A Longitudinal Study of Functional Unmet Need Among People with Dementia.

BACKGROUND: Understanding the changes of unmet need in dementia may enable effective targeting of help and allow people to stay in their homes longer. OBJECTIVE: We investigated changes in unmet need and functioning over a 4-year period and the role of socio-demographic factors in these changes among people with dementia. METHODS: 234 community-dwelling people with dementia at baseline were studied in three consecutive waves (four years) of the English Longitudinal Study of Ageing (ELSA). Unmet needs (self/informant-reported limitations for which no help was received) and functional limitations (self/informant-reported difficulties in activities/instrumental activities of daily living and mobility) were modelled with latent growth curves. Sex, age, partnership, and socioeconomic status at baseline were used as predictors. Admission to a care home was an additional outcome. RESULTS: Unmet needs increased over time, especially among those who initially had more functional limitations. Unmet needs contributed to faster decline in functional capability, except among those with many limitations initially. The major driver of increased unmet needs was not having a partner (direct effect). Age, sex, and wealth contributed indirectly via the initial level of functional limitations and/or unmet need. Those with several functional limitations but few unmet needs were most likely to move to a care home. CONCLUSION: Unmet need increases over time in those with dementia with mitigating effects of having a partner and initial levels of functioning. Meeting needs at early stages of dementia, especially for those living alone and when functional limitations are low may help slow functional decline.

Enhanced Home Care Interventions for Community Residing Adults Compared With Usual Care on Health and Cost-effectiveness Outcomes: A Systematic Review.

ABSTRACT: The need for home care services is expanding around the world with increased attention to the resources required to produce them. To assist decision making, there is a need to assess the cost-effectiveness of alternative programs within home care. Electronic searches were performed in five databases (before February 2020) identifying 3292 potentially relevant studies that assessed new or enhanced home care interventions compared with usual care for adults with an accompanying economic evaluation. From these, 133 articles were selected for full-text screening; 17 met the inclusion criteria and were analyzed. Six main areas of research were identified including the following: alternative nursing care (n = 4), interdisciplinary care coordination (n = 4), fall prevention (n = 4), telemedicine/remote monitoring (n = 2), restorative/reablement care (n = 2), and one multifactorial undernutrition intervention study. Risk of bias was found to be high/weak (n = 7) or have some concerns/moderate (n = 6) rating, in addition to inconsistent reporting of important information required for economic evaluations. Both health and cost outcomes had mixed results. Cost-effective interventions were found in two areas including alternative nursing care and reablement/restorative care. Clinicians and decision makers are encouraged to carefully evaluate the quality of the studies because of issues with risk of bias and incomplete reporting of economic outcomes.

Major Cost Drivers in Assessing the Economic Burden of Alzheimer's Disease: A Structured, Rapid Review.

BACKGROUND: Alzheimer's Disease is the most common cause of dementia, affecting memory, thinking and behavior. Symptoms eventually grow severe enough to interfere with daily tasks. AD is predicted to increase healthcare spending and costs associated with formal and informal caregiving. The aim of this study was to identify and quantify the contribution of the different cost components associated with AD. METHODS: A structured literature review was conducted to identify studies reporting the economic burden of Alzheimer`s Disease beyond the healthcare setting. The search was conducted in Medline, Embase and EconLit and limited to studies published in the last 10 years. For each identified cost component, frequency weighted mean costs were calculated across countries to estimate the percentage contribution of each component by care setting and disease severity. Results obtained by each costing approach were also compared. RESULTS: For community-dwelling adults, the percentage of healthcare, social care and indirect costs to total costs were 13.9%, 17.4% and 68.7%, respectively. The percentage of costs varied by disease severity with 26.0% and 10.4% of costs spent on healthcare for mild and severe disease, respectively. The proportion of total spending on indirect costs changed from 60.7% to 72.5% as disease progressed. For those in residential care, the contribution of each cost component was similar between moderate and severe disease. Social care accounted on average for 85.9% of total costs. CONCLUSION: The contribution of healthcare costs to the overall burden was not negligible; but was generally exceeded by social and informal care costs.

Predictors of pain severity among community-dwelling older adults with pain in the United States: Findings from a cross-sectional, retrospective study using 2017 Medical Expenditure Panel Survey.

ABSTRACT: The purpose of this study was to determine predictors of pain severity among older United States (US) adults with pain.This cross-sectional, retrospective study utilized 2017 Medical Expenditure Panel Survey data. Eligible participants were alive for the calendar year, aged ≥50 years, and reported pain in the past 4 weeks. Hierarchical logistic regression models, adjusting for the survey design, were used to identify significant predictors of pain severity (i.e., extreme/quite a bit or moderate/little pain).An estimated 14,250,534 adults aged ≥50 with pain reported extreme/quite a bit of pain. Many variables were associated with extreme/quite a bit of pain, including: age 50 to 64 vs ≥65 years (adjusted odds ratio [AOR] = 1.49, 95% confidence interval [95% CI] = 1.22-1.82); males vs females (AOR = 0.80, 95% CI = 0.67-0.95); white race vs others (AOR = 0.75, 95% CI = 0.61-0.92); married vs other marital status (AOR = 1.31, 95% CI = 1.08-1.57); income <200% vs ≥200% federal poverty level (AOR = 1.30, 95% CI = 1.06-1.60); employed vs unemployed (AOR = 0.47, 95% CI = 0.37-0.60); limitation vs no limitation (AOR = 2.64, 95% CI = 2.09-3.33); 0, 1, 3, or 4 vs ≥5 chronic conditions (AOR ranged from 0.39 for 0 conditions to 0.77 for 4 conditions); excellent/very good or good vs fair/poor perceived physical health status (AOR ranged from 0.28 for excellent/very good to 0.40 for good); smokers vs non-smokers (AOR = 1.56, 95% CI = 1.27-1.93); exercise versus no exercise (AOR = 0.74, 95% CI = 0.62-0.88); and South vs West census region (AOR = 1.34, 95% CI = 1.04-1.74).This study found several characteristics could predict pain severity among older US adults who reported extreme/quite a bit of pain. These characteristics may guide specific areas of focus to improve patients' pain management.

A longitudinal evaluation of family caregivers' willingness to pay for an in-home nonpharmacologic intervention for people living with dementia: results from a randomized trial.

OBJECTIVE: To determine the willingness-to-pay (WTP) of family caregivers to learn care strategies for persons living with dementia (PLwD). DESIGN: Randomized clinical trial. SETTING: Community-dwelling PLwD and their caregivers (dyads) in Maryland and Washington, DC. PARTICIPANTS: 250 dyads. INTERVENTION: Tailored Activity Program (TAP) compared to attention control. TAP provides activities tailored to the PLwD and instructs caregivers in their use. MEASUREMENT: At baseline, 3 and 6 months, caregivers were asked their WTP per session for an 8-session 3-month in-home nonpharmacologic intervention to address behavioral symptoms and functional dependence. RESULTS: At baseline, 3 and 6 months, caregivers assigned to TAP were willing to pay $26.10/session (95%CI:$20.42, $33.00), $28.70 (95%CI:$19.73, $39.30), and $22.79 (95%CI: $16.64, $30.09), respectively; attention control caregivers were willing to pay $37.90/session (95%CI: $27.10, $52.02), $30.92 (95%CI: $23.44, $40.94), $27.44 (95%CI: $20.82, $35.34), respectively. The difference in baseline to 3 and 6 months change in WTP between TAP and the attention control was $9.58 (95%CI: -$5.00, $25.47) and $7.15 (95%CI: -$5.72, $21.81). The difference between TAP and attention control in change in the proportion of caregivers willing to pay something from baseline to 3 and 6 months was -12% (95%CI: -28%, -5%) and -7% (95%CI:-25%, -11%), respectively. The difference in change in WTP, among caregivers willing to pay something, between TAP and attention control from baseline to 3 and 6 months was $17.93 (95%CI: $0.22, $38.30) and $11.81 (95%CI: -$2.57, $28.17). CONCLUSIONS: Family caregivers are willing to pay more for an intervention immediately following participation in a program similar to which they were asked to value.

Behavioral economic indicators of risky drinking among community-dwelling emerging adults.

Objective: Behavioral economic (BE) approaches to understanding and reducing risky drinking among college students are well established, but little is known about the generalizability of prior findings to peers who currently are not traditional college students and are more difficult to reach for assessment and intervention. This cross-sectional survey investigated whether drinking practices and negative consequences were associated with greater alcohol demand, alcohol reward value, and delay discounting in this target population. Method: Community-dwelling emerging adult drinkers aged 21 to 29 (N = 357) were recruited using Respondent-Driven Sampling adapted to a digital platform (Mage = 23.6 years, 64% women). Peers recruited peers in an iterative fashion. Participants completed a web-based survey of drinking practices, negative alcohol-related consequences, and BE measures of alcohol demand, alcohol reward value, and delay discounting. Results: Regression analyses supported the study hypotheses. Higher alcohol demand (intensity and elasticity) predicted higher drinks per drinking day, more past-month drinking days, and more negative consequences. Higher alcohol reward value (discretionary alcohol spending and alcohol-involved activities) and stronger preference for sooner smaller versus later larger rewards predicted select drinking risk variables in the hypothesized direction (p < .05). Conclusions: BE risk characteristics were generalized to community-dwelling emerging adult risky drinkers, with the most consistent associations found between alcohol demand and drinking risk measures. The findings lay a foundation for extending successful BE interventions with college drinkers to this underserved population. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

The Impact of Poor Nutrient Intakes and Food Insecurity on the Psychological Distress among Community-Dwelling Middle-Aged and Older Adults during the COVID-19 Pandemic.

This study aimed to investigate the impact of food insecurity and poor nutrient intake on the psychological health of middle-aged and older adults during the COVID-19 pandemic. A sub-sample of 535 individuals aged 52 years and above, from the earlier cohort and interventional studies (n = 4) from four selected states in Peninsular Malaysia, were recruited during the COVID-19 outbreak (April to June 2020). Telephone interviews were conducted by trained interviewers with a health sciences background to obtain participants' information on health status, physical activity, food security, and psychological health (General Health Questionnaire-12; normal and psychological distress). Univariate analyses were performed for each variable, followed by a logistic regression analysis using SPSS Statistics version 25.0. Results revealed food insecurity (OR = 17.06, 95% CI: 8.24-35.32, p < 0.001), low protein (OR = 0.981, 95% CI: 0.965-0.998, p < 0.05), and fiber intakes (OR = 0.822, 95% CI: 0.695-0.972, p < 0.05) were found to be significant factors associated with the psychological distress group after adjusting for confounding factors. The findings suggested that food insecurity and insufficiencies of protein and fiber intakes heightened the psychological distress during the COVID-19 pandemic. Optimal nutrition is vital to ensure the physical and psychological health of the older population, specifically during the current pandemic.

Community-Dwelling and Recently Widowed Older Adults: Effects of Spousal Loss on Psychological Well-Being, Perceived Quality of Life, and Health-Care Costs.

This study is on the effects of spousal loss among older adults who continue to live independently after bereavement. Little longitudinal studies focus on this group, which is of special interest, since in many countries, care policy and system reform are aimed at increasing independent living among older adults. Using longitudinal data from a Dutch public data repository, we investigate the effects of spousal loss on psychological well-being, perceived quality of life, and (indication of) yearly health-care costs. Of the respondents who had a spouse and were living independently (N = 9,400) at baseline, the majority had not lost their spouse after 12 months (T12, n = 9,150), but 2.7% (n = 250) had lost their spouse and still lived independently. We compared both groups using multivariate regression (ordinary least squares) analyses. The results show that spousal loss significantly lowers scores on psychological well-being and perceived quality of life, but we found no effect on health-care costs.

Cost-effectiveness of Screening for Osteoporosis in Older Men With a History of Falls.

Importance: Falls and osteoporosis share the potential clinical end point of fractures among older patients. To date, few fall prevention guidelines incorporate screening for osteoporosis to reduce fall-related fractures. Objective: To assess the cost-effectiveness of screening for osteoporosis using dual-energy x-ray absorptiometry (DXA) followed by osteoporosis treatment in older men with a history of falls. Design, Setting, and Participants: In this economic evaluation, a Markov model was developed to simulate the incidence of major osteoporotic fractures in a hypothetical cohort of community-dwelling men aged 65 years who had fallen at least once in the past year. Data sources included literature published from January 1, 1946, to July 31, 2020. The model adopted a societal perspective, a lifetime horizon, a 1-year cycle length, and a discount rate of 3% per year for both health benefits and costs. The analysis was designed and conducted from October 1, 2019, to September 30, 2020. Interventions: Screening with DXA followed by treatment for men diagnosed with osteoporosis compared with usual care. Main Outcomes and Measures: Incremental cost-effectiveness ratio (ICER), measured by cost per quality-adjusted life-year (QALY) gained. Results: Among the hypothetical cohort of men aged 65 years, the screening strategy had an ICER of $33 169/QALY gained and was preferred over usual care at the willingness-to-pay threshold of $100 000/QALY gained. The number needed to screen to prevent 1 hip fracture was 1876; to prevent 1 major osteoporotic fracture, 746. The screening strategy would become more effective and less costly than usual care for men 77 years and older. The ICER for the screening strategy did not substantially change across a wide range of assumptions tested in all other deterministic sensitivity analyses. At a willingness-to-pay threshold of $50 000/QALY gained, screening was cost-effective in 56.0% of simulations; at $100 000/QALY gained, 90.8% of simulations; and at $200 000/QALY gained, 99.6% of simulations. Conclusions and Relevance: These findings suggest that for older men who have fallen at least once in the past year, screening with DXA followed by treatment for those diagnosed with osteoporosis is a cost-effective use of resources. Fall history could be a useful cue to trigger assessment for osteoporosis in men.

National Trends in Potentially Preventable Hospitalizations of Older Adults with Dementia.

BACKGROUND/OBJECTIVES: Dementia is associated with higher healthcare expenditures, in large part due to increased hospitalization rates relative to patients without dementia. Data on contemporary trends in the incidence and outcomes of potentially preventable hospitalizations of patients with dementia are lacking. DESIGN: Retrospective cohort study using the National Inpatient Sample from 2012 to 2016. SETTING: U.S. acute care hospitals. PARTICIPANTS: A total of 1,843,632 unique hospitalizations of older adults (aged ≥65 years) with diagnosed dementia. MEASUREMENTS: Annual trends in the incidence of hospitalizations for all causes and for potentially preventable conditions including acute ambulatory care sensitive conditions (ACSCs), chronic ACSCs, and injuries. In-hospital outcomes including mortality, discharge disposition, and hospital costs. RESULTS: The survey weighted sample represented an estimated 9.27 million hospitalizations for patients with diagnosed dementia (mean [standard deviation] age = 82.6 [6.7] years; 61.4% female). In total, 3.72 million hospitalizations were for potentially preventable conditions (40.1%), 2.07 million for acute ACSCs, .76 million for chronic ACSCs, and .89 million for injuries. Between 2012 and 2016, the incidence of all-cause hospitalizations declined from 1.87 million to 1.85 million per year (P = .04) while the incidence of potentially preventable hospitalizations increased from .75 million to .87 million per year (P < .001), driven by an increased number of hospitalizations of community-dwelling older adults. Among patients with dementia hospitalized for potentially preventable conditions, inpatient mortality declined from 6.4% to 6.1% (P < .001), inflation-adjusted median costs increased from $7,319 to $7,543 (P < .001), and total annual costs increased from $7.4 to $9.3 billion. Although 86.0% of hospitalized patients were admitted from the community, only 32.7% were discharged to the community. CONCLUSION: The number of potentially preventable hospitalizations of older adults with dementia is increasing, driven by hospitalizations of community-dwelling older adults. Improved strategies for early detection and goal-directed treatment of potentially preventable conditions in patients with dementia are urgently needed. J Am Geriatr Soc 68:2240-2248, 2020.

Living Alone in the United States and Europe: The Impact of Public Support on the Independence of Older Adults.

While we know that living alone is often associated with greater risk of financial hardship, we have limited knowledge on the possible link between the availability of public support and independent living. We use data from the 2014 Health and Retirement Study and the 2011-2015 Survey of Health, Ageing and Retirement in Europe to compare income and wealth profiles of the population aged 60 and above who are living alone in the United States and 19 European countries. We find that the likelihood of living alone is higher in generous welfare states, with social support and spending both positively associated with living alone. The relationship between personal resources and living alone has a smaller positive gradient in countries with robust welfare systems. The lack of adequate public support in less generous welfare states may constrain the ability of many low-income older adults without a partner to continue living independently.

Cost-Effectiveness of Pharmacist-Led Deprescribing of NSAIDs in Community-Dwelling Older Adults.

OBJECTIVES: Older adults are often prescribed potentially inappropriate medications associated with adverse health outcomes and increased health services utilization. Developing Pharmacist-led Research to Educate and Sensitize Community Residents to the Inappropriate Prescriptions Burden in the Elderly (D-PRESCRIBE), a pragmatic randomized clinical trial, demonstrated how a community pharmacist-led evidence-based educational intervention successfully empowered community-dwelling older adults and their physicians to reduce chronic use of inappropriate medications. The objective of this study was to evaluate the cost-effectiveness of the D-PRESCRIBE intervention for discontinuing nonsteroidal anti-inflammatory drugs (NSAIDs). DESIGN: Cost-effectiveness analysis. SETTING: Canada. PARTICIPANTS: Community-dwelling adults aged 65 years and older. MEASUREMENTS: Decision analysis combining decision tree and Markov state transition modeling was developed to estimate the cost-effectiveness of D-PRESCRIBE (NSAIDs) compared with usual care from a Canadian healthcare system perspective with a time horizon of 1 year. Data from the D-PRESCRIBE trial and published literature were used to calculate effectiveness, utilities, and costs. Reference case and scenario analyses were conducted using probabilistic modeling. Sensitivity analyses assessed the robustness of the reference case model. RESULTS: D-PRESCRIBE (NSAIDs) was less costly (-$1008.61) and more effective (.11 quality-adjusted life-years [QALYs]) than usual care and was the dominant strategy. At willingness-to-pay thresholds of $50 000 per QALY and $100 000 per QALY, D-PRESCRIBE (NSAIDs) incurred a positive incremental net benefit compared with usual care, suggesting it is cost-effective. Compared with the reference case, scenario analyses gave comparable QALYs with modest variation in cost estimates. CONCLUSION: For community-dwelling older adults, D-PRESCRIBE (NSAIDs) provides greater benefits at lower system costs, making it a compelling strategy to reduce the use and harms associated with chronic NSAID consumption. Our findings support reimbursing community pharmacists' clinical professional services for deprescribing inappropriate NSAIDs in community-dwelling older adults. J Am Geriatr Soc 68:1090-1097, 2020.

Costs and Resource Use Associated with Community-Dwelling Patients with Alzheimer's Disease in Japan: Baseline Results from the Prospective Observational GERAS-J Study.

BACKGROUND: As the Japanese population ages, caring for people with Alzheimer's disease (AD) dementia is becoming a major socioeconomic issue. OBJECTIVE: To determine the contribution of patient and caregiver costs to total societal costs associated with AD dementia. METHODS: Baseline data was used from the longitudinal, observational GERAS-J study. Using the Mini-Mental State Examination (MMSE) score, patients routinely visiting memory clinics were stratified into three groups based on AD severity. Health care resource utilizationwas recorded using the Resource Utilization in Dementia questionnaire. Total monthly societal costs were estimated using Japan-specific unit costs of services and products (patient direct health care use, patient social care use, and informal caregiving time). Uncertainty around mean costs was estimated using bootstrapping methods. RESULTS: Overall, 553 community-dwelling patients withADdementia (28.3% mild[MMSE21-26], 37.8% moderate[MMSE 15-20], and 34.0% moderately severe/severe [MMSE < 14]) and their caregivers were enrolled. Patient characteristics were: mean age 80.3 years, 72.7% female, and 13.6% living alone. Caregiver characteristics were: mean age 62.1 years, 70.7% female, 78.8% living with patient, 49.0% child of patient, and 39.2% sole caregiver. Total monthly societal costs of AD dementia (Japanese yen) were: 158,454 (mild), 211,301 (moderate), and 294,224 (moderately severe/severe). Informal caregiving costs comprised over 50% of total costs. CONCLUSION: Baseline results of GERAS-J showed that total monthly societal costs associated with AD dementia increased with AD severity. Caregiver-related costs were the largest cost component. Interventions are needed to decrease informal costs and decrease caregiver burden.

The Shapley value for a fair division of group discounts for coordinating cooling loads.

We consider a demand response program in which a block of apartments receive a discount from their electricity supplier if they ensure that their aggregate load from air conditioning does not exceed a predetermined threshold. The goal of the participants is to obtain the discount, while ensuring that their individual temperature preferences are also satisfied. As such, the apartments need to collectively optimise their use of air conditioning so as to satisfy these constraints and minimise their costs. Given an optimal cooling profile that secures the discount, the problem that the apartments face then is to divide the total discounted cost in a fair way. To achieve this, we take a coalitional game approach and propose the use of the Shapley value from cooperative game theory, which is the normative payoff division mechanism that offers a unique set of desirable fairness properties. However, applying the Shapley value in this setting presents a novel computational challenge. This is because its calculation requires, as input, the cost of every subset of apartments, which means solving an exponential number of collective optimisations, each of which is a computationally intensive problem. To address this, we propose solving the optimisation problem of each subset suboptimally, to allow for acceptable solutions that require less computation. We show that, due to the linearity property of the Shapley value, if suboptimal costs are used rather than optimal ones, the division of the discount will be fair in the following sense: each apartment is fairly "rewarded" for its contribution to the optimal cost and, at the same time, is fairly "penalised" for its contribution to the discrepancy between the suboptimal and the optimal costs. Importantly, this is achieved without requiring the optimal solutions.

Sharing is caring: The potential of the sharing economy to support aging in place.

This article explores innovative applications of sharing economy services that have the potential to support a population aging in place, especially the "oldest old," aged 85 and older, and their caregivers. A mixed-methods study conducted by the MIT AgeLab examined perceptions of and experiences with sharing economy services, ultimately finding opportunities and barriers to use. Thus, although sharing economy services have potential to support aging in place, to do so successfully will require reconstructing how older adults, family caregivers, aging service professionals, gerontology educators, and gerontology students conceptualize and deliver care to an aging population. We suggest examples for gerontology educators to integrate into their classrooms to further cultivate an appreciation among students of multiple approaches to intervention, including those that leverage sharing economy and technology-enabled platforms to support older adults and their caregivers.

Different Lifestyle Interventions in Adults From Underserved Communities: The FAMILIA Trial.

BACKGROUND: The current trends of unhealthy lifestyle behaviors in underserved communities are disturbing. Thus, effective health promotion strategies constitute an unmet need. OBJECTIVES: The purpose of this study was to assess the impact of 2 different lifestyle interventions on parents/caregivers of children attending preschools in a socioeconomically disadvantaged community. METHODS: The FAMILIA (Family-Based Approach in a Minority Community Integrating Systems-Biology for Promotion of Health) study is a cluster-randomized trial involving 15 Head Start preschools in Harlem, New York. Schools, and their children's parents/caregivers, were randomized to receive either an "individual-focused" or "peer-to-peer-based" lifestyle intervention program for 12 months or control. The primary outcome was the change from baseline to 12 months in a composite health score related to blood pressure, exercise, weight, alimentation, and tobacco (Fuster-BEWAT Score [FBS]), ranging from 0 to 15 (ideal health = 15). To assess the sustainability of the intervention, this study evaluated the change of FBS at 24 months. Main pre-specified secondary outcomes included changes in FBS subcomponents and the effect of the knowledge of presence of atherosclerosis as assessed by bilateral carotid/femoral vascular ultrasound. Mixed-effects models were used to test for intervention effects. RESULTS: A total of 635 parents/caregivers were enrolled: mean age 38 ± 11 years, 83% women, 57% Hispanic/Latino, 31% African American, and a baseline FBS of 9.3 ± 2.4 points. The mean within-group change in FBS from baseline to 12 months was ∼0.20 points in all groups, with no overall between-group differences. However, high-adherence participants to the intervention exhibited a greater change in FBS than their low-adherence counterparts: 0.30 points (95% confidence interval: 0.03 to 0.57; p = 0.027) versus 0.00 points (95% confidence interval: -0.43 to 0.43; p = 1.0), respectively. Furthermore, the knowledge by the participant of the presence of atherosclerosis significantly boosted the intervention effects. Similar results were sustained at 24 months. CONCLUSIONS: Although overall significant differences were not observed between intervention and control groups, the FAMILIA trial highlights that high adherence rates to lifestyle interventions may improve health outcomes. It also suggests a potential contributory role of the presentation of atherosclerosis pictures, providing helpful information to improve future lifestyle interventions in adults.

Promoting Independence in Dementia (PRIDE): protocol for a feasibility randomised controlled trial.

BACKGROUND: Memory services often see people with early stage dementia who are largely independent and able to participate in community activities but who run the risk of reducing activities and social networks. PRIDE is a self-management intervention designed to promote living well and enhance independence for people with mild dementia. This study aims to examine the feasibility of conducting a definitive randomised trial comparing the clinical and cost-effectiveness of the PRIDE intervention offered in addition to usual care or with usual care alone. METHODS/DESIGN: PRIDE is a parallel, two-arm, multicentre, feasibility, randomised controlled trial (RCT). Eligible participants aged 18 or over who have mild dementia (defined as a score of 0.5 or 1 on the Clinical Dementia Rating Scale) who can participate in the intervention and provide informed consent will be randomised (1:1) to treatment with the PRIDE intervention delivered in addition to usual care, or usual care only. Participants will be followed-up at 3 and 6 month's post-randomisation. There will be an option for a supporter to join each participant. Each supporter will be provided with questionnaires at baseline and follow-ups at 3 to 6 months. Embedded qualitative research with both participants and supporters will explore their perspectives on the intervention investigating a range of themes including acceptability and barriers and facilitators to delivery and participation. The feasibility of conducting a full RCT associated with participant recruitment and follow-up of both conditions, intervention delivery including the recruitment, training, retention of PRIDE trained facilitators, clinical outcomes, intervention and resource use costs and the acceptability of the intervention and study related procedures will be examined. DISCUSSION: This study will assess whether a definitive randomised trial comparing the clinical and cost-effectiveness of whether the PRIDE intervention offered in addition to usual care is feasible in comparison to usual care alone, and if so, will provide data to inform the design and conduct of a future trial. TRIAL REGISTRATION: ISRCTN, ISRCTN11288961, registered on 23 October 2019, http://www.isrctn.com/ISRCTN12345678 Protocol V2.1 dated 19 June 2019.

Mobile Geriatric Teams - A Cost-Effective Way Of Improving Patient Safety And Reducing Traditional Healthcare Utilization Among The Frail Elderly? A Randomized Controlled Trial.

BACKGROUND: Demographic changes combined with costly technological progress put a financial strain on the healthcare sector in the industrialized world. Hence, there is a constant need to develop new cost-effective treatment procedures in order to optimize the use of available resources. As a response, the concept of a Mobile Geriatric Team (MGT) has emerged not only nationally but also internationally during the last decade; however, scientific evaluation of this initiative has been very scarce. Thus, the objective of this study was to perform a mixed methods analysis, including a prospective, controlled and randomized quantitative evaluation, in combination with an interview-based qualitative assessment, to measure the effectiveness and user satisfaction of MGT. MATERIALS AND METHODS: Community-dwelling, frail elderly people were randomized to an intervention group (n=31, mean age 84) and a control group (n=31, mean age 86). A two-year retrospective quantitative data collection and a prospective one-year follow-up on healthcare utilization were combined with qualitative interviews. Non-parametric statistics and difference-in-difference (DiD) analyses were applied to the quantitative data. Qualitative data were analyzed using content analysis. RESULTS: No significant group differences in healthcare utilization were found before inclusion. Post intervention, primary care contact (including MGTs) increased for the MGT group. Inpatient care decreased dramatically for both groups. Hence, the increase in primary care contact for MGT patients was not accompanied by a reduction in inpatient care compared to the control group. Utilization of non-primary care was lower (p< 0.01) post-intervention in both groups. CONCLUSION: There appears to be a "natural" variation in healthcare needs over time among frail elderly people. Hence, it is vital to perform open, controlled clinical studies in tandem with the implementation of new caregiving strategies. The MGT initiative was clearly appreciated but did not fully achieve the desired reduction in healthcare utilization in this study. TRIAL REGISTRATION: Retrospectively registered 09/10/2018, ClinicalTrials.gov ID NCT03662945.

Age group differences in association between IADL decline and depressive symptoms in community-dwelling elderly.

BACKGROUND: Instrumental Activities of Daily Living (IADL) is an indicator of whether a community-dwelling elderly can live independently. IADL decline was reported to be associated with aging and depression. The present study aimed to investigate whether the association between IADL decline and depressive symptoms differs with aging, using two age groups of community-dwelling Japanese elderly in their 70s and 80s. METHODS: We conducted longitudinal analysis among participants in their 70s and 80s at the baseline from Septuagenarians, Octogenarians, Nonagenarians Investigation with Centenarians (SONIC) study. IADL was assessed by The Tokyo Metropolitan Institute of Gerontology (TMIG) index of competence. As a main predictor, depressive symptoms were measured by the five-item version of the Geriatrics Depression Scale (GDS-5). As possible confounders, we considered cognitive function, body mass index, solitary living, education, economic status, medical history of stroke and heart disease, hypertension, dyslipidemia, diabetes, and sex. We obtained odds ratios (ORs) of IADL decline for having depressive symptoms in each age group (70s/80s) and tested interactions between depressive symptoms and age groups in relation to IADL decline in 3 years by logistic regression. Additionally, to confirm age group differences, we conducted multiple group analysis. RESULTS: There were 559 participants in their 70s and 519 in their 80s. Compared to participants without depressive symptoms, those with depressive symptoms had higher OR of IADL decline in 70s (OR [95% CI] = 2.33 [1.13, 4.78]), but not in 80s (OR [95% CI] = 0.85 [0.46, 1.53]). There were significant interactions between depressive symptoms and age groups in relation to IADL decline (p-value = 0.03). Multiple group analyses showed differences between the age groups by Akaike information criterion (AIC), and ORs (95%CI) decline for depressive symptoms was 2.33 (1.14, 4.77) in 70s and 0.85 (0.47, 1.54) in 80s. CONCLUSION: The association of depressive symptoms and IADL decline during the 3 years was significantly different between the 70s and 80s age groups, and significant association was found only in people in their 70s. Detecting depressive symptoms may be a key for preventing IADL decline in people in their 70s and not for those in their 80s.

Social position and geriatric syndromes among Swedish older people: a population-based study.

BACKGROUND: Older people with a low social position are at higher risk of poor health outcomes compared to those with a higher social position. Whether lower social position also increases the risk of geriatric syndromes (GSs) remains to be determined. This study investigates the association of social position with GSs among older community-dwellers. METHODS: Three consecutive population-based health surveys in 2006, 2010 and 2014 among older community-dwellers (age 65-84 years) in Stockholm County were combined (n = 17,612) and linked with Swedish administrative registry information. Social position was assessed using registry information (i.e. education, country of origin and civil status) and by self-reports (i.e. type of housing and financial stress). GSs were assessed by self-reports of the following conditions: insomnia, urinary incontinence, functional decline, falls, depressive disorder, hearing or vision problems. Binomial logistic regression analyses were used to estimate the association between social position and GSs after adjusting for age, sex, health status, health behavior and social stress. RESULTS: The prevalence of GSs was 70.0%, but varied across GSs and ranged from 1.9% for depression to 39.1% for insomnia. Living in rented accommodation, being born outside the Nordic countries, being widowed or divorced were associated with GS presence. Financial stress was most strongly associated with GSs (adjusted odds ratio, 2.59; 95% CI, 2.13-3.15). CONCLUSION: GSs are highly prevalent among older Swedish community-dwellers with wide variations across syndromes and strong association with all measures of social position, most strikingly that of experiencing financial stress.