Overwhelmed: a Dementia Caregiver Vital Sign Reuben, David B.; Romero, Tahmineh; Evertson, Leslie Chang ...
Journal of general internal medicine,
08/2022, Letnik:
37, Številka:
10
Journal Article
Recenzirano
Odprti dostop
Background
The emotional stress of caring for someone with Alzheimer’s disease and related dementias is high and results in adverse effects on caregivers and the persons living with disease. In ...preliminary work, caregiver reports of regularly feeling “completely overwhelmed” were associated with lack of measurable clinical benefit from a comprehensive dementia care program.
Objective
To examine the sociodemographic and clinical characteristics of all caregivers who felt overwhelmed at entry into a comprehensive dementia care program, the trajectory of this symptom over 1 year, and its predictive value for 1-year caregiver outcomes.
Design
Longitudinal cohort study
Setting
Academic health center
Participants
Caregivers of patients enrolled in a comprehensive dementia care program
Exposures
Caregiver report of feeling “completely overwhelmed” at baseline
Main Measures
Caregiver report of feeling “completely overwhelmed” at baseline and 1 year, and validated scales of caregiver strain, distress, depressive symptoms, burden, mortality, and long-term nursing home placement
Key Results
Compared to caregivers who were not overwhelmed, overwhelmed caregivers had more distress from behavioral symptoms of the person living with dementia, worse depression scores, and higher composite dementia burden scores at baseline. They also had worse depressive symptoms, strain, and composite burden scores at 1 year, after adjustment for baseline scores. Having an overwhelmed caregiver did not predict long-term nursing home placement or mortality among persons with dementia.
Conclusions
A single question about whether a caregiver is overwhelmed might indicate caregivers who have considerable current and future symptom burden and who may benefit from increased support and resources.
Background.
Although life tables provide a basis for estimating remaining life by age, gender, and race, these tables do not consider clinical characteristics or functional status, which can lead to ...wide variations in remaining years. Inclusion of functional status may permit more precise prognostic estimates of life expectancy and proportion of time in various functional states.
Methods.
We used longitudinal data from the Established Populations for Epidemiologic Studies of the Elderly to determine transition probabilities between three functional states (independent in activities of daily living ADL and mobility, dependent in mobility but independent in ADL, and dependent in ADL) and death. These were used to estimate total life expectancy and life expectancy in each functional state.
Results.
In general, the largest proportion of remaining life expectancy was spent in the persons' baseline functional status category. Persons younger than 80 years with dependencies, however, spend substantial proportions of their remaining years in a better functional status category, and mobility-disabled 70-year-old persons spend the greatest part of their life expectancy in the independent functional state. Functional status has a dramatic impact on life expectancy. For example, 75-year-old men and women without limitations have life expectancies 5 years longer than those with ADL limitation and more than 1 year longer than those limited in mobility. The life expectancy of an ADL-disabled 75-year-old is similar to that of an 85-year-old independent person; thus, the impact of the disability approximates being 10 years older with much more of the remaining life spent disabled.
Conclusions.
Both ADL and mobility disability result in diminished survival and more of that survival period spent in disabled states.
BACKGROUND/OBJECTIVES
Although nurse practitioner dementia care co‐management has been shown to reduce total cost of care for fee‐for‐service (FFS) Medicare beneficiaries, the reasons for cost ...savings are unknown. To further understand the impact of dementia co‐management on costs, we examined acute care utilization, long‐term care admissions, and hospice use of program enrollees as compared with persons with dementia not in the program using FFS and managed Medicare claims data.
DESIGN
Quasi‐experimental controlled before‐and‐after comparison.
SETTING
Urban academic medical center.
PARTICIPANTS
A total of 856 University of California, Los Angeles (UCLA) Alzheimer's and Dementia Care program patients were enrolled between July 1, 2012, and December 31, 2015, and 3,139 similar UCLA patients with dementia not in the program. Comparison patients were identified as having dementia using International Classification of Diseases‐9 codes and natural language processing of clinical notes. Coarsened exact matching was used to reduce covariate imbalance between intervention and comparison patients.
INTERVENTION
Dementia co‐management model using nurse practitioners partnered with primary care providers and community organizations.
MEASUREMENTS
Average difference‐in‐differences per quarter over the 2.5‐year intervention period for all‐cause hospitalization, emergency department (ED) visits, intensive care unit (ICU) stays, and number of inpatient hospitalization days; admissions to long‐term care facilities; and hospice use in the last 6 months of life.
RESULTS
Intervention patients had fewer ED visits (odds ratio OR = .80; 95% confidence interval CI = .66–.97) and shorter hospital length of stay (incident rate ratio = .74; 95% CI = .55–.99). There were no significant differences between groups for hospitalizations or ICU stays. Program participants were less likely to be admitted to a long‐term care facility (hazard ratio = .65; 95% CI = .47–.89) and more likely to receive hospice services in the last 6 months of life (adjusted OR = 1.64; 95% CI = 1.13–2.37).
CONCLUSION
Comprehensive nurse practitioner dementia care co‐management reduced ED visits, shortened hospital length of stay, increased hospice use, and delayed admission to long‐term care.
See related editorial by Callahan et al. in this issue.
Dementia is a chronic disease that requires medical and social services to provide high‐quality care and prevent complications. As a result of time constraints in practice, lack of systems‐based ...approaches, and poor integration of community‐based organizations (CBOs), the quality of care for dementia is poorer than that for other diseases that affect older persons. The University of California at Los Angeles (UCLA) Alzheimer's and Dementia Care (UCLA ADC) program partners with CBOs to provide comprehensive, coordinated, patient‐centered care for individuals with Alzheimer's disease and other dementias. The goals of the program are to maximize function, independence, and dignity; minimize caregiver strain and burnout; and reduce unnecessary costs. The UCLA ADC program consists of five core components: recruitment and a dementia registry, structured needs assessments of individuals in the registry and their caregivers, creation and implementation of individualized dementia care plans based on needs assessments and input from the primary care physicians, monitoring and revising care plans as needed, and around‐the‐clock access for assistance and advice. The program uses a comanagement model with a nurse practitioner Dementia Care Manager working with primary care physicians and CBOs. Based on the first 150 individuals served, the most common recommendations in the initial care plans were referrals to support groups (73%) and Alzheimer's Association Safe Return (73%), caregiver training (45%), and medication adjustment (41%). The program will be evaluated on its ability to achieve the triple aim of better care for individuals, better health for populations, and lower costs.
Exome sequencing is increasingly being used for clinical diagnostics, with an impetus to expand reporting of incidental findings across a wide range of disorders. Analysis of population cohorts can ...help reduce risk for genetic variant misclassification and resultant unnecessary referrals to subspecialists.
To examine the burden of candidate pathogenic variants for kidney and genitourinary disorders emerging from exome sequencing.
Secondary analysis of genetic data.
A tertiary care academic medical center.
A convenience sample of exome sequence data from 7974 self-declared healthy adults.
Assessment of the prevalence of candidate pathogenic variants in 625 genes associated with Mendelian kidney and genitourinary disorders.
Of all participants, 23.3% carried a candidate pathogenic variant, most of which were attributable to previously reported variants that had implausibly high allele frequencies. In particular, 25 genes (discovered before the creation of the Exome Aggregation Consortium, a genetic database comprising data from a large control population) accounted for 67.7% of persons with candidate pathogenic variants. After stringent filtering based on allele frequency, 1.4% of persons still had a candidate pathogenic variant, an excessive rate given the prevalence of monogenic kidney and genitourinary disorders. Manual annotation of a subset of variants showed that the majority would be classified as nonbenign under current guidelines for clinical sequence interpretation and could prompt subspecialty referrals if returned.
Limited access to health record data prevented comprehensive assessment of the phenotypic concordance with genetic diagnoses.
Widespread reporting of incidental genetic findings related to kidney and genitourinary disorders will require stringent curation of clinical variant databases and detailed case-level review to avoid genetic misdiagnosis and unnecessary referrals. These findings motivate similar analyses for genes relevant to other medical subspecialties.
National Institute of Diabetes and Digestive and Kidney Diseases and National Human Genome Research Institute.
Previous research has suggested that socio-economic status (SES) differences in mortality are only partially explained by differences in life-style, psychological and social factors. Seven year ...mortality data (1988–1995) from the MacArthur Study of Successful Aging, a longitudinal study of adults, aged 70–79, from New Haven, CT; East Boston, MA; and Durham, NC; were used to test the hypothesis that a cumulative measure of biological dysregulation (“allostatic load”), reflecting multiple regulatory systems, would serve as a further mediator of SES differences in mortality. Logistic regression analyses revealed that a cumulative index of biological risk explained 35.4% of the difference in mortality risk between those with higher versus lower SES (as measured by less than high school education versus high school or greater educational attainment). Importantly, the cumulative index provided independent explanatory power, over and above a measure of doctor-diagnosed disease, though the latter also contributed to education-related variation in mortality risks. The summary measure of biological risk also accounted for more variance than individual biological parameters, suggesting the potential value of a multi-systems view of biological pathways through which SES ultimately affects morbidity and mortality.
A series of tert-butyl-substituted pincer ligands based on 1,3-diaminobenzene and 3-aminophenol scaffolds, tBu4PXCYP (1e, X = Y = NH; 1f, X = NH; Y = O) and the corresponding iridium hydridochloro ...complexes (tBu4PXCYP)IrHCl (2e, X = Y = NH; 2f, X = NH; Y = O) were prepared with moderate yields and high purity and were fully characterized by 1H and 31P NMR spectroscopy. Unsymmetrical hybrid pincer ligands R2PNCOPtBu2 (1g, R = isopropyl; 1h, R = cyclohexyl) were prepared conveniently in high yield via a one-pot procedure by judiciously choosing reaction conditions and base; the corresponding iridium hydrido chloro complexes iPr2PNCOPtBu2IrHCl (2g) and Cy2PNCOPtBu2IrHCl (2h) were synthesized by the reaction of IrCl(COE)22 with ligands. X-ray crystallography reveals that these iridium pincer complexes adopt similar square-pyramidal geometries and exhibit strong intermolecular hydrogen bonding between the NH linker and chloride ions of the adjacent iridium complex in the solid state. 1H NMR chemical shifts of tert-butyl based pincer ligated iridium hydrides move downfield when the electronegativity of the linker between the benzene backbone and phosphine moiety increases for 2a, 2e, 2f, and 2b. Accordingly the corresponding iridium pincer carbonyl complexes (tBu4PXCYP)Ir(CO), 3a, 3e, 3f, and 3b show a blue shift in the CO stretching frequency. The activities of iridium complexes containing NH linkers were briefly examined for transfer dehydrogenation from cyclooctane to tert-butylethylene; (iPr2PNCOPtBu2)IrHCl (2g) exhibits the highest activity among all tested iridium pincer complexes, including the most studied (tBu4PCP)IrHCl (2a) and (tBu4POCOP)IrHCl (2b). The enhanced catalytic activity could be related to combined electronic and steric effects of the NH/O hybrid linker and different alkyl groups at phosphorus. This new class of iridium pincer complexes could have great implications in catalytic transformation of polar compounds due to the strong hydrogen-bond-donating ability of the NH linker.
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