The development of quality indicators to improve psychosocial care in dementia.

BACKGROUND: The evidence for the effectiveness of psychosocial interventions in dementia care is growing but the implementation of available evidence is not automatic. Our objective was to develop valid quality indicators (QIs) for psychosocial dementia care that facilitate the implementation process in various countries and settings. METHODS: A RAND-modified Delphi technique was used to develop a potential set of QIs. Two multidisciplinary, international expert panels were involved in achieving content and face validity. Consensus on the final set was reached after a conference meeting where a third panel of dementia experts discussed measurability and applicability of the potential set. A retrospective cohort study was conducted to study the feasibility of using the final set in day care centers, hospitals, and nursing homes in Spain and The Netherlands. RESULTS: A total of 104 recommendations were selected from guidelines and systematic reviews and appraised for their contribution to improving the quality of dementia care by 49 dementia experts. Twenty-five experts attended the conference meeting and reached consensus on a set of 12 QIs representing the key elements of effective psychosocial care, such as shared decision-making and interventions tailored to needs and preferences. Data from 153 patient records showed that all but one QI subitem were applicable to all three settings in both countries. CONCLUSION: Our multidisciplinary and multinational strategy resulted in a set of unique QIs that aims exclusively at assessing the quality of psychosocial dementia care. Following implementation, these QIs will assist dementia care professionals to individualize and tailor psychosocial interventions.

Impact of hip fracture, heart failure and weight loss on the risk of institutionalization of community-dwelling patients with dementia.

OBJECTIVES: This study sought to identify the influence of medical symptoms and diseases on the risk of nursing home placement in a prospective cohort of newly diagnosed community-dwelling patients with dementia. STUDY DESIGN AND SETTING: This study included 348 patients with dementia, consecutively diagnosed, recruited and followed at a geriatric outpatient center (mean age: 81 years, 65.5% with Alzheimer's disease, mean baseline MMSE score: 20.5, mean follow-up: 20.5 months). RESULTS: After adjustment for factors commonly associated with institutionalization in this population, hip fracture in the 3 years preceding diagnosis, acute congestive heart failure during follow-up and weight loss of more than 5% in any year during follow-up were independently associated with nursing home placement. CONCLUSION: This study confirms the independent contribution of specific medical symptoms and diseases to earlier institutionalization of patients with dementia. These results stress the importance of better knowledge of the specific characteristics of hip fracture, weight loss and congestive heart failure in the context of dementia, to make more effective prevention possible in this patient population.

[Non pharmacological interventions in dementia: a review and prospect]. / Démence et interventions non médicamenteuses: revue critique, bilan et perspectives.

Non pharmacological interventions in Alzheimer's disease and related disorders are a growing area of research. If, to date, the limited number of randomized controlled trials, the small size of the samples, the variable degree of precision of the interventions provide limited evidence of the efficacy of such interventions, some appear most promising: among cognitive interventions, individualized cognitive rehabilitation strategies, among emotion-oriented interventions, reminiscence therapy, and among interventions designed for carers, those who include interventions with the patients present, to date, the most reliable data. Among the environmental and behavioral interventions, the very promising results of behavioral therapies for carers in the treatment of depression, as well as of behavioral techniques in improving the relationship between staff members and residents in challenging care situations (bathing) are emphasized. The differential impact of the physical environment and of different sensory stimulation techniques on the mood and behavior of people with dementia is a very promising area, which deserves more precise evidence based work in the future.

The world of dementia beyond 2020.

Counterpoised against dire projections of the tripling of the prevalence of dementia over the next 40 years are major developments in diagnostic biomarkers, neuroimaging, the molecular biology of Alzheimer's disease (AD), epidemiology of risk and protective factors, and drug treatments-mainly targeting the amyloid pathway, tau protein, and immunotherapy-that may have the potential to modify the progression of AD. Drug combinations and presymptomatic treatments are also being investigated. Previous trials of dementia-modifying drugs have not shown benefit, and even if current Phase III trials prove successful, these drugs will not eradicate other dementias, could (if not curative) increase dementia duration and prevalence, and are unlikely to come onto the market before 2020. In the meantime, delaying the onset of dementia by even 2 years would have significant economic and societal effects. This article provides an overview of current achievements and potentials of basic and clinical research that might affect the development of dementia prevalence and care within the near future.

Major depression as a risk factor for early institutionalization of dementia patients living in the community.

OBJECTIVE: Although depression is known to be frequently associated with dementia, it is nonetheless under-diagnosed and under-treated among this patient population. Its effect on outcome for dementia patients is thought to be substantial, because depression appears to induce higher than normal rates of disability as well as supplementary cognitive decline. The aim of this study was to measure the impact of major depression on the institutionalization rate of community-dwelling dementia patients. DESIGN: Prospective cohort study. SETTING: Paris, France. PARTICIPANTS: Three-hundred forty-eight consecutive dementia outpatients of a geriatric clinic (mean age: 81 years, 69.8% women, 65.5% dementia of Alzheimer's type, mean baseline MMSE score: 20.5), followed between 1997 and 2002 (mean follow-up: 20.5 months). RESULTS: Twenty-five percent of the patients met the criteria of major depression at baseline, and only 30.3% of these received antidepressant medication. Major depression at baseline was independently associated with nursing home admission within one year of the baseline assessment. Antidepressant medication tended to protect against this outcome, but not to a statistically significant extent. CONCLUSIONS: Major depression at baseline is an independent risk factor for early institutionalization of dementia sufferers. Early institutionalization is defined in this study as nursing home placement within a year of diagnosis with dementia at our specialized outpatient center. The study highlights the need for better management of depression among dementia outpatients. Further investigation is needed to evaluate the protective effect of antidepressant medication (and/or non-pharmacological therapies) on the institutionalization rate.