presents an overview of a framework which has been developed and which could be used to improve the care of older patients with delirium. A discussion of the medical costs that are associated with treating older patients with delirium and other age related diseases such as Alzheimer's disease, and of an increase which is expected to be seen across the globe in the number of older patients who are diagnosed with delirium and other age related diseases, is presented.

Objectives: To determine the acceptability of dementia screening in two populations of older adults in different primary care settings. Methods: Cross-sectional study of consecutive patients presenting for primary care appointments in the Duke University Health System (n¼152) or Durham VA Medical Center (n=193) were evaluated face to face using the Dementia Screening and Perceived Harms (SAPH) questionnaire. Results: Overall, 81% of primary care patients indicated that they would want to be screened to determine if they are developing dementia. After exposure to possible risks and benefits of screening, 86% of patients indicated they would like to be screened. The SAPH was easy to use and contained five relevant and cohesive domains. The items most associated with a desire for dementia screening were male gender, acceptance of other types of screening, and a belief that a treatment for dementia exists. Conclusions: Primary care patients in two different health care systems indicated they would like to be screened for dementia. The SAPH was easy to use and contains cohesive domains. Copyright # 2010 John Wiley & Sons, Ltd. [ABSTRACT FROM AUTHOR]

OBJECTIVES: To compare attitudes toward dementia screening of older adults with and without an experience of dementia caregiving. DESIGN: A cross-sectional study. SETTING: Primary care clinics in Indianapolis, Indiana. PARTICIPANTS: Eighty-one participants with dementia caregiving experience (CG) and a random sample of 125 participants without dementia caregiving experience (NCG). MEASUREMENTS: Attitudes of dementia screening, including acceptance of dementia screening and its perceived harms and benefits, as determined according to the Perceptions Regarding Investigational Screening for Memory in Primary Care questionnaire. RESULTS: After adjusting for age, race, sex, and education, CGs had a lower dementia screening acceptance mean score (53.9 vs 60.6; P=.03) and a higher perceived suffering score (61.6 vs 55.9, P=.04) than NCGs, but there were no differences in perceived benefits of dementia screening (72.8 vs 69.0; P=.50), perceived stigma (32.9 vs 37.5; P=.12), and perceived negative effect on independence (47.6 vs 54.0; P=.20). The top three barriers to screening identified by both groups were emotional suffering by the family (86% of CGs and 75% of NCGs), loss of driving privileges (75% of CGs and 78% of NCGs), and becoming depressed (64% of CGs and 43% of NCGs). CONCLUSION: The experience of being a dementia caregiver may influence one's own attitude about accepting dementia screening for oneself. [ABSTRACT FROM AUTHOR]

Background: Recent randomized controlled trials have demonstrated the effectiveness of the collaborative dementia care model targeting both the patients suffering from dementia and their informal caregivers. Objective: To implement a sustainable collaborative dementia care program in a public health care system in Indianapolis. Methods: We used the framework of Complex Adaptive System and the tool of the Reflective Adaptive Process to translate the results of the dementia care trial into the Healthy Aging Brain Center (HABC). Results: Within its first year of operation, the HABC delivered 528 visits to serve 208 patients and 176 informal caregivers. The mean age of HABC patients was 73.8 (standard deviation, SD 9.5), 40% were African-Americans, 42% had less than high school education, 14% had normal cognitive status, 39% received a diagnosis of mild cognitive impairment, and 46% were diagnosed with dementia. Within 12 months of the initial HABC visit, 28% of patients had at least one visit to an emergency room (ER) and 14% were hospitalized with a mean length of stay of five days. The rate of a one-week ER revisit was 14% and the 30-day rehospitalization rate was 11%. Only 5% of HABC patients received an order for neuroleptics and only 16% had simultaneous orders for both definite anticholinergic and anti-dementia drugs. Conclusion: The tools of 'implementation science' can be utilized to translate a health care delivery model developed in the research laboratory to a practical, operational, health care delivery program. [ABSTRACT FROM AUTHOR]

Objectives: The purpose of this article is to describe our experience in implementing a primary care-based dementia and depression care program focused on providing collaborative care for dementia and late-life depression. Methods: Capitalizing on the substantial interest in the US on the patient-centered medical home concept, the Aging Brain Care Medical Home targets older adults with dementia and/or late-life depression in the primary care setting. We describe a structured set of activities that laid the foundation for a new partnership with the primary care practice and the lessons learned in implementing this new care model. We also provide a description of the core components of this innovative memory care program. Results: Findings from three recent randomized clinical trials provided the rationale and basic components for implementing the new memory care program. We used the reflective adaptive process as a relationship building framework that recognizes primary care practices as complex adaptive systems. This framework allows for local adaptation of the protocols and procedures developed in the clinical trials. Tailored care for individual patients is facilitated through a care manager working in collaboration with a primary care physician and supported by specialists in a memory care clinic as well as by information technology resources. Conclusions: We have successfully overcome many system-level barriers in implementing a collaborative care program for dementia and depression in primary care. Spontaneous adoption of new models of care is unlikely without specific attention to the complexities and resource constraints of health care systems. [ABSTRACT FROM AUTHOR]

Despite the significant burden of delirium among hospitalized adults, there is no approved pharmacologic intervention for delirium. This systematic review evaluates the efficacy and safety of pharmacologic interventions targeting either prevention or management of delirium. We searched Medline, PubMed, the Cochrane Register of Controlled Trials, and the Cumulative Index to Nursing and Allied Health Literature (CINAHL) information systems from January 1966 to October 2008. We included randomized, controlled trials comparing pharmacologic compounds either to each other or placebo. We excluded non-comparison trials, studies with patients aged < 18 years, a history of an Axis I psychiatric disorder, and patients with alcohol-related delirium. Three reviewers independently extracted the data for participants, interventions and outcome measures, and critically appraised each study using the JADAD scale. We identified 13 studies that met our inclusion criteria and evaluated 15 compounds: second-generation antipsychotics, first-generation antipsychotics, cholinergic enhancers, an antiepileptic agent, an inhaled anesthetic, injectable sedatives, and a benzodiazepine. Four trials evaluated delirium treatment and suggested no differences in efficacy or safety among the evaluated treatment methods (first and second generation antipsychotics). Neither cholinesterase inhibitors nor procholinergic drugs were effective in preventing delirium. Multiple studies, however, suggest either shorter severity and duration, or prevention of delirium with the use of haloperidol, risperidone, gabapentin, or a mixture of sedatives in patients undergoing elective or emergent surgical procedures. The existing limited data indicates no superiority for second-generation antipsychotics over haloperidol in managing delirium. Although preliminary results suggest delirium prevention may be accomplished through various mechanisms, further studies are necessary to prove effectiveness. [ABSTRACT FROM AUTHOR]

Background Dementia is a common and growing global public health problem. It leads to a high burden of suffering for society with an annual cost of $100 billion in the US and $10 billion in the UK. New strategies for both treatment and prevention of dementia are currently being developed. Implementation of these strategies will depend on the presence of a viable community or primary care based dementia screening and diagnosis program and patient acceptance of such a program. Objective To compare the acceptance, perceived harms and perceived benefits of dementia screening among older adults receiving their care in two different primary health care systems in two countries. Design A Cross-sectional study. Setting Primary care clinics in Indianapolis, USA and Kent, UK. Participants A convenience sample of 245 older adults (Indianapolis, n = 125; Kent, n = 120). Outcomes Acceptance of dementia screening and its perceived harms and benefits as determined by a 52-item questionnaire (PRISM-PC questionnaire). Results Four of the five domains were significantly different across the two samples. The UK sample had significantly higher dementia screening acceptance scores (p < 0.05); higher perceived stigma scores (p < 0.05); higher perceived loss of independence scores (p < 0.01); and higher perceived suffering scores (p < 0.01) than the US sample. Both groups perceived dementia screening as beneficial (p = 0.218). After controlling for prior experience with dementia, acceptance and stigma were marginalized. Conclusions Older adults attending primary care clinics across the Atlantic value dementia screening but have significant concerns about dementia screening although these concerns differed between the two countries. Low acceptance rates and high rates of perceived harms might be a significant barrier for the introduction of treatment or preventive methods for dementia in the future. Copyright © 2008 John Wiley & Sons, Ltd. [ABSTRACT FROM AUTHOR]

Background: Caring for an individual with Alzheimer's dementia (AD) is stressful, and studies show that this stress has an impact on both the physical and mental health of the caregiver. However, many questions remain about the characteristics of AD patients and their caregivers that contribute to this stress and how it impacts caregivers' use of healthcare resources.Objective: To study the impact of stress on the physical and mental health of the caregiver.Design: Patients underwent extensive testing to allow description of their degree of cognitive impairment, behavioral and psychological symptoms, medical comorbidities, and functional abilities. Caregivers were assessed for depressive symptoms and also for emergency department (ED) use and hospitalizations in the previous six months. Multivariate logistic regression was used to evaluate impact of patients' dementia symptoms on caregivers' acute care utilization.Participants: One hundred and fifty-three AD patients and their caregivers attending two large, urban, university-affiliated primary care practices were enrolled in a cross-sectional study to examine the facets of dementia caregiving that impact caregiver acute health care utilization.Results: Twenty-four percent of the caregivers had at least one ED visit or hospitalization in the six months prior to enrollment. After adjusting for caregiver age, gender, and education, our logistic regression model found that the caregivers' acute care utilization was associated with their depression as measured by the PHQ-9 (OR 1.09, 95% CI 1.00-1.18), the patients' behavioral and psychological symptoms as measured by the NPI (OR 1.04, 95% CI 1.01-1.08), and the patients' functional status as measured by the ADCS-ADL (OR 1.05, 95% CI 1.01-1.09).Conclusion: To improve the health of AD caregivers, a primary care system needs to reallocate resources to manage the functional, behavioral, and psychological symptoms related to the care-recipients suffering from AD. [ABSTRACT FROM AUTHOR]

Objectives To develop a questionnaire that will capture patients' attitudes about dementia screening in primary care. Methods Cross-sectional study of 315 patients aged 65 and older attending urban and rural primary care clinics in Indianapolis and North Carolina. The Perceptions Regarding Investigational Screening for Memory in Primary Care (PRISM-PC) questionnaire was administered via face-to-face or telephone interview. Results The PRISM-PC questionnaire consists of two separate scales: the patient's acceptance of dementia screening scale and the patient's perceived harms and benefits of dementia screening scale. The face validity of the PRISM-PC questionnaire was based on a systematic literature review and the opinions of 16 clinician-investigators with experience in screening for dementia. Exploratory factor analyses for the acceptance scale revealed the presence of two dimensions: knowledge about dementia risk and testing for dementia. For the benefits and harms scale, exploratory factor analyses identified four dimensions: perceived benefits of screening, stigma of screening, suffering from screening, and impact of screening on patients' independence. The internal consistency of each of the above subscales was good with Cronbach's alpha ranging from 0.58–0.85. Conclusion The PRISM-PC questionnaire captures primary care patients' acceptance, perceived harms, and perceived benefits of dementia screening. Copyright © 2008 John Wiley & Sons, Ltd. [ABSTRACT FROM AUTHOR]

OBJECTIVES: To evaluate the association between histamine-2 receptor antagonist (H2A) exposure and incident cognitive impairment in a community-based sample of African Americans. DESIGN: Five-year longitudinal observational study. PARTICIPANTS: A sample of 1,558 community-dwelling African Americans aged 65 and older with no baseline cognitive impairment living in Indianapolis, Indiana. OUTCOME MEASURE: Incident cognitive impairment, defined as incident dementia, cognitive impairment without dementia, or poor cognitive performance, as determined using combined cognitive assessments that included the Community Screening Instrument for Dementia, a comprehensive clinical assessment including informant interview, and neuropsychological testing. EXPOSURE: Trained interviewers assessed the use of prescription and over-the-counter H2As using in-home inspection of medications and report of participants and informants. RESULTS: Incident cognitive impairment occurred in 275 (17.7%) participants. After controlling for age, education, baseline cognitive score, the use of anticholinergics, and history of diabetes mellitus and depression, continuous use of H2As was associated with greater risk of incident cognitive impairment than for nonusers (odds ratio=2.42; 95% confidence interval=1.17–5.04). CONCLUSION: H2As might be a risk factor for the development of cognitive impairment in African Americans. This finding requires confirmation from future studies. [ABSTRACT FROM AUTHOR]

ObjectiveEarly screening and detection of dementia in primary care remains controversial. At least half of the patients identified as cognitively impaired by screening instruments do not meet criteria for dementia and some patients refuse further evaluation following a positive screen. The aim of this study was to identify the characteristics of patients who refuse a clinical diagnostic assessment for dementia after screening. DesignCross sectional study. SettingSeven primary care practice centers in Indianapolis. ParticipantsFour hundred and thirty-four individuals aged 65 and older who screened positive for dementia with a mean age of 74.6, 67% women, and 68% African-American. Main outcome measurePatients' acceptance of undergoing a dementia diagnostic assessment that included neuropsychological testing, caregiver interview, and medical chart review. ResultsAmong patients with positive screening results for dementia, approximately half (47.7%) refused further assessment to confirm their screening results. In a bivariate analysis, possible factors associated with a higher probability of refusing dementia assessment were older age and better screening score. In a multiple logistic regression model, performing well on the temporal orientation of the screening instrument was associated with a higher probability of refusing diagnostic assessment for dementia (OR = 1.37; p = 0.001). Also, African-American patients aged 80 and older were more likely to refuse the diagnostic assessment than African-Americans less than 80 years of age (OR = 3.1, p < 0.001), while there was no significant age association for white patients (OR = 0.9, p = 0.728). ConclusionsOlder primary care patients who perceived themselves as having no cognitive symptoms refused dementia diagnostic assessment despite their positive screening results. We must improve our understanding of the decision-making process driving patients' beliefs and behaviors about the benefits and risks of dementia screening and diagnosis before implementing any broad-based screening initiatives for dementia. Copyright © 2006 John Wiley & Sons, Ltd. [ABSTRACT FROM AUTHOR]

The article presents a medical study conducted to test the efficacy of collaborative care versus augmented usual care to improve the quality of care in a primary care setting for geriatric patients with Alzheimer disease. The study stresses nonpharmacological management of behavioral and psychological aspects of dementia and focuses on team-centered intervention and group-caregiver case management. The article includes the study's design, methods, outcome measures, results, and conclusions as well as its limitations.

OBJECTIVES: To compare the medical comorbidity of older patients with and without dementia in primary care. DESIGN: Cross-sectional study. SETTING: Wishard Health Services, which includes a university-affiliated, urban public hospital and seven community-based primary care practice centers in Indianapolis. PARTICIPANTS: Three thousand thirteen patients aged 65 and older attending seven primary care centers in Indianapolis, Indiana. MEASUREMENTS: An expert panel diagnosed dementia using International Classification of Diseases, 10th Revision, criteria. Comorbidity was assessed using 10 physician-diagnosed chronic comorbid conditions and the Chronic Disease Score (CDS). RESULTS: Patients with dementia attending primary care have on average 2.4 chronic conditions and receive 5.1 medications. Approximately 50% of dementia patients in this setting are exposed to at least one anticholinergic medication, and 20% are prescribed at least one psychotropic medication. After adjusting for patients' age, race, and sex, patients with and without dementia have a similar level of comorbidity (mean number of chronic medical conditions, 2.4 vs 2.3, P=.66; average CDS, 5.8 vs 6.2, P=.83). CONCLUSION: Multiple medical comorbid conditions are common in older adults with and without dementia in primary care. Despite their cholinergic deficit, a substantial proportion of patients with dementia are exposed to anticholinergic medications. Models of care that incorporate this medical complexity are needed to improve the treatment of dementia in primary care. [ABSTRACT FROM AUTHOR]

Background: Primary care physicians are positioned to provide early recognition and treatment of dementia. We evaluated the feasibility and utility of a comprehensive screening and diagnosis program for dementia in primary care.Methods: We screened individuals aged 65 and older attending 7 urban and racially diverse primary care practices in Indianapolis. Dementia was diagnosed according to International Classification of Diseases (ICD)-10 criteria by an expert panel using the results of neuropsychologic testing and information collected from patients, caregivers, and medical records.Results: Among 3,340 patients screened, 434 scored positive but only 227 would agree to a formal diagnostic assessment. Among those who completed the diagnostic assessment, 47% were diagnosed with dementia, 33% had cognitive impairment-no dementia (CIND), and 20% were considered to have no cognitive deficit. The overall estimated prevalence of dementia was 6.0% (95% confidence interval (CI) 5.5% to 6.6%) and the overall estimate of the program cost was $128 per patient screened for dementia and $3,983 per patient diagnosed with dementia. Only 19% of patients with confirmed dementia diagnosis had documentation of dementia in their medical record.Conclusions: Dementia is common and undiagnosed in primary care. Screening instruments alone have insufficient specificity to establish a valid diagnosis of dementia when used in a comprehensive screening program; these results may not be generalized to older adults presenting with cognitive complaints. Multiple health system and patient-level factors present barriers to this formal assessment and thus render the current standard of care for dementia diagnosis impractical in primary care settings. [ABSTRACT FROM AUTHOR]

This article describes care for behavioral symptoms related to dementia (BSRD) and identifies their potential correlates among 347 residents with dementia living in 45 assisted living facilities and nursing homes from four states. The prevalence of BSRD was associated with staff training and resident cognition, mood, mobility, and psychotropic use. Attention to staff training and depression management might improve BSRD. [ABSTRACT FROM AUTHOR]

(Editorial comments by Drs. Kathy Ruckdeschel and Ira Katz on pp 1774–1775).To examine the prevalence, correlates, and medication management of behavioral symptoms in elderly people living in residential care/assisted living (RC/AL) facilities.Cross-sectional study.A stratified random sample of 193 RC/AL facilities in four states (Florida, Maryland, New Jersey, North Carolina).A total of 2,078 RC/AL residents aged 65 and older.Behavioral symptoms were classified using a modified version of the Cohen-Mansfield Agitation Inventory. Additional items on resistance to care were also examined.Approximately one-third (34%) of RC/AL residents exhibited one or more behavioral symptoms at least once a week. Thirteen percent exhibited aggressive behavioral symptoms, 20% demonstrated physically nonaggressive behavioral symptoms, 22% expressed verbal behavioral symptoms, and 13% resisted taking medications or activities of daily living care. Behavioral symptoms were associated with the presence of depression, psychosis, dementia, cognitive impairment, and functional dependency, and these relationships persisted across subtypes of behavioral symptoms. Overall, behavioral symptoms were more prevalent in smaller facilities. More than 50% of RC/AL residents were taking a psychotropic medication, and two-thirds had some mental health problem indicator (dementia, depression, psychosis, or other psychiatric illness).Integrating mental health services within the process of care in RC/AL is needed to manage and accommodate the high prevalence of behavioral symptoms in this evolving long-term setting. [ABSTRACT FROM AUTHOR]

Background In a recent systematic review of the evidence for dementia screening to support recommendations from the US Preventive Services Task Force, we found no evidence regarding the interest or willingness of older adults to be screened, and insufficient evidence to provide an estimate of the potential harms of dementia screening. Objective In an attempt to address the acceptability of dementia screening, we asked older adults living in two Continuous Care Retirement Communities (CCRC) if they would agree to routine screening for memory problems. Design Cross-sectional study using self-administered mailed survey questionnaires. Setting Two CCRCs in Orange County, North Carolina. Participants 500 residents of the independent living section of CCRCs. Results There was a 64% survey response rate. Of these, 49% of participants stated they would agree to routine screening for memory problems. In comparison to people who would not agree to routine memory screening, those who accepted memory screening were more likely to accept depression screening, be male, use drug-administration assisted devices, and take more medications. Conclusion Approximately half of the residents in this affluent residential community setting were not willing to be screened routinely for memory problems. This high refusal rate indicates that dementia screening may be associated with perceived harms. We must improve our understanding of the decision-making process driving individual's beliefs and behaviors about dementia screening before implementing any broad-based screening initiatives for dementia or cognitive impairment. Copyright © 2003 John Wiley & Sons, Ltd. [ABSTRACT FROM AUTHOR]

Background: Dementia is a large and growing problem but is often not diagnosed in its earlier stages. Screening and earlier treatment could reduce the burden of suffering of this syndrome. Purpose: To review the evidence of benefits and harms of screening for and earlier treatment of dementia. Data Sources: MEDLINE, PsycINFO, EMBASE, the Cochrane Library, experts, and bibliographies of reviews. Study Selection: The authors developed eight key questions representing a logical chain between screening and improved health outcomes, along with eligibility criteria for admissible evidence for each question. Admissible evidence was obtained by searching the data sources. Data Extraction: Two reviewers abstracted relevant information using standardized abstraction forms and graded article quality according to U.S. Preventive Services Task Force criteria. Data Synthesis: No randomized, controlled trial of screening for dementia has been completed. Brief screening tools can detect some persons with early dementia (positive predictive value ≤ 50%). Six to 12 months of treatment with cholinesterase inhibitors modestly slows the decline of cognitive and global clinical change scores in some patients with mild to moderate Alzheimer disease. Function is minimally affected, and fewer than 20% of patients stop taking cholinesterase inhibitors because of side effects. Only limited evidence indicates that any other pharmacologic or nonpharmacologic intervention slows decline in persons with early dementia. Although intensive multicomponent caregiver interventions may delay nursing home placement of patients who have caregivers, the relevance of this finding for persons who do not yet have caregivers is uncertain. Other potential benefits and harms of screening have not been studied. Conclusions: Screening tests can detect undiagnosed dementia. In persons with mild to moderate clinically detected Alzheimer disease, cholinesterase inhibitors are somewhat effective in... [ABSTRACT FROM AUTHOR]

Patient-family member dyads experience transitions through illness as an interdependent team. This study measures the association of depression, anxiety, and health-related quality of life (HRQOL) of older adult primary care patient-family member dyads. Baseline data from 1,808 patient-family member dyads enrolled in a trial testing early detection of Alzheimer's disease and related dementias in primary care. Actor-Partner Independence Model was used to analyze dyadic relationships between patients' and family members' depression (PHQ-9), anxiety (GAD-7), and HRQOL (SF-36 Physical Component Summary score and Mental Component Summary score). Family member mean (SD) age is 64.2 (13) years; 32.2% male; 84.6% White; and 64.8% being the patient's spouse/partner. Patient mean (SD) age is 73.7 (5.7) years; 47% male; and 85.1% White. For HRQOL, there were significant actor effects for patient and family member depression alone and depression and anxiety together on their own HRQOL (p < 0.001). There were significant partner effects where family member depression combined with anxiety was associated with the patient's physical component summary score of the SF-36 (p = 0.010), and where the family member's anxiety alone was associated with the patient's mental component summary score of the SF-36 (p = 0.031). Results from this study reveal that many dyads experience covarying health status (e.g. depression, anxiety) even prior to entering a caregiving situation. [ABSTRACT FROM AUTHOR]

Anticholinergic medications are known to cause adverse cognitive effects in community-dwelling older adults and medical inpatients, including dementia. The prevalence with which such medications are prescribed in older adults undergoing major surgery is not well described nor is their mediating relationship with delirium and dementia. We sought to determine the prevalence of high-risk medication use in major surgery patients and their relationship with the subsequent development of dementia. This was a retrospective cohort study which used data between January 2013 and December 2019, in a large midwestern health system, including sixteen hospitals. All patients over age 50 undergoing surgery requiring an inpatient stay were included. The primary exposure was the number of doses of anticholinergic medications delivered during the hospital stay. The primary outcome was a new diagnosis of Alzheimer's disease and related dementias at 1-y postsurgery. Regression methods and a mediation analysis were used to explore relationships between anticholinergic medication usage, delirium, and dementia. There were 39,665 patients included, with a median age of 66. Most patients were exposed to anticholinergic medications (35,957/39,665; 91%), and 7588/39,665 (19.1%) patients received six or more doses during their hospital stay. Patients with at least six doses of these medications were more likely to be female, black, and with a lower American Society of Anesthesiologists class. Upon adjusted analysis, high doses of anticholinergic medications were associated with increased odds of dementia at 1 y relative to those with no exposure (odds ratio 2.7; 95% confidence interval 2.2-3.3). On mediation analysis, postoperative delirium mediated the effect of anticholinergic medications on dementia, explaining an estimated 57.6% of their association. High doses of anticholinergic medications are common in major surgery patients and, in part via a mediating relationship with postoperative delirium, are associated with the development of dementia 1 y following surgery. Strategies to decrease the use of these medications and encourage the use of alternatives may improve long-term cognitive recovery. [ABSTRACT FROM AUTHOR]

Background: Early detection of Alzheimer's disease (AD) is a key component for the success of the recently approved lecanemab and aducanumab. Patients with neuroinflammation-related conditions are associated with a higher risk for developing AD. Objective: Investigate the incidence of AD among patients with neuroinflammation-related conditions including epilepsy, hemorrhage stroke, multiple sclerosis (MS), and traumatic brain injury (TBI). Methods: We used Optum's de-identified Clinformatics Data Mart Database (CDM). We derived covariate-matched cohorts including patients with neuroinflammation-related conditions and controls without the corresponding condition. The matched cohorts were: 1) patients with epilepsy and controls (N = 67,825 matched pairs); 2) patients with hemorrhage stroke and controls (N = 81,510 matched pairs); 3) patients with MS and controls (N = 9,853 matched pairs); and 4) patients TBI and controls (N = 104,637 matched pairs). We used the Cox model to investigate the associations between neuroinflammation-related conditions and AD. Results: We identified that epilepsy, hemorrhage stroke, and TBI were associated with increased risks of AD in both males and females (hazard ratios [HRs]≥1.74, p < 0.001), as well as in gender- and race-conscious subpopulations (HRs≥1.64, p < 0.001). We identified that MS was associated with increased risks of AD in both males and females (HRs≥1.47, p≤0.004), while gender- and race-conscious subgroup analysis shown mixed associations. Conclusions: Patients with epilepsy, hemorrhage stroke, MS, and/or TBI are associated with a higher risk of developing AD. More attention on cognitive status should be given to older patients with these conditions. [ABSTRACT FROM AUTHOR]

In this article the author reflects on the possibility of developing a dementia screening program which could be used in primary care in the U.S. and on the possible unintended consequences and possible harms of such a program. He is critical of developing a dementia screening program and suggests that before one can be established for use in primary care there needs to be additional research which proves the benefits of such a program.

The article relates the author's view on the ability of the primary care to meet the biopsychosocial needs of patients with dementia. The author shares that the current primary care system is experiencing big challenges in delivering safe, high quality and cost-effective services to its patients. He mentions that the qualitative study about the problem showed the operational structure of primary care which is not prepared to manage the biopsychosocial needs of patients suffering from dementia.

Focuses on the complex interface between depression and dementia. Difficulty in the diagnosis of depression in dementia; Interaction of depression in dementia with other behavioral and psychological symptoms, such as agitation, delusions, hallucinations and wandering; Goal of antidepressant treatment in dementia to alleviate depressive suffering and improve cognitive performance.

Background: Loneliness is a significant public health challenge in the United States, especially among older adults. The epidemiology of loneliness among older adults in primary care is lacking, and specific research is needed on how loneliness impacts older primary patients' physical, mental, and cognitive health. A large sample of older primary care patients were recruited for a trial during the COVID‐19 pandemic to measure the relationship between loneliness and physical and mental quality of life (QOL). Methods: Baseline data come from the Caregiver Outcomes of Alzheimer's Disease Screening (COADS) study, an ongoing randomized controlled trial evaluating benefits and risks of Alzheimer's disease and related dementias screening among primary care patients ages 65 and older, collected April 2020 to September 2021. Loneliness was measured with the 5‐item, Loneliness Fixed Form Ages 18+ from The NIH Toolbox Emotion Battery, physical and mental health‐related QOL was measured with the SF‐36v2, and depression and anxiety severity were measured with the PHQ‐9 and GAD‐7, respectively. Results: Spearman correlation analyses revealed that loneliness was moderately correlated with mental health QOL (r[601] = −0.43, p < 0.001), anxiety severity (r[601] = 0.44, p < 0.001), and depression severity (r[601] = 0.42, p < 0.001), while weakly correlated with physical health QOL (r[601] = −0.15, p < 0.001). After conducting unadjusted and adjusted linear regression models, we found that loneliness was significantly associated with both lower mental (p < 0.001) and physical (p < 0.001) QOL. Furthermore, loneliness remained significantly associated with worse mental QOL after adjusting for age, gender, race, ethnicity, educational level, perceived income status, neighborhood disadvantage, severity of comorbidities, and comorbid depression and anxiety. Conclusion: Primary care providers should discuss loneliness with their older adult patients and provide resources to help patients develop and maintain meaningful social relationships. [ABSTRACT FROM AUTHOR]

Multimodal pain regimen (MMPR) protocols are the standard of care per the 2020 Trauma Quality Improvement Program guidelines. MMPR implementation methodology in trauma services has not been reported. The primary objective of this study was to evaluate the adoption of an MMPR order set at a level 1 trauma center and to describe its implementation. We hypothesized that order set utilization would be about 50%, and barriers to adoption would be related to personal biases. This was a mixed-methods study at a level 1 trauma center. We retrospectively evaluated MMPR utilization from July 1, 2021 to February 28, 2022. Agile implementation was the method used to implement a clinical decision support tool for the MMPR: a flow chart order set in the electronic medical record. This methodology utilizes short experiment sprints during which data are collected to guide the next iterations. During this process quantitative as well as qualitative data were collected. This included end user testing of the order set and a survey distributed to surgical residents about the order set. Manual thematic network analysis was employed to identify basic and organizing themes from the survey responses. A total of 587 trauma patients were admitted during the study period and 95 patients (16.2%) had MMPR ordered through the order set. The survey response rate was 19% (13/68). We identified ease of use, desire for options, inadequate education, and assumption of personal expertise as the four basic themes from the survey. These basic themes were further analyzed to two organizing themes: heuristics and overconfidence bias. The MMPR order set was easy to use but had low adoption at our center in the first 8 months of implementation. Agile implementation methodology provided an ideal framework to identify reasons for low adoption and guide the next sprint to address personal biases, improve heuristics, and provide effective education and dissemination. Evaluation of utilization and qualitative analysis are key components to ensuring clinical decision support tool adoption. [ABSTRACT FROM AUTHOR]

Background: The primary aim of the current pilot study was to examine enrollment rate, data completion, usability, acceptance and use of a mobile telehealth application, Brain CareNotes. A secondary aim was to estimate the application's effect in reducing caregiver burden and behavioral and psychological symptoms related to dementia (BPSD). Methods: Patient‐caregiver dyads (n = 53) were recruited and randomized to intervention and control groups. Assessment of usability, acceptance, BPSD symptoms, and caregiver burden were collected at baseline, 3‐ and 6‐month follow‐up. Results: The enrollment rate was acceptable despite pandemic related challenges (53/60 target recruitment sample). Among randomized individuals, there was a retention rate of 85% and data completion was attained for 81.5% of those allocated to usual care and 88.5% of those allocated to Brain CareNotes. Mean caregiver‐reported app usability at 6 months was 72.5 (IQR 70.0–90.0) on the System Usability Scale—considered "Good to Excellent"—and user acceptance was reasonable as indicated by 85%–90% of caregivers reporting they would intend to use the app to some degree in the next 6 months, if able. Regarding intervention effect, although differences in outcome measures between the groups were not statistically significant, compared to baseline, we found a reduction of caregiver burden (NPI‐Caregiver Distress) of 1.0 at 3 months and 0.7 at 6 months for those in the intervention group. BPSD (NPI Total Score) was also reduced from baseline by 4.0 at 3 months and by 0.5 at 6 months. Conclusions: Brain CareNotes is a highly scalable, usable and acceptable mobile caregiver intervention. Future studies should focus on testing Brain CareNotes on a larger sample size to examine efficacy of reducing caregiver burden and BPSD. [ABSTRACT FROM AUTHOR]

Background: Primary care clinicians (PCCs) are typically the first practitioners to detect cognitive impairment in their patients, including those with Alzheimer's disease or related dementias (ADRD). However, conversations around cognitive changes can be challenging for patients, family members, and clinicians to initiate, with all groups reporting barriers to open dialogue. With the expanding array of evidence-based interventions for ADRD, from multidomain care management to novel biotherapeutics for early-stage AD, incorporating conversations about brain health into routine healthcare should become a standard of care. We conducted a systematic review to identify barriers to and facilitators of brain health conversations in primary care settings. Methods: We systematically searched PubMed, Scopus, Web of Science, and the Cochrane Library for qualitative or quantitative studies conducted in the US between January 2000 and October 2022 that evaluated perceptions of cognition and provider-patient brain health conversations prior to formal screening for, or diagnosis of, mild cognitive impairment or ADRD. We assessed the quality of the included studies using the Mixed Methods Appraisal Tool. Results: In total, 5547 unique abstracts were screened and 22 articles describing 19 studies were included. The studies explored perceptions of cognition among laypersons or clinicians, or provider-patient interactions in the context of a patient's cognitive concerns. We identified 4 main themes: (1) PCCs are hesitant to discuss brain health and cognitive concerns; (2) patients are hesitant to raise cognitive concerns; (3) evidence to guide clinicians in developing treatment plans that address cognitive decline is often poorly communicated; and (4) social and cultural context influence perceptions of brain health and cognition, and therefore affect clinical engagement. Conclusions: Early conversations about brain health between PCCs and their patients are rare, and effective tools, processes, and strategies are needed to make these vital conversations routine. [ABSTRACT FROM AUTHOR]

Background: Delirium is a complex neuropsychiatric syndrome which consists of acute and varying changes in cognition and consciousness. Patients who develop delirium are at increased risk for a constellation of physical, cognitive, and psychological disabilities long after the delirium has ended. Collaborative care models integrating primary and specialty care in order to address patients with complex biopsychosocial needs have been demonstrated to improve outcomes in patients with chronic diseases. The purpose of this study is to evaluate the ability of a collaborative care model on the neuropsychologic recovery of delirium survivors following emergency surgery. Methods: This protocol describes a multicenter (eight hospitals in three states) randomized controlled trial in which 528 patients who develop delirium following emergency surgery will be randomized to either a collaborative care model or usual care. The efficacy of the collaborative care model on cognitive, physical, and psychological recovery in these delirium survivors will then be evaluated over 18 months. Discussion: This will be among the first randomized clinical trials in postoperative delirium survivors evaluating an intervention designed to mitigate the downstream effects of delirium and improve the neuropsychologic recovery after surgery. We hope that the results of this study will add to and inform strategies to improve postoperative recovery in this patient group. Trial registration: ClinicalTrials.gov NCT05373017. Registered on May 12, 2022. [ABSTRACT FROM AUTHOR]

The objective of this study was to evaluate the performance of the Healthy Aging Brain Care Monitor (HABC-M) as a patient-reported outcome tool to measure cognitive, functional, and psychological symptoms among older adults who sustained non-neurologic injuries requiring hospital admission. We used data from a multicenter randomized controlled trial to evaluate the utility of the HABC-M Self-Report version in older patients recovering from traumatic injuries. A total of 143 patients without cognitive impairment were included in the analysis. Cronbach's alpha was used to measure the internal consistency, and Spearman's rank correlation test was used to evaluate the relationship of the HABC-M with standard measures of cognitive, functional, and psychological outcomes. The HABC-M subscales and the total scale showed satisfactory internal consistency (Cronbach's alpha = 0.64 to 0.77). The HABC-M cognitive subscale did not correlate with the Mini-Mental State Examination. The HABC-M functional and psychological subscales correlated with corresponding standard reference measures (| r s | = 0.24-0.59). The HABC-M Self-Report version is a practical alternative to administering multiple surveys to monitor functional and psychological sequelae in older patients recovering from recent non-neurologic injuries. Its clinical application may facilitate personalized, multidisciplinary care coordination among older trauma survivors without cognitive impairment. • The HABC-M was used in a randomized controlled trial to guide postinjury care. • The HABC-M may be a useful tool to monitor recovery after traumatic injuries. • The use of the HABC-M cognitive subscale requires validation in future studies. [ABSTRACT FROM AUTHOR]

Objective: In critically ill adults with delirium, biomarkers of systemic inflammation, astrocyte activation, neuroprotection, and systemic inflammation measured at one week of critical illness may be associated with mortality. Design: Prospective observational study. Setting: Intensive care unit (ICU). Patients: 178 ICU patients with delirium, alive and remaining in ICU at one week. Interventions: None Measurements and main results: Blood samples collected for a pair of previously published, negative, clinical trials were utilized. Samples were collected at study enrollment/ICU admission (Day 1 sample) and one week later (Day 8 sample), and analyzed for interleukins (IL)-6, 8, 10, Insulin-like Growth Factor (IGF), S100 Binding Protein (S100B), Tumor Necrosis Factor Alpha (TNF-A) and C-Reactive Protein (CRP). Delirium, delirium severity, and coma were assessed twice daily using Confusion Assessment Method for the Intensive Care Unit (CAM-ICU), CAM-ICU-7, and Richmond Agitation-Sedation Scale (RASS), respectively. Mortality was assessed until discharge using the electronic medical record. Logistic regression models adjusting for age, sex, severity of illness, comorbidities, sepsis, and randomization status, were used to assess the relationship among biomarkers and mortality. Higher IL-10 quartiles at day 8 were associated with increased odds of hospital mortality (IL-10: OR 2.00 95%CI: 1.1–3.65, p = 0.023). There was a significant interaction between day 1 and day 8 biomarker quartiles only for IL-6. Patients with IL-6 values in the first three quartiles on admission to the ICU that transitioned to higher IL-6 quartiles at day 8 had increased probability of hospital mortality. Conclusion: In this hypothesis-generating study, higher IL-6 and IL-10 quartiles at one week, and increase in IL-6 from day 1 to day 8 were associated with increased hospital mortality. Studies with larger sample sizes are needed to confirm the mechanisms for these observations. [ABSTRACT FROM AUTHOR]

Patient-reported (PRO) and clinician-reported (CRO) outcomes are assessment instruments that are completed by patients and trained healthcare professionals, respectively. A PRO is a report of the direct experience of the patient with a given disease condition. A CRO is an assessment of the condition of the patient by the healthcare provider. PROs may not be accessible to all patients, especially those suffering from severe disease conditions. CROs are time-consuming and therefore administered infrequently. In the present study, we introduce a new form of assessment, the digital-reported outcome (DRO), which is automatically derived from the medical notes of the patient. DROs have a low overhead and can be generated at each patient's visit to complement other outcome-assessment instruments and enhance clinical decision support by identifying at-risk patients. In this study, a DRO is developed to evaluate the functional impairment in the daily activities of two cohorts of patients suffering from bipolar disorder and schizophrenia. The input of the DRO is a single medical note from the electronic medical record of the patient. This note is submitted to a hierarchical bidirectional encoder representations from transformers (BERT) model. First, a sentence-level embedding is produced for each sentence in the note using a token-level attention mechanism. Second, an embedding for the entire note is constructed using a sentence-level attention mechanism. Third, the final embedding is classified using a feed-forward neural network. The model is trained to classify patients into moderate or severe functioning impairment levels according to the general assessment of functioning (GAF) scale, a CRO instrument for the assessment of the impact of mental illness on the daily activities of the patient. The DRO is validated using medical notes that were labeled by multiple healthcare providers from different healthcare institutions. The results indicate that a general DRO is able to classify patients from the two cohorts according to the two functioning impairment levels (severe versus moderate) prior to the onset of disease with an AUC of 76%. Disease-specific DROs are only applicable after the onset of the disease and produced AUCs of nearly 85%. The methodology introduced in the present paper is practical and can support the automated monitoring of the severity of the functioning impairment of bipolar and schizophrenia patients. Extending the proposed DRO to other psychiatric conditions and types of impairments is the subject of ongoing research work. [ABSTRACT FROM AUTHOR]