Prior Diagnosis Of Dementia Research Articles

DIAGNOSTIC AND TREATMENT PATTERNS AND HEALTHCARE RESOURCE UTILIZATION AMONG DIAGNOSED DEMENTIA PATIENTS IN THE UNITED STATES

Background: Populations affected with a dementia will grow each year as the number and proportion of elder population (age 65) continue to increase. While it is known that a dementia diagnoses is associated with high direct and indirect costs, no data are available describing healthcare resource utilization (HRU) associated with diagnostic and treatment patterns in these patients. Methods: Using medical and pharmacy claims data between October 1, 2007 and September 30, 2012, subjects were selected from one of the diagnostic algorithms (1. Dementia not otherwise specified 2.Dementia diagnosis by specialist, 3. Dementia diagnosis by generalist). Subjects were required to have 1 year continuous enrollment pre-index date (date of first dementia diagnosis) and post-confirmed date (time of the confirmed diagnosis to end of available data) without prior dementia diagnosis or dementia-related medications. Time from first to confirmed dementia diagnosis was defined as diagnostic work-up period. All data were analyzed separately for the private-insured population (private) and the Medicare supplemental insurance population (Medicare). Results: Of the 745 private patients (61.1% female; mean age 1⁄459.8), 39.6% had a first dementia diagnosis of mild cognitive impairment(MCI), 21.6% Alzheimer’s disease(AD), 6.0% vascular dementia(VD), 1.9% frontotemporal, and 1.1% lewy body dementia(LBD). The average diagnostic work up period was 93.4 days. There were more average number of HRU per 100 member per month (PMPM) during diagnostic period compared to post-diagnosis period (head CT scan: 4.7 vs. 1.2; head/brain MRI: 20.7 vs. 2.0; generalist visit: 55.3 vs. 51.6; specialist visit: 90.7 vs. 33.7; emergency room visit: 4.4 vs. 3.6; inpatient admission: 5.0 vs.2.0). Of the 7,911 Medicare patients (62.0% female; mean age 1⁄481.6), 15.7% had a first dementia diagnosis of MCI, 59.0% AD, 8.0% VD, 0.5% frontotemporal, and 2.1% LBD. The average diagnostic work up period was 127.5 days. PMPMHRUwas higher during diagnostic period compared with postdiagnosis period (head CT scan: 12.2 vs. 3.7; head/brain MRI: 3.2 vs. 0.9; generalist visit: 100.3 vs. 79.5; specialist visit: 43.9 vs. 26.1; emergency room visit: 4.7 vs. 4.4; inpatient admission: 11.0 vs. 3.0). Conclusions: Data support that earlier diagnosis is associated with fewer use of health care utilization.

Screening for Cognitive Impairment: Comparing the Performance of Four Instruments in Primary Care

To determine whether brief cognitive screening tests perform as well as a longer screening test in diagnosis of cognitive impairment, no dementia (CIND) or dementia. A cross-sectional comparison of cognitive screening tests to an independent criterion standard evaluation using Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) criteria. Performance of the cognitive screening tests for identifying dementia, and separately for identifying dementia or CIND, was characterized using sensitivity, specificity, likelihood ratios, and diagnostic odds ratios. Three Department of Veterans Affairs primary care clinics. Of 826 independently living veterans aged 65 and older without a prior diagnosis of dementia, 639 participated and 630 were assigned a research diagnosis. Screening tests included the modified Mini-Mental State Examination (3MS; average time to administer, 17 minutes) and three brief instruments: the Memory Impairment Screen (MIS; 4 minutes), the Mini-Cog (3 minutes), and a novel two-item functional memory screen (MF-2; 1.5 minutes). Participants were aged 74.8 on average and were mostly white or black. They were mostly male (92.9%) and had been prescribed a mean of 7.7 medications for chronic conditions. The prevalence of dementia and CIND was 3.3% and 39.2%, respectively. Sensitivity and specificity for dementia were 86% and 79% for the 3MS, 76% and 73% for the Mini-Cog, 43% and 93% for the MIS, and 38% and 87% for the MF-2, respectively. In individuals without a prior diagnosis of cognitive impairment, the prevalence of dementia was low, but the prevalence of CIND was high. The 3MS and Mini-Cog had reasonable performance characteristics for detecting dementia, but a definitive diagnosis requires additional evaluation.

Risk factors for dementia after critical illness in elderly medicare beneficiaries

IntroductionHospitalization increases the risk of a subsequent diagnosis of dementia. We aimed to identify diagnoses or events during a hospitalization requiring critical care that are associated with a subsequent dementia diagnosis in the elderly.MethodsA cohort study of a random 5% sample of Medicare beneficiaries who received intensive care in 2005 and survived to hospital discharge, with three years of follow-up (through 2008) was conducted using Medicare claims files. We defined dementia using the International Classification of Diseases, 9th edition, clinical modification (ICD-9-CM) codes and excluded patients with any prior diagnosis of dementia or cognitive impairment in the year prior to admission. We used an extended Cox model to examine the association between diagnoses and events associated with the critical illness and a subsequent diagnosis of dementia, adjusting for known risk factors for dementia.ResultsOver the three years of follow-up, dementia was newly diagnosed in 4,519 (17.8%) of 25,368 patients who received intensive care and survived to hospital discharge. After accounting for known risk factors, having an infection (adjusted hazard ratio (AHR) = 1.25; 95% CI, 1.17 to 1.35), or a diagnosis of severe sepsis (AHR = 1.40; 95% CI, 1.28 to 1.53), acute neurologic dysfunction (AHR = 2.06; 95% CI, 1.72 to 2.46), and acute dialysis (AHR = 1.70; 95% CI, 1.30 to 2.23) were all independently associated with a subsequent diagnosis of dementia. No other measured ICU factors, such as need for mechanical ventilation, were independently associated.ConclusionsAmong ICU events, infection or severe sepsis, neurologic dysfunction, and acute dialysis were independently associated with a subsequent diagnosis of dementia. Patient prognostication, as well as future research into post-ICU cognitive decline, should focus on these higher-risk subgroups.

EVIDENCE FOR THE VALIDITY OF THE AMERICAN MEDICAL ASSOCIATION'S CAREGIVER SELF‐ASSESSMENT QUESTIONNAIRE AS A SCREENING MEASURE FOR DEPRESSION

EVIDENCE FOR THE VALIDITY OF THE AMERICAN MEDICAL ASSOCIATION'S CAREGIVER SELF‐ASSESSMENT QUESTIONNAIRE AS A SCREENING MEASURE FOR DEPRESSION

<b>Screening for Undiagnosed Cognitive Impairment in Homebound Older Adults</b>

To screen for undetected cognitive impairment in homebound elders receiving home health care services. A cross-sectional study of adults 60 years of age and older receiving visiting nurse services. A pharmacist administered the Mini-Cog, a rapid screening test for cognitive impairment, during the enrollment home visit. Participants' homes. A consecutive sample of 100 homebound adults, 60 years of age or older with no previous diagnosis of dementia, Alzheimer's disease, or other cognitive impairment. Percentage of participants scoring in the likely impaired range (screen failure) on the Mini-Cog. Seventeen percent of persons with no prior diagnosis of dementia or cognitive decline failed the Mini-Cog. Rates of undetected cognitive impairment are substantial in homebound elders receiving care from a visiting nurse service. The home health setting represents an important point in the continuum of geriatric care for detection of cognitive impairment. Future work should define the types and trajectories of cognitive impairment detected in home care patients by simple screens such as the Mini-Cog and test ways to integrate this knowledge into longitudinal treatment plans across settings of care.

Factors associated with hip fracture-related falls among patients with a history of recurrent falling

Background People who have suffered falls are at greater risk of falling again. We study the characteristics of falls leading to hip fracture in people with a history of recurrent falls, comparing them with those of people with a history of sporadic falling. Materials and methods Analysis of the characteristics of a sample of 1225 patients consecutively admitted to six hospitals because of a hip fracture secondary to a fall (index fall) — index fall characteristics (location, time and the possible cause of the fall: intrinsic, extrinsic or combined risk factors) were also determined. Patients with a history of three or more falls (recurrent fallers) in the year prior to the index fall were identified as high-risk fallers; those with less than three falls were considered to be sporadic fallers. Results The mean number of falls in the year prior to the index fall was 1.7 ± 6.5; 227 patients (22%) had experienced three or more falls within that period. Most index falls (880, 71.8%) took place at the patient's home, 232 (18.95%) in the street and 113 (9.2%) elsewhere; most (892, 72.9%) took place during daytime. Multiple stepwise logistic regression analysis showed that recurrent fallers were characterized by poorer baseline independence for activities of the daily living, a prior diagnosis of dementia, greater use of prescription drugs and a greater use of neuroleptics. For frequent fallers, the index fall was more often associated with an intrinsic factor than for sporadic fallers. Conclusions A significant percentage of patients experiencing a fall followed by hip fracture have a history of recurrent falling in the year prior to a fall-related hip fracture. Poorer functional and cognitive status, polypharmacy and the use of neuroleptics are more prevalent in this subgroup of patients, and intrinsic factors as a cause of the fall are more common in this group. Whether these circumstances associated with recurrent falling are responsible for this higher prevalence of intrinsic, non-accidental falls should be addressed prospectively in order to implement preventive strategies.

Pathologic findings in prospectively ascertained essential tremor subjects

To assess pathologic changes in prospectively characterized subjects with essential tremor (ET). Subjects enrolled in the Sun Health Research Institute Brain and Body Donation Program were examined annually by a movement disorders neurologist, and semiannually by a behavioral neurologist and neuropsychologist. Twenty-four subjects without a prior diagnosis of dementia or other major movement disorder met clinical criteria for ET and came to autopsy. Subjects with mild cognitive impairment (n = 3) were included. These subjects were compared with 21 controls. Brains were examined postmortem according to standardized protocols for assessment of age-related changes and specific pathologic conditions (e.g., Parkinson disease, Alzheimer disease). Subjects had a mean age of 86.2 years and a mean duration of tremor of 11.1 years. Seven subjects had evidence for cerebellar pathology (Purkinje cell loss, cerebellar cortical sclerosis, and proliferation of Bergmann glia). Pigmented neurons were qualitatively depleted in the locus ceruleus in eight subjects and in the substantia nigra in five subjects. Of these, three had Lewy bodies, one subject had brainstem predominant disease, and two had limbic stage. Three subjects had a nonspecific cerebral tauopathy and another met pathologic criteria for progressive supranuclear palsy. However, when compared with controls, only changes in the locus ceruleus and gliosis of the cerebellum remained significant findings. This study supports previous findings of heterogenous pathology in essential tremor (ET). There is an increased frequency of cerebellar gliosis and locus ceruleus depletion. We did not find an increased incidence of Lewy bodies in subjects with ET.

Construction of Atorvastatin Dose–Response Relationships Using Data from a Large Population‐Based DNA Biobank

Construction of Atorvastatin Dose–Response Relationships Using Data from a Large Population‐Based DNA Biobank

Are amyotrophic lateral sclerosis patients cognitively normal?

Patients with ALS are often told that the disease spares cognition; however, recent evidence suggests deficits in frontal executive skills occur in a sizable minority of ALS patients. In many instances, the frontal executive deficits represent the co-occurrence of frontotemporal lobar dementia (FTLD) and ALS. Word generation, a simple frontal task that takes <2 minutes, was tested in 100 consecutive patients with ALS seen in the authors' multidisciplinary clinic. Any patient with a prior dementia diagnosis was excluded from the study. A subset of 44 patients agreed to undergo further neuropsychological testing and clinical interview to confirm or deny a diagnosis of dementia. Diminished word generation was found in one-third. Of the patients with abnormal word generation who agreed to further evaluation, nearly all were shown to meet research criteria for FTLD. In addition, one-quarter of the patients with normal word generation who agreed to further evaluation met research criteria for FTLD; these patients had new-onset personality changes. This study suggests that frontal executive deficits are present in half of ALS patients, many of whom meet strict research criteria for FTLD. Word generation tests are a useful screening tool in this cohort.

Influenza vaccination and reduction in hospitalizations for cardiac disease and stroke among the elderly.

Upper respiratory tract illnesses have been associated with an increased risk of ischemic heart disease and stroke. During two influenza seasons, we assessed the influence of vaccination against influenza on the risk of hospitalization for heart disease and stroke, hospitalization for pneumonia and influenza, and death from all causes. Cohorts of community-dwelling members of three large managed-care organizations who were at least 65 years old were studied during the 1998-1999 and 1999-2000 influenza seasons. Administrative and clinical data were used to evaluate outcomes, with multivariable logistic regression to control for base-line demographic and health characteristics of the subjects. There were 140,055 subjects in the 1998-1999 cohort and 146,328 in the 1999-2000 cohort, of which 55.5 percent and 59.7 percent, respectively, were immunized. At base line, vaccinated subjects were on average sicker, having higher rates of most coexisting conditions, outpatient care, and prior hospitalization for pneumonia than unvaccinated subjects. Unvaccinated subjects, however, were more likely to have been given a prior diagnosis of dementia or stroke. Vaccination against influenza was associated with a reduction in the risk of hospitalization for cardiac disease (reduction of 19 percent during both seasons [P<0.001]), cerebrovascular disease (reduction of 16 percent during the 1998-1999 season [P<0.018] and 23 percent during the 1999-2000 season [P<0.001]), and pneumonia or influenza (reduction of 32 percent during the 1998-1999 season [P<0.001] and 29 percent during the 1999-2000 season [P<0.001]) and a reduction in the risk of death from all causes (reduction of 48 percent during the 1998-1999 season [P<0.001] and 50 percent during the 1999-2000 season [P<0.001]). In analyses according to age, the presence or absence of major medical conditions at base line, and study site, the findings were consistent across all subgroups. In the elderly, vaccination against influenza is associated with reductions in the risk of hospitalization for heart disease, cerebrovascular disease, and pneumonia or influenza as well as the risk of death from all causes during influenza seasons. These findings highlight the benefits of vaccination and support efforts to increase the rates of vaccination among the elderly.

Case Finding for Cognitive Impairment in Elderly Emergency Department Patients

See related editorial, p873. Study objectives: To determine the feasibility of a case-finding program for cognitive impairment in elderly emergency department patients, and to describe the prevalence of cognitive impairment in screened patients and identify factors associated with impairment. Design: A three-month cross-sectional study. The six-item Orientation-Memory- Concentration (OMC) Test was administered to eligible patients. Setting: Community teaching hospital with annual ED census of 69,000 adults. Participants: All patients 65 years of age and older physically able to communicate and without a prior diagnosis of dementia were eligible. Five hundred forty-seven of 958 patients (59%) were interviewed; only 95 (10%) refused. Other reasons for exclusion were too ill, 113 (12%); other (sleeping, privacy, repeat visits, incomplete forms), 99 (10%); known dementia, 59 (6%); and communication problems, 45 (5%). Results: A mean time of 1.9 minutes (±0.91 SD) was required to complete the test. One hundred eighty-three of 547 patients (33.5%) had scores that indicated at least moderate cognitive impairment. Logistic regression analyses identified two factors associated with impairment: age of more than 80 years (odds ratio, 3.68; 95% confidence interval, 2.21-6.14) and residence in a nursing home (odds ratio, 13.8; 95% confidence interval, 3.79-50.2). Conclusion: Screening for cognitive impairment in elderly ED patients using the OMC Test is feasible. There is a high prevalence of cognitive impairment in elderly ED patients, and the prevalence increases with age. Identification of cognitive impairment is important in the assessment of elderly ED patients and may affect clinical evaluation, patients' understanding of medical information, and compliance with discharge instructions. [Gerson LW, Counsell SR, Fontanarosa PB, Smucker WD: Case finding for cognitive impairment in elderly emergency department patients. Ann Emerg Med April 1994;23:813-817.]