Several longitudinal studies found an inverse relationship between levels of physical activity and cognitive decline, dementia, and/or Alzheimer's disease (AD), but results have been inconsistent. We ...followed an older, community-based cohort for over a decade to examine the association of physical activity with the risk of incident dementia and subclinical brain MRI markers of dementia.
The physical activity index (PAI) was assessed in the Framingham Study Original and Offspring cohorts, aged 60 years or older. We examined the association between PAI and risk of incident all-cause dementia and AD in participants of both cohorts who were cognitively intact and had available PAI (n = 3,714; 54% women; mean age = 70±7 years). We additionally examined the association between PAI and brain MRI in the Offspring cohort (n = 1,987).
Over a decade of follow-up, 236 participants developed dementia (188 AD). Participants in the lowest quintile of PAI had an increased risk of incident dementia compared with those in higher quintiles (hazard ratio HR = 1.50, 95% confidence interval CI = 1.04-1.97, p = .028) in a multivariable-adjusted model. Secondary analysis revealed that this relation was limited to participants who were apolipoprotein (APO)E ε4 allele noncarriers (HR = 1.58, 95% CI = 1.08-2.32; p = .018) and strongest in participants aged 75 years or older. PAI was also linearly related to total brain and hippocampal volumes (β ± SE = 0.24±0.06; p < .01 and 0.004±0.001; p = .003, respectively).
Low physical activity is associated with a higher risk for dementia in older individuals, suggesting that a reduced risk of dementia and higher brain volumes may be additional health benefits of maintaining physical activity into old age.
Alzheimer's disease and other dementias are chronic, incurable diseases that require coordinated care that addresses the medical, behavioral, and social aspects of the disease. With funding from the ...Center for Medicare and Medicaid Innovation, we launched a dementia care program in which a nurse practitioner acting as a dementia care manager worked with primary care physicians to develop and implement a dementia care plan that offers training and support to caregivers, manages care transitions, and facilitates access to community-based services. Postvisit surveys showed high levels of caregiver satisfaction. As program enrollment grows, outcomes will be tracked based on the Triple Aim developed by the Institute for Healthcare Improvement and adopted by the Centers for Medicare and Medicaid Services: better care, better health, and lower cost and utilization. The program, if successful at achieving the Triple Aim, may serve as a national model for how dementia and other chronic diseases can be managed in partnership with primary care practices. It may also inform policy and reimbursement decisions for the recently released transitional care management codes and the complex chronic care management codes to be released by Medicare in 2015.
BACKGROUND/OBJECTIVES
Persons with Alzheimer disease and related dementias (ADRDs) require comprehensive care that spans health systems and community‐based organizations. This study examined the ...clinical outcomes of a comprehensive dementia care program and identified subgroups who were more likely to benefit.
DESIGN
Observational, baseline and 1 year after intervention.
SETTING
Urban, academic medical center.
PARTICIPANTS
A total of 554 persons with dementia and their caregivers who had 1‐year follow‐up evaluations and data on clinical outcomes.
INTERVENTION
Health system‐based comprehensive dementia care management program using nurse practitioner dementia care managers.
MEASUREMENTS
Patient measures included the Mini‐Mental State Examination (MMSE), the Functional Activities Questionnaire, Basic and Instrumental Activities of Daily Living scales, the Cornell Scale for Depression in Dementia, and the Neuropsychiatric Inventory Questionnaire (NPI‐Q) Severity. Caregiver measures included the Modified Caregiver Strain Index, the Patient Health Questionnaire‐9, NPI‐Q Distress, and the Dementia Burden Scale‐Caregiver). We used established minimal clinically important differences and lowest tertiles of baseline symptoms to define improving symptoms and maintaining low symptoms as clinical benefit for patients and caregivers.
RESULTS
At year 1, persons with ADRD improved on all scales, except MMSE and functional status measures; caregivers improved on all scales. Using validated instruments, 314/543 (58%) of patients, 282/447 (63%) of caregivers, and 376/501 (75%) of patients or caregivers demonstrated clinical benefit. In adjusted multivariate models, at year 1, more behavioral symptoms and fewer depression symptoms at baseline were associated with patient improvement; and fewer baseline depression symptoms were associated with maintaining low behavioral symptoms. Male caregiver sex, higher baseline caregiver burden, and caring for patients with fewer baseline depression symptoms were associated with caregiver improvement. Male caregiver sex and patients with fewer depression symptoms, fewer behavioral symptoms, and more functional impairment at baseline were associated with caregivers maintaining low burden at 1 year.
CONCLUSIONS
Health system‐based comprehensive dementia care management is a promising approach to improving clinical outcomes, with benefits for both patients and caregivers. J Am Geriatr Soc 67:2267–2273, 2019
The United States faces a growing challenge with over 6.5 million people living with dementia (PLwD). PLwD and their caregivers struggle with cognitive, functional, behavioral, and psychosocial ...issues. As dementia care shifts to home settings, caregivers receive inadequate support but bear increasing responsibilities, leading to higher healthcare costs. In response, the Centers for Medicare & Medicaid Services (CMS) introduced the Guiding an Improving Dementia Experience (GUIDE) Model. The study explores the real-world implementation of the Cedars-Sinai C.A.R.E.S. Program, a pragmatic dementia care model, detailing its recruitment process and initial outcomes.
The Cedars-Sinai C.A.R.E.S. Program was integrated into the Epic electronic health record system and focused on proactive patient identification, engagement, interdisciplinary collaboration, care transitions, and ongoing care management. Eligible patients with a dementia diagnosis were identified through electronic health record and invited to join the program. Nurse practitioners with specialized training in dementia care performed comprehensive assessments using the CEDARS-6 tool, leading to personalized care plans developed in consultation with primary care providers. Patients benefited from a multidisciplinary team and support from care navigators.
Of the 781 eligible patients identified, 431 were enrolled in the C.A.R.E.S.
Enrollees were racially diverse, with lower caregiver strain and patient behavioral and psychological symptoms of dementia (BPSD) severity compared to other programs dementia care programs. Healthcare utilization, including hospitalizations, emergency department (ED) admissions, and urgent care visits showed a downward trend over time. Completion of advanced directives and Physician Order of Life-Sustaining Treatment (POLST) increased after enrollment.
The Cedars-Sinai C.A.R.E.S. Program offers a promising approach to dementia care. Its real-world implementation demonstrates the feasibility of enrolling a diverse population and achieving positive outcomes for PLwD and their caregivers, supporting the goals of national dementia care initiatives.
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.
Background
The risk of developing Alzheimer’s Disease and Related Dementias (ADRD) is associated with visit‐to‐visit blood pressure (BP) variability, including variability independent of the mean ...(VIM).1,2 The association between ADRD and VIM has primarily been evaluated using standardized BP measurements from clinical trials and cohorts, rather than utilizing measurements from clinical practice, potentially limiting generalizability to the real‐world context. As such, we sought to evaluate the relationship between ADRD and BP VIM utilizing real‐world data collected from the electronic health record (EHR).
Method
We studied all patients with repeated BP measurements and without a prior diagnosis of ADRD across ambulatory visits within a high‐volume academic healthcare system from 2013 to 2016. Using EHR data, we calculated BP VIM for all patients during the first 4 years of the study period and followed all patients through the end of 2019 or most recent office visit, whichever came first. The primary outcome of interest was incident ADRD, defined by presence of ICD‐10 codes for ADRD or prescription for dementia medication. We used multivariable adjusted Cox proportional hazards models to examine risk of incident ADRD associated with increasing BP VIM.
Result
We identified 46,703 patients with repeated BP measurements over 730,721 ambulatory visits between 2013 and 2016. In multivariable analyses, higher levels of both systolic (HR, 95% CI: 1.26, 1.15‐1.38) and diastolic (1.15, 1.04‐1.27) BP VIM were positively associated with risk of incident dementia (Figure A). In subgroup analyses, results were similar when stratified by age, diabetes, prior stroke, renal disease, and hypertension (Figures B‐D). For both systolic (p = 0.036) and diastolic (p = 0.043) BP VIM, risk of incident dementia was higher among patients below the age of 60 compared to those 60 and older.
Conclusion
Visit‐to‐visit variability in BP, a measure readily ascertainable from the EHR, is associated with increased risk for incident dementia independent of mean BP in the context of a high‐volume, real‐world patient care setting. These findings indicate the EHR derived VIM may serve as an additional tool in risk assessment for incident ADRD. Future research is needed to determine efficacy of targeted interventions aimed at lowering BP variability in clinical practice.
Background
Asian American and Pacific Islanders (AAPI) are the fastest growing minority population in the United States. While 14% of older AAPIs have been reported to experience memory loss and ...confusion, the prevalence and incidence of Alzheimer’s disease and related dementias (ADRD) in the AAPI population are not well understood. Moreover, little is known about AAPI attitudes on memory loss and confidence in managing ADRD.
Method
We administered an 8‐item survey on attitudes and beliefs regarding memory loss and ADRD to attendees of a virtual conference on brain health. Responses were on a 5‐point Likert scale with range of 1 = strongly disagree to 5 = strongly agree. We analyzed responses (agree/strongly agree vs. disagree/strongly disagree) of AAPI participants and non‐AAPI attendees using chi‐square test.
Result
Fifty‐four participants completed the survey, with majority of respondents aged 65 years or older (56%) and women (72%). AAPI participants (N = 37) self‐identified to be Chinese, Filipino, Indian, Japanese, Korean, Vietnamese, Native Hawaiian or other Pacific Islander. Non‐AAPI respondents (N = 14) self‐identified to be White, Black or African American, American Indian or Alaska Native. We found that compared to non‐AAPI, AAPI individuals were less confident in navigating the healthcare system for persons with ADRD (p = 0.049). AAPI respondents were also less confident in finding community resources for ADRD, though this did not reach statistical significance (p = 0.073). We found no significant differences between AAPI and non‐AAPI participants’ attitudes and beliefs on the normality of memory loss with age, understanding of ADRD as a medical condition, or interest in participating in and understanding of clinical trials for ADRD.
Conclusion
Asian Americans and Pacific Islanders (AAPI) have less confidence in navigating the complex healthcare system for patients with Alzheimer’s disease and related dementias (ADRD). More research is needed to better characterize the differences in prevalence, presentation, challenges, and outcomes of ADRD in the AAPI population.
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