Functional Assessment Staging Test Research Articles

Validation of Claims-Based Frailty Index for Identifying Moderate-to-Severe Dementia in Medicare Beneficiaries

Previous research using the National Health and Aging Trends Study showed that a claims-based frailty index (CFI) could be useful for identifying moderate-to-severe dementia in Medicare claims data. This study aims to validate the findings in an independent cohort. Retrospective cohort study. The study included 658 fee-for-service beneficiaries with dementia who participated in the 2016-2020 Medicare Current Beneficiary Survey in the community-dwelling. We operationalized the Functional Assessment Staging Test (FAST) scale (range: 1-7, stages 5-7 indicate moderate-to-severe dementia) using survey information. CFI (range: 0-1, higher scores indicate greater frailty) was calculated using Medicare claims 12months before the participants' interview date. Using the previously proposed cut point of 0.280, we calculated sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) for identifying moderate-to-severe dementia. Survey procedures were used to account for survey design and weighted to reflect national estimates. The population had a mean age (SD) of 80.7 (8.9) years, 58.5% female, and 101 beneficiaries (14.8%) had moderate-to-severe dementia. The CFI cut point of 0.280 demonstrated sensitivity 0.49 (95% CI, 0.38-0.59), specificity 0.80 (0.77-0.84), PPV 0.30 (0.23-0.38), and NPV 0.90 (0.87-0.93). Compared with those with a CFI <0.280, beneficiaries with a CFI ≥0.280 had an elevated risk of mortality (2.9% vs 4.1%) over 1year. These results confirm our previous findings that CFI among beneficiaries with a dementia diagnosis is a useful measure of moderate-to-severe dementia for Medicare claims data.

Claims-Based Frailty Index as a Measure of Dementia Severity in Medicare Claims Data.

Dementia severity is unavailable in administrative claims data. We examined whether a claims-based frailty index (CFI) can measure dementia severity in Medicare claims. This cross-sectional study included the National Health and Aging Trends Study Round 5 participants with possible or probable dementia whose Medicare claims were available. We estimated the Functional Assessment Staging Test (FAST) scale (range: 3 [mild cognitive impairment] to 7 [severe dementia]) using information from the survey. We calculated CFI (range: 0-1, higher scores indicating greater frailty) using Medicare claims 12 months prior to the participants' interview date. We examined C-statistics to evaluate the ability of the CFI in identifying moderate-to-severe dementia (FAST stage 5-7) and determined the optimal CFI cut-point that maximized both sensitivity and specificity. Of the 814 participants with possible or probable dementia and measurable CFI, 686 (72.2%) patients were ≥75 years old, 448 (50.8%) were female, and 244 (25.9%) had FAST stage 5-7. The C-statistic of CFI to identify FAST stage 5-7 was 0.78 (95% confidence interval: 0.72-0.83), with a CFI cut-point of 0.280, achieving the maximum sensitivity of 76.9% and specificity of 62.8%. Participants with CFI ≥0.280 had a higher prevalence of disability (19.4% vs 58.3%) and dementia medication use (6.0% vs 22.8%) and higher risk of mortality (10.7% vs 26.3%) and nursing home admission (4.5% vs 10.6%) over 2 years than those with CFI <0.280. Our study suggests that CFI can be useful in identifying moderate-to-severe dementia from administrative claims among older adults with dementia.

Families of patients with Alzheimer's disease dementia notice progression from symptoms of disorientation and visual memory disturbance.

Alzheimer's disease dementia (ADD) is the most common cognitive disease, but patients' families may notice some symptoms yet not recognise that they indicate ADD. This study investigated the symptoms that families notice as ADD as the disease progresses. New outpatients diagnosed with ADD (n = 315) at five memory clinics completed two cognitive assessments, the Revised Hasegawa Dementia Scale (HDS-R) and Mini-Mental State Examination (MMSE). During an interview, family members completed the Functional Assessment Staging Test (FAST), an observational assessment tool that classifies ADD progression into seven stages. We then examined the relationship of the family-assessed FAST score with clinician-assessed HDS-R and MMSE domain scores by comparing between patients with FAST 1-3 and FAST 4-7. Next, we divided the FAST 4-7 group into the FAST 4-5 and FAST 6-7 subgroups and divided the FAST 1-3 group into the FAST 1-2 and FAST 3 subgroups. Surprisingly, half of the families did not recognise that the symptoms indicated ADD. Scores for orientation of time and place on the HDS-R and MMSE and for visual memory on the HDS-R were significantly related to family-assessed FAST score. Moreover, the orientation of time and place score on both scales and visual memory on the HDS-R were significantly worse in the FAST 4-7 group than in FAST 1-3 group. In the FAST 4-7 group, scores for age on the HDS-R and for reading and drawing on the MMSE were significantly worse in the FAST 6-7 subgroup. In the analysis of the FAST 1-3 group, there was no significant difference among the HDS-R and MMSE domains between the FAST 1-2 and FAST 3 subgroups. Family members of patients with ADD tend to notice the progression of ADD from the symptoms of disorientation and visual memory.

PROGNOSTIC SIGNIFICANCE OF OROPHARYNGEAL DYSPHAGIA IN DEMENTIA PATIENTS WITH EATING DISORDERS

SUMMARY Purpose: The purpose of the study was to study the prognostic value of OD in patients with ongoing dementia with eating disorders. Materials and methods: 46 patients with dementia were selected for the study, 35 of whom had eating disorders. The research contingent was divided into three groups: Group 1 (n=22) - patients with eating disorders with dysphagia, Group 2 (n=13) - patients with eating disorders without dysphagia, Group 3 (n=11) - patients without eating disorders. A minimental scale was used to assess mental status, Mental State Examination – MMSE), To evaluate the severity of the disease - clinical scale of dementia, (Clinical Dementia Rating – СDR); For assessment of the functional state – we use the test of assessment staging test - (Functional Assessment Staging Test - FAST). The obtained results were statistically processed with computer program SPSS 24.0. Quantitative parameters were analyzed by Student's t-test, and categorical parameters by Chi2-test. p&lt;0.05 was used as a reliability criterion. Results: The results of the study showed that patients with dementia and eating disorders with dysphagia had statistically significantly lower MMSE scores compared to groups 2 and 3. It should also be noted that the MMSE indicators of groups 2 and 3 did not reliably differ from each other. The same trend was observed in CDR indicators. Patients with dementia and eating disorders with dysphagia had a statistically significantly higher percentage of CDR=3 compared to groups 2 and 3. It should also be noted that the indicators of CDR=3 of the 2nd and 3rd groups did not reliably differ from each other. According to the FAST indicators, there was no reliable difference in the distribution of responses between the groups. Conclusion: OD is a common condition in patients with advanced dementia and is associated with severe complications, poor prognosis, and poor compliance with fluid and texture adaptations. Supported by the study results, we believe that new nutrition-related strategies should be developed to increase the therapeutic effect in the clinical management of patients with dementia, and new evidence should be provided for these promising interventions.

CLAIMS-BASED FRAILTY INDEX (CFI) AS A MEASURE OF DEMENTIA SEVERITY IN MEDICARE BENEFICIARIES WITH ADRD

Abstract Lack of a dementia severity measure in administrative claims data is a major barrier in Alzheimer’s Disease and Related Dementias (ADRD) research using such data sources. A claims-based frailty index (CFI; range 0 to 1, higher scores indicating greater frailty) is a validated measure of frailty that can be calculated from administrative claims data and is correlated with functional status. We conducted a cross-sectional study to examine whether CFI can be a claims-based measure to differentiate dementia severity in 814 participants with ADRD with linked to Medicare claims in the National Health and Aging Trends Study (NHATS). We estimated the Functional Assessment Staging Test (FAST) scale (3: mild cognitive impairment; 4: mild dementia; 5: moderate dementia; 6–7 moderate-to-severe dementia) using NHATS variables and calculated CFI from Medicare claims in the prior 12 months. The prevalence of FAST stage 5 or higher was 244 (weighted percentage, 25.9%). The C-statistic of CFI to identify FAST stage 5 or higher was 0.78 [95% CI:0.73–0.82], with a CFI cut-point of 0.3 achieving the maximum sensitivity 72.5% and specificity 67.5%. The equipercentile linking procedure showed that CFI scores of 0.30, 0.35, and 0.40 corresponded to FAST stages 4, 5, and 6, respectively. Our results support the utility of a CFI as a proxy of dementia severity in administrative claims data.

Process and Outcome Evaluations of Smartphone Apps for Bipolar Disorder: Scoping Review.

BackgroundMental health apps (MHAs) provide opportunities for accessible, immediate, and innovative approaches to better understand and support the treatment of mental health disorders, especially those with a high burden, such as bipolar disorder (BD). Many MHAs have been developed, but few have had their effectiveness evaluated.ObjectiveThis systematic scoping review explores current process and outcome measures of MHAs for BD with the aim to provide a comprehensive overview of current research. This will identify the best practice for evaluating MHAs for BD and inform future studies.MethodsA systematic literature search of the health science databases PsycINFO, MEDLINE, Embase, EBSCO, Scopus, and Web of Science was undertaken up to January 2021 (with no start date) to narratively assess how studies had evaluated MHAs for BD.ResultsOf 4051 original search results, 12 articles were included. These 12 studies included 435 participants, and of these, 343 had BD type I or II. Moreover, 11 of the 12 studies provided the ages (mean 37 years) of the participants. One study did not report age data. The male to female ratio of the 343 participants was 137:206. The most widely employed validated outcome measure was the Young Mania Rating Scale, being used 8 times. The Hamilton Depression Rating Scale-17/Hamilton Depression Rating Scale was used thrice; the Altman Self-Rating Mania Scale, Quick Inventory of Depressive Symptomatology, and Functional Assessment Staging Test were used twice; and the Coping Inventory for Stressful Situations, EuroQoL 5-Dimension Health Questionnaire, Generalized Anxiety Disorder Scale-7, Inventory of Depressive Symptomatology, Mindfulness Attention Awareness Scale, Major Depression Index, Morisky-Green 8-item, Perceived Stress Scale, and World Health Organization Quality of Life-BREF were used once. Self-report measures were captured in 9 different studies, 6 of which used MONARCA. Mood and energy levels were the most commonly used self-report measures, being used 4 times each. Furthermore, 11 of the 12 studies discussed the various confounding factors and barriers to the use of MHAs for BD.ConclusionsReported low adherence rates, usability challenges, and privacy concerns act as barriers to the use of MHAs for BD. Moreover, as MHA evaluation is itself developing, guidance for clinicians in how to aid patient choices in mobile health needs to develop. These obstacles could be ameliorated by incorporating co-production and co-design using participatory patient approaches during the development and evaluation stages of MHAs for BD. Further, including qualitative aspects in trials that examine patient experience of both mental ill health and the MHA itself could result in a more patient-friendly fit-for-purpose MHA for BD.

The Coaching for Cognition in Alzheimer's (COCOA) trial: Study design.

Comprehensive treatment of Alzheimer's disease (AD) requires not only pharmacologic treatment but also management of existing medical conditions and lifestyle modifications including diet, cognitive training, and exercise. We present the design and methodology for the Coaching for Cognition in Alzheimer's (COCOA) trial. AD and other dementias result from the interplay of multiple interacting dysfunctional biological systems. Monotherapies have had limited success. More interventional studies are needed to test the effectiveness of multimodal multi‐domain therapies for dementia prevention and treatment. Multimodal therapies use multiple interventions to address multiple systemic causes and potentiators of cognitive decline and functional loss; they can be personalized, as different sets of etiologies and systems responsive to therapy may be present in different individuals. COCOA is designed to test the hypothesis that coached multimodal interventions beneficially alter the trajectory of cognitive decline for individuals on the spectrum of AD and related dementias (ADRD). COCOA is a two‐arm prospective randomized controlled trial (RCT). COCOA collects psychometric, clinical, lifestyle, genomic, proteomic, metabolomic, and microbiome data at multiple timepoints across 2 years for each participant. These data enable systems biology analyses. One arm receives standard of care and generic healthy aging recommendations. The other arm receives standard of care and personalized data‐driven remote coaching. The primary outcome measure is the Memory Performance Index (MPI), a measure of cognition. The MPI is a summary statistic of the MCI Screen (MCIS). Secondary outcome measures include the Functional Assessment Staging Test (FAST), a measure of function. COCOA began enrollment in January 2018. We hypothesize that multimodal interventions will ameliorate cognitive decline and that data‐driven health coaching will increase compliance, assist in personalizing multimodal interventions, and improve outcomes for patients, particularly for those in the early stages of the AD spectrum.Highlights The Coaching for Cognition in Alzheimer's (COCOA) trial tests personalized multimodal lifestyle interventions for Alzheimer's disease and related dementias.Dense longitudinal molecular data will be useful for future studies.Increased use of Hill's criteria in analyses may advance knowledge generation.Remote coaching may be an effective intervention.Because lifestyle interventions are inexpensive, they may be particularly valuable in reducing global socioeconomic disparities in dementia care.

Long-term effects of alcohol consumption on cognitive function in seniors: a cohort study in China

BackgroundIn the context of increasing global aging, the long-term effects of alcohol consumption on cognitive function in older adults were analyzed in order to provide rationalized health recommendations to the elderly population.MethodsThe study used the Chinese Longitudinal Healthy Longevity Survey (CLHLS) dataset, from which 5354 Chinese seniors aged 65–112 years were selected as the subjects, spanning the years 1998–2018. Data on alcohol, diet, activity, and cognition were collected by questionnaire and cognitive levels were judged by the Mini-Mental State Examination scale (also referenced to the Functional Assessment Staging Test). Data cleaning and preprocessing was implemented by R software. The dynamic Cox model was applied for model construction and data analysis.ResultsThe results of the dynamic Cox model suggested that seniors who drank alcohol were at higher risk of cognitive decline compared to those who never drank (HR = 1.291, 95%CI: 1.175–1.419). The risk was similarly exacerbated by perennial drinking habits (i.e., longer drinking years, HR = 1.008, 95%CI: 1.004–1.013). Compared to non-alcoholic beverages, liquor (≥ 38°), liquor (< 38°), wine and rice wine all showed negative effects. Whereas, the risk of cognitive decline was relatively lower in seniors who consumed liquors (< 38°) and rice wine compared to the high-level liquor (HR: 0.672 (0.508, 0.887) and 0.732 (0.559, 0.957), respectively).ConclusionsAlcohol consumption has a negative and long-term effects on cognitive function in seniors. For the elderly, we suggested that alcohol intake should be avoided as much as possible.

Clinical Spectrum- Cognition, Stages, Functionality among Elderly with Dementia: A Cross-Sectional Study

Introduction: Although cognitive and functional impairment are the hallmark features of Dementia but it is often undetected and neglected as a normal part of aging. So we conducted this study on clinical profile of dementia patients. Aims: The aim of this study is to evaluate the Patient’s cognitive impairment, functional capacities, and stages of severity of dementia. Methods: A descriptive cross sectional study was conducted among 50 patients aged 60 years and above, of both sexes with the diagnosis of Dementia, admitted in Medicine ward of Nepalgunj Medical College, Nepalgunj, Nepal. The screening of dementia was done using Mini-Mental State Examination tool and the diagnosis of Dementia was confirmed using the International Classification of Disease-10 Diagnostic Criteria for Research. Cognition, functionality and stages of severity of dementia were assessed using Hierarchic Dementia Scale, Functional Autonomy Measurement System, Functional Assessment Staging Test tools respectively. Results: Among a total of 50 dementia patients, the mean and standard deviation of age was 82.4±6.1 years, majority of cases 60 % were in the age group ≥85 years and most patients were female 56%. The mean Mini-Mental State Examination score was 9.6±3.0, and 50 % had severe impairment of cognition on Hierarchic Dementia Scale. Stage 7 dementia 32 % was most prevalent stage on Functional Assessment Staging and severe deterioration in the functional autonomy was seen in 54% dementia patients (score ≥41 on Functional Autonomy Measurement System). Conclusion: This study concludes that significant number of elderly patients attending tertiary care hospital suffers from dementia with severe impairment in cognition and functionality in various stages of dementia in the elderly patients.

Prognostication in Home-Dwelling Patients with Advanced Dementia: The Palliative Support DEMentia Model (PalS-DEM)

ObjectiveDifficulties with prognostication prevent more patients with advanced dementia from receiving timely palliative support. The aim of this study is to develop and validate a prognostic model for 6-month and 1-year mortality in home-dwelling patients with advanced dementia. DesignProspective cohort study. Setting and ParticipantsThe data set of 555 home-dwelling patients with dementia at Functional Assessment Staging Test stage 7 was split into derivation (n = 275) and validation (n = 280) cohorts. MethodsCox proportional hazards regression modeled survival in the derivation cohort using prognostic variables identified in univariate analysis. The model was validated internally and using 10-fold cross-validation. Area under the receiver operating characteristic curve measured the accuracy of the final model. ResultsFour hundred nineteen (75.5%) patients died with a median follow-up of 47 days [interquartile range (IQR) 161]. Prognostic variables in the multivariate model included serum albumin level, dementia etiology, number of homecare admission criteria fulfilled, presence of moderate to severe chronic kidney disease, peripheral vascular disease, quality of life in late-stage dementia scores, housing type, and the Australian National Sub-Acute and Non-Acute Patient palliative care phase.The model was refined into a parsimonious 6-variable model [Palliative Support DEMentia Model (PalS-DEM)] consisting of age, dementia etiology, Functional Assessment Staging Test stage, Charlson Comorbidity Index scores, Australian National Sub-Acute and Non-Acute Patient palliative care phase, and 30-day readmission frequency for the prediction of 1-year mortality. The area under the receiver operating characteristic curve was 0.65 (95% confidence interval 0.59–0.70). Risk scores categorized patients into 3 prognostic groups, with a median survival of 175 days (IQR 365), 104 days (IQR 246), and 19 days (IQR 88) for the low-risk (0‒1 points), moderate-risk (2‒4), and high-risk (≥5) groups, respectively. Conclusions and ImplicationsThe PalS-DEM identifies patients at high risk of death in the next 1 year. The model produced consistent survival results across the derivation, validation, and cross-validation cohorts and will help healthcare providers identify patients with advanced dementia earlier for palliative care.

Family Caregiver Perspectives on Suffering of Persons With Severe Dementia: A Qualitative Study

ContextDementia involves suffering. Assessing the experience of suffering among persons with severe dementia is instrumental to delivering quality end-of-life care to them and their caregivers. ObjectivesWe aimed to assess dimensions of suffering from the perspective of family caregivers and the resulting impact on their decisions for the care of persons with severe dementia. MethodsBetween July 2018 and February 2019, we conducted qualitative in-depth interviews with 27 family caregivers of community-dwelling persons with severe dementia with Functional Assessment Staging Test staging 7. We asked caregivers if they perceived persons with severe dementia to be suffering and explored reasons for their perceptions. We analyzed data using principles of reflexive thematic analysis. ResultsWe conceptualized five dimensions of suffering among persons with severe dementia from the perspective of their caregivers: 1) untreated physical or behavioral symptoms, 2) emotional pain, 3) loss of agency, 4) loss of engagement with society, and 5) loss of personhood. Suffering among persons with severe dementia influences their caregivers' expression of a wish for their death and caregivers’ decision regarding the use of life-prolonging interventions for them. ConclusionFindings suggest that suffering among persons with severe dementia can occur independent of physical symptoms and requires provision of person-centered care. The study adds to the understanding of end-of-life care in persons with severe dementia and their caregivers.

Use of Patient-Reported Symptoms from an Online Symptom Tracking Tool for Dementia Severity Staging: Development and Validation of a Machine Learning Approach.

BackgroundSymptomGuide Dementia (DGI Clinical Inc) is a publicly available online symptom tracking tool to support caregivers of persons living with dementia. The value of such data are enhanced when the specific dementia stage is identified.ObjectiveWe aimed to develop a supervised machine learning algorithm to classify dementia stages based on tracked symptoms.MethodsWe employed clinical data from 717 people from 3 sources: (1) a memory clinic; (2) long-term care; and (3) an open-label trial of donepezil in vascular and mixed dementia (VASPECT). Symptoms were captured with SymptomGuide Dementia. A clinician classified participants into 4 groups using either the Functional Assessment Staging Test or the Global Deterioration Scale as mild cognitive impairment, mild dementia, moderate dementia, or severe dementia. Individualized symptom profiles from the pooled data were used to train machine learning models to predict dementia severity. Models trained with 6 different machine learning algorithms were compared using nested cross-validation to identify the best performing model. Model performance was assessed using measures of balanced accuracy, precision, recall, Cohen κ, area under the receiver operating characteristic curve (AUROC), and area under the precision-recall curve (AUPRC). The best performing algorithm was used to train a model optimized for balanced accuracy.ResultsThe study population was mostly female (424/717, 59.1%), older adults (mean 77.3 years, SD 10.6, range 40-100) with mild to moderate dementia (332/717, 46.3%). Age, duration of symptoms, 37 unique dementia symptoms, and 10 symptom-derived variables were used to distinguish dementia stages. A model trained with a support vector machine learning algorithm using a one-versus-rest approach showed the best performance. The correct dementia stage was identified with 83% balanced accuracy (Cohen κ=0.81, AUPRC 0.91, AUROC 0.96). The best performance was seen when classifying severe dementia (AUROC 0.99).ConclusionsA supervised machine learning algorithm exhibited excellent performance in identifying dementia stages based on dementia symptoms reported in an online environment. This novel dementia staging algorithm can be used to describe dementia stage based on user-reported symptoms. This type of symptom recording offers real-world data that reflect important symptoms in people with dementia.

Counting Backward by Seven.

I delayed my neurology rotation in medical school because I was trying to ignore the symptoms of dementia developing in my mother. They became painfully apparent when I saw my parents less frequently after I moved away for residency, and finally had to be addressed when I had a child of my own and felt unsafe having her care for him. Through my experiences with her and in my training in palliative care and oncology, I have learned that tools like the Mini Mental State Examination (MMSE) and Functional Assessment Staging Test (FAST) can only tell us so much; the true measure of a patient's decline can be found in the patient's and family's own story.

466 - Reliability“and Validity Study of the Thai version of the Pain Assessment in Advanced Dementia”(PAINAD-Th)

Background: Dementia is a syndrome that affects multiple cognitive domains and causes functional decline. People with dementia (PwD) often experience pain, still could not report the symptom due to the decline in cognition that leads to communication problems. Therefore, pain in PwD is often underrecognized and undertreated. Many behavioral observation tools have been developed to help identify pain in PwD; the Pain Assessment in Advanced Dementia (PAINAD) scale is one of the recommended tools to evaluate pain in PwD. The PAINAD has been translated into many languages, yet not translated into Thai language. Since there is no pain assessment tool for PwD in Thailand.Objective: This study aimed to assess the reliability"and validity of the PAINAD in Thai version (PAINAD-Th) for measuring pain in people with"PwDMaterials and Methods: The cross-cultural translation including forward translation and back-translation of PAINAD-Th were performed, then the content validity was assessed by the expert committee. Enrolled participants were inpatients aged 60 years or over, and had dementia with Functional Assessment Staging Test (FAST) of at least 6 which represented moderately severe stage. A research assistant recorded 5-minute videos of the participants, the first video was during the activity that could provoke the pain and the second video was at rest. Two trained nurses independently rated the pain of the participants by observing the videos using the PAINAD-Th to examine the inter-rater reliability and the concurrent validity of the test against the reference standard which was the numeric rating scale (NRS) rated by the expert committee. The same rating process was reproduced one week apart to explore the test-retest reliability.Results: The content validity index of the PAINAD-Th was 1.00 and 0.93 (forward and back-translation, respectively)."The inter -rater and test-retest reliability showed an excellent intra-class correlation coefficient of"0.92 and 0.96, respectively. The concurrent validity was significantly correlated with the reference standard with an excellent intra-class correlation coefficient of"0.95.Conclusions: The PAINAD-Th is a promising tool for pain evaluation in PwD as it provides an excellent concurrent validity against the reference standard. Also, it has excellent content validity, inter-rater, and test-retest reliability.

Palliative care for nursing home patients with dementia: service evaluation and risk factors of mortality

BackgroundDifficulties in prognostication are common deterrents to palliative care among dementia patients. This study aimed to evaluate the effectiveness of palliative care in reducing the extent of utilization of medical services and the potential risk factors of mortality among dementia patients receiving palliative care.MethodsWe surveyed dementia patients involved in a palliative care program at a long-term care facility in Taipei, Taiwan. We enrolled 57 patients with advanced dementia (clinical dementia rating ≥ 5 or functional assessment staging test stage 7b). We then compared the extent of their utilization of medical services before and after the provision of palliative care. Based on multivariable logistic regression, we identified potential risk factors before and after the provision of palliative care associated with 6-month mortality.ResultsThe utilization of medical services was significantly lower among dementia patients after the provision of palliative care than before, including visits to medical departments (p < 0.001), medications prescribed (p < 0.001), frequency of hospitalization (p < 0.001), and visits to the emergency room (p < 0.001). Moreover, patients dying within 6 months after the palliative care program had a slightly but not significantly higher number of admissions before receiving hospice care (p = 0.058) on univariate analysis. However, no significant differences were observed in multivariate analysis.ConclusionsThe provision of palliative care to dementia patients reduces the extent of utilization of medical services. However, further studies with larger patient cohorts are required to stratify the potential risk factors of mortality in this patient group.

Caregiver Preference for Tube Feeding in Community-Dwelling Persons with Severe Dementia.

Evidence suggests that tube feeding persons with severe dementia (PWSDs) does not improve survival or quality of life, yet many continue to be tube fed. Reasons why caregivers choose to do so are not entirely understood. To understand what shapes caregiver preference toward nasogastric (NG) tube feeding for community-dwelling PWSDs. A qualitative study that employed semistructured interviews. Primary informal caregivers of community-dwelling persons diagnosed with dementia Functional Assessment Staging Test (FAST) stage 7 in Singapore. Caregivers participated in qualitative in-depth interviews during which their preferences toward NG tube feeding of PWSDs were explored. We used principles of reflexive thematic analysis to compare caregivers who expressed a preference for NG tube feeding with those who did not prefer it. We interviewed 27 caregivers of PWSDs. Most caregivers, 67% (n = 18), expressed a preference for tube feeding. We conceptualized four main themes describing what shapes caregiver preference toward NG tube feeding: (1) willingness to use tube feeding to prolong life at the expense of suffering, (2) deference to healthcare provider's (HCP's) recommendation, (3) caregiver knowledge of alternatives to tube feeding, and (4) caregivers' internal and external conflicts. Results from this study highlight the need for new inclusive approaches to shared decision-making between HCPs and caregivers regarding tube feeding for community-dwelling PWSDs. J Am Geriatr Soc 68:2264-2269, 2020.

Dementia Care Mapping™ to reduce agitation in care home residents with dementia: the EPIC cluster RCT.

The quality of care for people with dementia in care homes is of concern. Interventions that can improve care outcomes are required. To investigate the clinical effectiveness and cost-effectiveness of Dementia Care Mapping™ (DCM) for reducing agitation and improving care outcomes for people living with dementia in care homes, versus usual care. A pragmatic, cluster randomised controlled trial with an open-cohort design, follow-up at 6 and 16 months, integrated cost-effectiveness analysis and process evaluation. Clusters were not blinded to allocation. The primary end point was completed by staff proxy and independent assessors. Stratified randomisation of 50 care homes to the intervention and control groups on a 3 : 2 ratio by type, size, staff exposure to dementia training and recruiting hub. Fifty care homes were randomised (intervention, n = 31; control, n = 19), with 726 residents recruited at baseline and a further 261 recruited after 16 months. Care homes were eligible if they recruited a minimum of 10 residents, were not subject to improvement notices, had not used DCM in the previous 18 months and were not participating in conflicting research. Residents were eligible if they lived there permanently, had a formal diagnosis of dementia or a score of 4+ on the Functional Assessment Staging Test of Alzheimer's Disease, were proficient in English and were not terminally ill or permanently cared for in bed. All homes were audited on the delivery of dementia and person-centred care awareness training. Those not reaching a minimum standard were provided training ahead of randomisation. Eighteen homes took part in the process evaluation. Two staff members from each intervention home were trained to use DCM and were asked to carry out three DCM cycles; the first was supported by an external expert. The primary outcome was agitation (Cohen-Mansfield Agitation Inventory), measured at 16 months. Secondary outcomes included resident behaviours and quality of life. There were 675 residents in the final analysis (intervention, n = 388; control, n = 287). There was no evidence of a difference in agitation levels between the treatment arms. The adjusted mean difference in Cohen-Mansfield Agitation Inventory score was -2.11 points, being lower in the intervention group than in the control (95% confidence interval -4.66 to 0.44; p = 0.104; adjusted intracluster correlation coefficient: control = 0, intervention = 0.001). The sensitivity analyses results supported the primary analysis. No differences were detected in any of the secondary outcomes. The health economic analyses indicated that DCM was not cost-effective. Intervention adherence was problematic; only 26% of homes completed more than their first DCM cycle. Impacts, barriers to and facilitators of DCM implementation were identified. The primary completion of resident outcomes was by staff proxy, owing to self-report difficulties for residents with advanced dementia. Clusters were not blinded to allocation, although supportive analyses suggested that any reporting bias was not clinically important. There was no benefit of DCM over control for any outcomes. The implementation of DCM by care home staff was suboptimal compared with the protocol in the majority of homes. Alternative models of DCM implementation should be considered that do not rely solely on leadership by care home staff. Current Controlled Trials ISRCTN82288852. This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 24, No. 16. See the NIHR Journals Library website for further project information.

An application of multinomial processing tree models and Bayesian methods to understanding memory impairment

We model word-list learning over sequences of immediate and delayed free recall tasks to study the impact of memory impairment on episodic memory. We use a previously developed Multinomial Processing Tree (MPT) model of encoding, retrieval, and learning (Alexander et al., 2016), and apply it to behavioral data from thousands of patients tested tens of thousands of times in a cognitive disorders clinic. The patients were independently diagnosed, using the Functional Assessment Staging Test (FAST), into six stages of impairment. We apply hierarchical and latent-mixture versions of the MPT model to patients in each FAST stage, exploring individual differences among people and item-position effects across the word lists. Our results show clear and theoretically interpretable regularities in how model parameters change over item positions, corresponding to standard primacy and recency effects in free recall. Accordingly, we develop an extended model that directly incorporates theoretical assumptions about serial position. Inferences from this model allow us to reach conclusions about how learning, encoding, and retrieval processes change as memory impairment progresses.

A group intervention to improve quality of life for people with advanced dementia living in care homes: the Namaste feasibility cluster RCT

People with advanced dementia who live and die in nursing homes experience variable quality of life, care and dying. There is a need to identify appropriate, cost-effective interventions that facilitate high-quality end-of-life care provision. To establish the feasibility and acceptability to staff and family of conducting a cluster randomised controlled trial of the Namaste Care intervention for people with advanced dementia in nursing homes. The study had three phases: (1) realist review and (2) intervention refinement to inform the design of (3) a feasibility cluster randomised controlled trial with a process evaluation and economic analysis. Clusters (nursing homes) were randomised in a 3 : 1 ratio to intervention or control (usual care). The nature of the intervention meant that blinding was not possible. Nursing homes in England providing care for people with dementia. Residents with advanced dementia (assessed as having a Functional Assessment Staging Test score of 6 or 7), their informal carers and nursing home staff. Namaste Care is a complex group intervention that provides structured personalised care in a dedicated space, focusing on enhancements to the physical environment, comfort management and sensory engagement. The two contender primary outcome measures were Comfort Assessment in Dying - End of Life Care in Dementia for quality of dying (dementia) and Quality of Life in Late Stage Dementia for quality of life. The secondary outcomes were as follows: person with dementia, sleep/activity (actigraphy), neuropsychiatric symptoms, agitation and pain; informal carers, satisfaction with care at the end of life; staff members, person-centred care assessment, satisfaction with care at the end of life and readiness for change; and other data - health economic outcomes, medication/service use and intervention activity. Phase 1 (realist review; 86 papers) identified that a key intervention component was the activities enabling the development of moments of connection. In phase 2, refinement of the intervention enabled the production of a user-friendly 16-page A4 booklet. In phase 3, eight nursing homes were recruited. Two homes withdrew before the intervention commenced; four intervention and two control homes completed the study. Residents with advanced dementia (n = 32) were recruited in intervention (n = 18) and control (n = 14) homes. Informal carers (total, n = 12: intervention, n = 5; control, n = 7) and 97 staff from eight sites (intervention, n = 75; control, n = 22) were recruited over a 6-month period. Recruitment is feasible. Completion rates of the primary outcome questionnaires were high at baseline (100%) and at 4 weeks (96.8%). The Quality of Life in Late Stage Dementia was more responsive to change over 24 weeks. Even where economic data were missing, these could be collected in a full trial. The intervention was acceptable; the dose varied depending on the staffing and physical environment of each care home. Staff and informal carers reported changes for the person with dementia in two ways: increased social engagement and greater calm. No adverse events related to the intervention were reported. A subsequent definitive trial is feasible if there are amendments to the recruitment process, outcome measure choice and intervention specification. In a full trial, consideration is needed of the appropriate outcome measure that is sensitive to different participant responses, and of clear implementation principles for this person-centred intervention in a nursing home context. Current Controlled Trials ISRCTN14948133. This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 24, No. 6. See the NIHR Journals Library website for further project information.

Development and Validation of a Tool to Screen for Cognitive Frailty among Community-Dwelling Elders.

Reciprocal age-related impairments in physical and cognitive functioning have been termed 'cognitive frailty', which is associated with adverse health outcomes and is a potential target for preventing or delaying the onset of disability in older people. However, cognitive frailty as currently defined is challenging to diagnose. To facilitate earlier diagnosis and intervention, we conducted this study to develop and validate a simple evidence-based instrument to identify community-dwelling elders at risk of cognitive frailty. Retrospective analyses of data from the I-Lan Longitudinal Aging Study (ILAS) to develop a prediction model, and from the Longitudinal Aging Study of Taipei (LAST) for external validation. Community-dwelling adults from Taipei City, New Taipei City and Yilan (I-Lan) County, Taiwan. 1271 community residents ≥65 years old, without impaired global cognition or dependency for activities of daily living/instrumental activities of daily living. Demographic characteristics, anthropometric measurements, medical history, Mini-Mental State Examination, Montreal Cognitive Assessment, Functional Autonomy Measuring System, Functional Assessment Staging Test, Center for Epidemiologic Studies Depression Scale, handgrip strength, 6-metre walk speed. Baseline characteristics of groups with/without cognitive frailty were analyzed and factors differing significantly in univariate analysis input to binary logistic regression to develop a cognitive frailty risk (CFR) score. The prevalence of cognitive frailty was 15.8% overall; ILAS 21.4%, LAST 8.4%. Predictors of CFR comprised: age ≥75 years; female sex; waist circumference ≥90 cm (male), ≥80 cm (female); calf circumference <33 cm (male), <32 cm (female); memory deficits; and diabetes mellitus. CFR ≥5/14 had sensitivity of 70%, specificity of 60%, and predictive accuracy of 72%. A CFR score based on simple history-taking and anthropometric measurements integrates age, sex, cardiometabolic risk, memory deficits, sarcopenia, and nutrition, with validated predictive accuracy, and could be performed easily in community settings to identify seniors with cognitive frailty for appropriate interventions.