A Transdisciplinary Program for Care of Veterans With Neurocognitive Disorders.

Background: Veterans face specific risk factors for neurocognitive disorders. Providing them with comprehensive care for dementia and related neurocognitive disorders is a challenge as the population ages. There is a need for family-centered interventions, specialized expertise, and collaboration among clinicians and caregivers. The literature suggests that application of a transdisciplinary care model can address these needs and provide effective dementia care. Observations: The Veterans Affairs Greater Los Angeles Healthcare System has employed existing expertise to create a conference-centered transdisciplinary model that responds to the US Department of Veterans Affairs directive for a dementia system of care. This model involves direct participation of behavioral neurology, geriatric psychiatry, geriatrics, neuropsychology, nursing, and social work. In this model, the social worker serves as a dementia care manager and, along with the nurse specialist, assures long-term management through follow-up and monitoring. Transdisciplinary interactions occur in a clinical case conference where each discipline contributes to the veteran's care. The team generates a final report on treating these veterans, the caregiver's needs, referral for psychosocial services, and plans for monitoring and follow-up. Conclusions: This model could be a template of a program for implementing the Dementia System of Care across Veteran Affairs medical centers.

The relationship between cognitive impairment and diabetes self-management in a population-based community sample of older adults with Type 2 diabetes.

Although nearly one-third of older diabetics are cognitively impaired, their diabetes management remains poorly understood. To examine the relationship between cognitive impairment and diabetes self-management in a population-based community sample of older adults with Type 2 diabetes. Cross-sectional observational analysis. 1,398 persons with diabetes, aged 60 years or older, who responded to the 2003 Health and Retirement Study Diabetes Survey. We conducted logistic regressions on the effects of cognitive impairment on respondents' self-management ability after controlling for diabetes comorbidities, demographics, and clinical characteristics. Participants with greater cognitive impairment were less likely to adhere to exercise (Adjusted Odds ratio [AOR] = 0.725 and 0.712 for moderate and severe cognitive impairment, both P < 0.05), and to diet (AOR = 0.906 and 0.618 for moderate and severe cognitive impairment, both P < 0.01). Cognitive impairment is associated with worse self-care and may pose challenges to diabetic older persons, notably in diet and exercise. Cognitive screening may be indicated in this high risk group.

Risk of hypoglycemia in older veterans with dementia and cognitive impairment: implications for practice and policy.

OBJECTIVES: To examine the relationship between management of diabetes mellitus and hypoglycemia in older adults with and without dementia and cognitive impairment. DESIGN: Cross-sectional database analysis of veterans aged 65 years and older stratified according to dementia, cognitive impairment, age, antiglycemic medications, and glycosylated hemoglobin (Hba1c) level. SETTING: Research database with linked clinical, laboratory, pharmacy, and International Classification of Diseases, Ninth Revision, Clinical Modification, codes. PARTICIPANTS: Four hundred ninety-seven thousand nine hundred veterans aged 65 and older with diabetes mellitus who obtained services from the Department of Veterans Affairs in fiscal years (FYs) 2002 and 2003. MEASUREMENTS: Hypoglycemia, the outcome variable, was identified from outpatient visits, emergency department and inpatient admission codes in FY2003. Independent variables (FY2002-03) included dementia and cognitive impairment, comorbid conditions, extended care and nursing home stays, demographics, antiglycemic medication, and HbA1c levels. RESULTS: Prevalence of combined dementia and cognitive impairment was 13.1% for individuals aged 65 to 74 and 24.2% for those aged 75 and older. Mean HbA1c levels were 7.0 ± 1.3% for all participants and 6.9 ± 1.3% for those with dementia. The proportion of participants taking insulin was higher in those with dementia or cognitive impairment (30%) than in those with neither condition (24%). Of all participants taking insulin, more with dementia (26.5%) and cognitive impairment (19.5%) were hypoglycemic than of those with neither condition (14.4%). For all participants, unadjusted odds ratios (ORs) for hypoglycemia were 2.42 (95% confidence interval (CI) = 2.36-2.48) for dementia and 1.72 (95% CI = 1.65-1.79) for cognitive impairment; adjusted ORs were 1.58 (95% CI = 1.53-1.62) for dementia and 1.13 (95% CI = 1.08-1.18) for cognitive impairment. CONCLUSION: Diabetes mellitus was managed more intensively in older veterans with dementia and cognitive impairment, and dementia and cognitive impairment were independently associated with greater risk of hypoglycemia.

Impact of dementia on caring for patients' diabetes.

OBJECTIVE: To explore caregivers' challenges and quality-of-life issues managing diabetes in patients with dementia. METHOD: We conducted six focus groups with 21 caregivers of patients with dementia and type 2 diabetes. Focus groups were digitally recorded, transcribed, and translated using a software coding system. Emergent themes were identified and confirmed. RESULTS: Three themes emerged. (1) Memory loss was the first identified cause of self-care neglect leading to caregiver intervention. (2) Behavioral and psychological symptoms of dementia (BPSD) disrupted the daily diabetes care routine, with 'denial' of having diabetes or memory loss (anosognosia) being the most disruptive. (3) Caregivers reported that caring for both diabetes and dementia was highly burdensome, felt overwhelmed with BPSD, and wanted more support from family and patients' healthcare providers. CONCLUSION: Caregivers of patients with dementia and diabetes face extraordinary challenges managing both conditions and the accompanying BPSD. Their identified need for a greater response from the healthcare system should be tested in quality improvement programs for this overlooked yet rapidly growing population.

The role of cognitive impairment and caregiver support in diabetes management of older outpatients.

OBJECTIVES: To examine the role of cognitive impairment and caregiver support in diabetes care adherence and glycemic control. METHODS: Fifty-one veteran male outpatients (27 with caregivers) aged 60 years and older with type 2 diabetes were evaluated for cognitive impairment with the Cognitive Abilities Screening Instrument. Patients or caregivers completed diabetes self-care and depression scales. Medical morbidity information and HbA1c plasma levels at baseline and 1 year later were obtained from electronic medical records. RESULTS: Greater cognitive impairment (F = 5.1, p < .05), and presence of a caregiver (F = 5.3, p < .05), were independently associated with worse diabetes care adherence (adjusting for age, education, medical comorbidity, and depression). In addition, Mean HbA1c levels were worse in the cognitively impaired group with caregivers relative to the three other groups (F = 4.10, p < .05, eta2 = .09). One year later, mean HbA1c levels rose from 7.7 to 8.2% in the cognitively impaired group with caregivers. CONCLUSION: Cognitive impairment is associated with worse diabetes care management. Surprisingly, the presence of a caregiver is not protective. Further research is necessary to examine the healthcare needs of cognitively impaired, diabetic patients and their caregivers.