Comprehensive In-home Assessment Research Articles

The associations between unmet needs with protective factors, risk factors and outcomes among care partners of community-dwelling persons living with dementia

Objectives Describe the prevalence and types of unmet needs among community-dwelling dementia care partners (CPs) and determine associations between unmet needs with protective factors, risk factors and outcomes. Method A cross-sectional analysis of 638 racially and cognitively diverse community-dwelling persons living with dementia (PLWD) and their CPs participating in a comprehensive in-home assessment of dementia-related needs. Unmet CP needs (19 items, 6 domains) were rated by a clinician using the Johns Hopkins Dementia Care Needs Assessment (JHDCNA). Multivariate linear regression models were used to examine associations between total percent unmet CP needs with demographic, protective and risk factors. Results Nearly all CPs had at least one unmet need (99.53%), with a mean of 5.7 (±2.6). The most common domains with ≥1 unmet need were memory disorder education, care skills and knowledge of resources (98%), legal issues/concerns (73.8%), CP mental health (44.6%) and access to informal support (42.7%). Adjusted multivariate models suggest the strongest consistent predictive factors relate to informal emotional support, CP physical health, use or difficulty getting formal services/supports (both for CPs and PLWD), and CP time spent with PLWD. Greater levels of unmet needs were associated with worse PLWD outcomes and CP outcomes, after adjusting for demographics. Conclusions CPs have high rates of diverse, but modifiable unmet needs. Data suggest optimal approaches to dementia care should take a family-centered home-based approach that includes routine CP needs assessment, offer targeted interventions that include both traditional medical supports as well as strategies to increase and leverage informal social networks, and ones that can bridge and coordinate medical with non-medical supports. These findings can be used to inform new approaches to support CPs, improve PLWD and CP outcomes, and target groups most at risk for inequities.

COMMON UNMET NEEDS OF DEMENTIA CAREGIVERS AND HOW THESE DIFFER BY DISEASE STAGE AND RACE

This presentation (co-presentation Samus and Sloan) will use combined cross-sectional, baseline data from two intervention studies (n=-642) conducted in Maryland evaluating the impact of dementia care coordination model (MIND at home) to provide a detailed description of common modifiable unmet care needs of family caregivers of community-living persons with dementia (PWD), explore how care needs may differ by the disease stage of the PWD, and presence of racial disparities in care needs. Unmet caregiver needs were identified based on comprehensive in-home assessments using a standardized tool (JHDCNA 2.0) with 6 care domains and 18 items covering caregiver needs. Family caregivers were 77% women; 63 years old (mean); 60% White; and 52% adult children. The most prevalent needs were for education/resources (98%), legal (74%), mental health (44%), and informal support (43%). Needs varied based on dementia severity. African American caregivers (vs. white) had significantly more unmet caregiver needs at baseline (p<.001).

Implementation of an Interdisciplinary, Team-Based Complex Care Support Health Care Model at an Academic Medical Center: Impact on Health Care Utilization and Quality of Life.

IntroductionThe Geriatric Resources for the Assessment and Care of Elders (GRACE) program has been shown to decrease acute care utilization and increase patient self-rated health in low-income seniors at community-based health centers.AimsTo describe adaptation of the GRACE model to include adults of all ages (named Care Support) and to evaluate the process and impact of Care Support implementation at an urban academic medical center.Setting152 high-risk patients (≥5 ED visits or ≥2 hospitalizations in the past 12 months) enrolled from four medical clinics from 4/29/2013 to 5/31/2014.Program DescriptionPatients received a comprehensive in-home assessment by a nurse practitioner/social worker (NP/SW) team, who then met with a larger interdisciplinary team to develop an individualized care plan. In consultation with the primary care team, standardized care protocols were activated to address relevant key issues as needed.Program EvaluationA process evaluation based on the Consolidated Framework for Implementation Research identified key adaptations of the original model, which included streamlining of standardized protocols, augmenting mental health interventions and performing some assessments in the clinic. A summative evaluation found a significant decline in the median number of ED visits (5.5 to 0, p = 0.015) and hospitalizations (5.5 to 0, p<0.001) 6 months before enrollment in Care Support compared to 6 months after enrollment. In addition, the percent of patients reporting better self-rated health increased from 31% at enrollment to 64% at 9 months (p = 0.002). Semi-structured interviews with Care Support team members identified patients with multiple, complex conditions; little community support; and mild anxiety as those who appeared to benefit the most from the program.DiscussionIt was feasible to implement GRACE/Care Support at an academic medical center by making adaptations based on local needs. Care Support patients experienced significant reductions in acute care utilization and significant improvements in self-rated health.

Statin Use, Incident Dementia and Alzheimer Disease in Elderly African Americans.

To investigate the association between statin use, incident dementia, and Alzheimer disease (AD) in a prospective elderly African American cohort. Two stage design with a screening interview followed by a comprehensive in-home assessment conducted over an eight-year period. Diagnoses of incident AD and dementia were made by consensus. Statin use was collected at each evaluation. Measurements of low-density lipoprotein cholesterol (LDL), C-reactive protein (CRP) and APOE genotype were obtained from baseline blood samples. Logistic regression models were used to test the association of statin use on incident dementia and AD and its possible association with lipid and CRP levels. Indianapolis, Indiana. From an original cohort of 2629 participants, a subsample of 974 African Americans aged >70 years with normal cognition, at least one follow up evaluation, complete statin information, and biomarker availability were included. Incident dementia and incident AD. After controlling for age at diagnosis, sex, education level, presence of the APOE ε4 allele and history of stroke for the incident dementia model, baseline use of statins was associated with a significantly decreased risk of incident dementia (OR=.44, P=.029) and incident AD (OR=.40, P=.029). The significant effect of statin use on reduced AD risk and trend for dementia risk was found only for those participants who reported consistent use over the observational period (incident AD: P=.034; incident dementia: P=.061). Additional models found no significant interaction between baseline statin use, baseline LDL, or CRP level and incident dementia/AD. Consistent use of statin medications during eight years of follow-up resulted in significantly reduced risk for incident AD and a trend toward reduced risk for incident dementia.

Incidence of dementia and cognitive impairment, not dementia in the united states

Estimates of incident dementia, and cognitive impairment, not dementia (CIND) (or the related mild cognitive impairment) are important for public health and clinical care policy. In this paper, we report US national incidence rates for dementia and CIND. Participants in the Aging, Demographic, and Memory Study (ADAMS) were evaluated for cognitive impairment using a comprehensive in-home assessment. A total of 456 individuals aged 72 years and older, who were not demented at baseline, were followed longitudinally from August 2001 to December 2009. An expert consensus panel assigned a diagnosis of normal cognition, CIND, or dementia and its subtypes. Using a population-weighted sample, we estimated the incidence of dementia, Alzheimer disease (AD), vascular dementia (VaD), and CIND by age. We also estimated the incidence of progression from CIND to dementia. The incidence of dementia was 33.3 (standard error [SE], 4.2) per 1,000 person-years and 22.9 (SE, 2.9) per 1,000 person-years for AD. The incidence of CIND was 60.4 (SE, 7.2) cases per 1,000 person-years. An estimated 120.3 (SE, 16.9) individuals per 1,000 person-years progressed from CIND to dementia. Over a 5.9-year period, about 3.4 million individuals aged 72 and older in the United States developed incident dementia, of whom approximately 2.3 million developed AD, and about 637,000 developed VaD. Over this same period, almost 4.8 million individuals developed incident CIND. The incidence of CIND is greater than the incidence of dementia, and those with CIND are at high risk of progressing to dementia, making CIND a potentially valuable target for treatments aimed at slowing cognitive decline.

Identification of community‐residing individuals with dementia and their unmet needs for care

Innovative approaches to the widespread delivery of evidence-based dementia care are needed. The aims of this study were to determine whether a telephone screening method could efficiently identify individuals in the community in need of care for dementia and to develop a multidimensional needs assessment tool for identifying the type and frequency of unmet needs related to memory disorders in the home setting. This was a cross-sectional evaluation of 292 community-residing individuals aged 70 and older in Maryland. Participants were given a brief cognitive telephone screen. A subsample (n=43) received a comprehensive in-home assessment for dementia and dementia-related needs. Cognitive, functional, behavioral, and clinical factors were assessed. The Johns Hopkins Dementia Care Needs Assessment (JHDCNA) was used to identify unmet needs related to dementia. Telephone screening for the sample took 350 h, and 27% screened positive for dementia. Virtually all participants with dementia who received an in-home assessment had at least one unmet need, with the most frequent unmet needs being for a dementia workup, general medical care, environmental safety, assistance with ADL impairments, and access to meaningful activities. Caregivers, when present, also had a number of unmet needs, with the most common being caregiver education about dementia, knowledge of community resources, and caregiver mental health care. Effective and efficient means for identifying community-residing individuals with dementia are needed so that dementia care interventions can be provided to address unmet care needs of patients and their caregivers.

Using multiple household food inventories to measure food availability in the home over 30 days: a pilot study

BackgroundThe consumption of foods, especially by children, may be determined by the types of foods that are available in the home. Because most studies use a single point of data collection to determine the types of foods in the home, which can miss the change in availability when resources are not available, the primary objective of this study was to determine the extent to which the weekly availability of household food items changed over one month by 1) developing the methodology for the direct observation of the presence and amount of food items in the home; 2) conducting five in-home household food inventories over a thirty-day period in a small convenience sample; and 3) determining the frequency that food items were present in the participating households.MethodsAfter the development and pre-testing of the 251-item home observation guide that used direct observation to determine the presence and amount of food items in the home (refrigerator, freezer, pantry, elsewhere), two trained researchers recruited a convenience sample of 9 households (44.4% minority); administered a baseline questionnaire (personal info, shopping habits, food resources, and food security); and conducted 5 in-home assessments (7-day interval) over a 30-day period. Each in-home assessment included food-related activities since the last assessment, and an observational survey of types and amounts of foods present.ResultsComplete data were collected from all 9 women (32.8 y ± 6.0; 3 married; 4 ± 1.6 adults/children in household; 4 received food assistance; and 6 had very low food security) and their households. Weekly grocery purchases (place, amount, and purpose) varied from once (n = 1) to every week (n = 5); 4 used fast food 2-3 times/wk for 4 weeks. The weekly presence and amounts of fresh and processed fruits and vegetables and dairy varied.ConclusionsThe feasibility of conducting multiple in-home assessments was confirmed with 100% retention of participants through 5 in-home assessments, which paid particular attention to the intra-monthly changes in household availability in type and amount of foods. This study contributes to research on home food availability by identifying the importance of multiple measures, presence of certain foods in the home, and the feasibility of comprehensive in-home assessments.

Prevalence of Dementia in the United States: The Aging, Demographics, and Memory Study

Aim: To estimate the prevalence of Alzheimer’s disease (AD) and other dementias in the USA using a nationally representative sample. Methods: The Aging, Demographics, and Memory Study sample was composed of 856 individuals aged 71 years and older from the nationally representative Health and Retirement Study (HRS) who were evaluated for dementia using a comprehensive in-home assessment. An expert consensus panel used this information to assign a diagnosis of normal cognition, cognitive impairment but not demented, or dementia (and dementia subtype). Using sampling weights derived from the HRS, we estimated the national prevalence of dementia, AD and vascular dementia by age and gender. Results: The prevalence of dementia among individuals aged 71 and older was 13.9%, comprising about 3.4 million individuals in the USA in 2002. The corresponding values for AD were 9.7% and 2.4 million individuals. Dementia prevalence increased with age, from 5.0% of those aged 71–79 years to 37.4% of those aged 90 and older. Conclusions: Dementia prevalence estimates from this first nationally representative population-based study of dementia in the USA to include subjects from all regions of the country can provide essential information for effective planning for the impending healthcare needs of the large and increasing number of individuals at risk for dementia as our population ages.

Health-related quality of life in middle-aged African Americans.

In this article we explore the measurement properties of the Medical Outcomes Study 36-Item Short-Form Health Survey (SF-36) in 49- to 65-year-old African Americans, compare their health-related quality of life (HRQoL) with that of the nation, and evaluate the association of selected covariates with HRQoL. A probability sample of 998 African Americans in St. Louis received comprehensive in-home assessments. We used an item analysis, exploratory and confirmatory factor analysis, and internal consistency reliability to evaluate the measurement properties of the eight SF-36 scales and their interrelationships. We used a multiple linear regression analysis to characterize the effects of the demographic, socioeconomic status, psychosocial attributes, and biomedical markers. Assessments averaged 2.5 hr. Each SF-36 scale was unidimensional, all items had robust factor loadings, and all but one scale achieved excellent (alpha > or = .80) internal consistency reliability levels. The overall factor structure of the SF-36 scales was generally consistent with national norms. Substantial variance was explained by the covariates, mostly attributable to socioeconomic status and the biomedical markers. The SF-36 is a reliable and valid measure of HRQoL for use with African Americans. In this sample, the HRQoL was below national averages. Future social epidemiologic studies should include grip strength, vision, and hearing assessments, which had substantial and consistent associations with the SF-36 scale scores.

The development of fear of falling among community-living older women: predisposing factors and subsequent fall events.

Fear of falling is a common and potentially modifiable health problem among older persons. However, relatively little is known about who develops fear of falling or why. From a representative cohort of community-living persons aged 72 years or older, we evaluated 313 women who had no fear of falling. These participants underwent a comprehensive in-home assessment and were reassessed for fear of falling 1 year later. Fall events were ascertained monthly using a validated fall calendar. 84 (27%) participants developed fear of falling at 1 year and 77 (25%) participants experienced at least one fall event. The predisposing factors for developing fear of falling included age 80 years or older (adjusted relative risk 1.48; 95% confidence intervals 1.04-2.12), visual impairment (1.42; 1.01-2.00), a sedentary lifestyle (1.96; 1.35-2.84), and no available emotional support (2.64; 1.57-4.41). The occurrence of a subsequent fall event was also significantly associated with developing fear of falling (unadjusted relative risk 1.70; 1.18-2.45), although this effect was observed only among participants who had at least one predisposing factor. Among community-living older women, fear of falling develops due to a combination of predisposing factors and subsequent fall events. Since many of the predisposing factors are related to fall risk, preventive efforts to reduce fear of falling may also decrease the likelihood of falling.

CHOICES: Promoting Early Access to End-of-Life Care Through Home-Based Transition Management

CHOICES is a comprehensive home-based care coordination program designed to bridge the gap between home health and hospice for Medicare + Choice enrollees with advanced chronic illness in San Francisco's East Bay region. Key elements of the program include physician education, enrollment of patients with high disease burden who may not be terminally ill, co-management of care with the primary physician, and an advanced practice clinical team that provides comprehensive in-home assessments, a flexible mix of life-prolonging and palliative care that evolves with disease progression, focused education and advance planning, and caregiver support. During a 42-month demonstration, 208 patients were enrolled in the program. Eighty percent had a non-cancer diagnosis; 40% were people of color. After an 8-month follow-up, 44% of the study cohort had died in the program or after transfer to hospice, 51% had been discharged, and 5% remained active. Median length of stay for decedents was 260 days. Preliminary evidence supports the program's feasibility and acceptability to patients, families, physicians, and agency partners. However, the uncertain future of Medicare + Choice and of managed care may jeopardize the program's sustainability. Policymakers and taxpayers will need to determine how to care for the growing number of chronically ill elderly who wish to remain at home as illness advances. The care needs of these patients and their families may overwhelm a health system organized around hospital treatment of acute illness.

Subject Recruitment, Retention and Protocol Feasibility in a Prospective Study of Nutritional Risk Among Urban, Frail Homebound Elders

The feasibility of performing comprehensive in-home nutritional risk assessments in a prospective research study of urban, frail homebound elderly patients (aged 65-105) is important, given prior reports of difficulties conducting research with older adults. Trained field teams conducted nutritional and health status assessments on 239 subjects, patients of the Boston University Geriatric Services clinical home care program. Baseline data were obtained on 153 of the 159 interview items from 91% of respondents; three 24 hour dietary recalls from 73%; anthropometry from 60-93%; and other physical assessments from 63-94%. Attrition was 21%, and mortality was 9% over 12 months. Well-designed, flexibly administered study protocols, modest financial incentives and careful follow-up contributed to follow-up interview response rates of 81 to 89% among enrollees over the study's duration. Clearly, it is feasible to recruit frail, older subjects and for well-trained, two person field teams to conduct comprehensive in-home assessments of nutritional risk in under two hours with good retention over 12 months of follow-up.