Experiences of caregivers by care recipient's health condition: A study of caregivers for Alzheimer's disease and related dementias versus other chronic conditions.

This study described experiences of caregivers of persons with Alzheimer's disease and other dementias (ADRD) and caregivers of persons with other chronic conditions on self-reported health, type of assistance they provide, perceptions of how caregiving interferes with their lives, and perceived level of support. A secondary analysis was conducted of the 2013 Porter Novelli SummerStyles survey data. Of the 4033 respondents, 650 adults self-identified as caregivers with 11.6% caring for people with ADRD. Over half of all caregivers reported that caregiving interfered with their lives to some extent. The greater the perceived support caregivers reported, the less they thought that caregiving interfered with their lives (p < .001). No significant differences were found between ADRD and non-ADRD caregivers regarding general health, types of assistance they provided, and perceived level of support. These findings have the potential to inform future research and practice in the development of supportive services for caregivers.

Concern about developing Alzheimer's disease or dementia and intention to be screened: An analysis of national survey data.

OBJECTIVE: Early diagnosis of Alzheimer's disease (AD) or dementia is important so that patients can express treatment preferences, subsequently allowing caregivers to make decisions consistent with their wishes. This study explored the relationship between people's concern about developing AD/dementia, likelihood to be screened/tested, if experiencing changes in cognitive status or functioning, and concerns about sharing the diagnostic information with others. METHOD: A descriptive study was conducted using Porter Novelli's SummerStyles 2013 online survey data. Of the 6105 panelists aged 18+ who received the survey, 4033 adults responded (response rate: 66%). Chi squares were used with case-level weighting applied. RESULTS: Almost 13% of respondents reported being very worried or worried about getting AD/dementia, with women more worried than men (p<.001), and AD/dementia caregivers more worried than other types of caregivers (p=.04). Women were also more likely than men to agree to be screened/tested if experiencing changes in memory and/or thinking (p<.001). The greater the worry, the more likely respondents would agree to be screened/tested (p<.001). Nearly 66% of respondents were concerned that sharing a diagnosis would change the way others think/feel about them, with women reporting greater concern than men (p=.003). CONCLUSION: Findings demonstrate that level of worry about AD/dementia is associated with the reported likelihood that individuals agree to be screened/tested. This information will be useful in developing communication strategies to address public concern about AD/dementia that may increase the likelihood of screening and early detection.

Non-Emergency Medical Transportation Needs of Middle-Aged and Older Adults: A Rural-Urban Comparison in Delaware, USA.

Background: Older adults in rural areas have unique transportation barriers to accessing medical care, which include a lack of mass transit options and considerable distances to health-related services. This study contrasts non-emergency medical transportation (NEMT) service utilization patterns and associated costs for Medicaid middle-aged and older adults in rural versus urban areas. Methods: Data were analyzed from 39,194 NEMT users of LogistiCare-brokered services in Delaware residing in rural (68.3%) and urban (30.9%) areas. Multivariable logistic analyses compared trip characteristics by rurality designation. Results: Rural (37.2%) and urban (41.2%) participants used services more frequently for dialysis than for any other medical concern. Older age and personal accompaniment were more common and wheel chair use was less common for rural trips. The mean cost per trip was greater for rural users (difference of $2910 per trip), which was attributed to the greater distance per trip in rural areas. Conclusions: Among a sample who were eligible for subsidized NEMT and who utilized this service, rural trips tended to be longer and, therefore, higher in cost. Over 50% of trips were made for dialysis highlighting the need to address prevention and, potentially, health service improvements for rural dialysis patients.

Cognitive Training among Cognitively Impaired Older Adults: A Feasibility Study Assessing the Potential Improvement in Balance.

BACKGROUND: Emerging literature suggests that mobility and cognition are linked. Epidemiological data support a negative association between cognition and falls among cognitively intact older adults. A small number of intervention studies found that regimented cognitive training (CT) improves mobility among this population, suggesting that CT may be an under-explored approach toward reducing falls. To date, no studies have examined the impact of CT on balance among those who are cognitively impaired. The purpose of this study was to assess the feasibility of implementing a CT program among cognitively impaired older adults and examine whether there are potential improvements in balance following CT. METHOD: A single group repeated measures design was used to identify change in balance, depressive symptoms, and global cognition. A mixed method approach was employed to evaluate the feasibility of a CT intervention among a cohort of cognitively impaired older adults. CT was delivered in a group 2 days/week over 10 weeks using an online brain exercise program, Posit Science Brain HQ (20 h). All participants completed a one-on-one data collection interview at baseline and post-program. RESULTS: Participants (N = 20) were on average 80.5 years old and had mild to moderate cognitive impairment. Following the 10-week CT intervention, mean scores on 4 of the 5 balance measures improved among CT participants. Although none of the balance improvements reached significance, these findings are promising given the small sample size. Depressive symptoms significantly improved between baseline and 10 weeks (p = 0.021). Mean global cognition also improved across the study period, but neither of these improvements were statistically significant. Based on participant responses, the CT program was feasible for this population. CONCLUSION: This study provides support for the feasibility of implementing a CT program among cognitively impaired older adults in an adult day setting. Our findings also add to emerging literature that CT may be a novel and innovative approach to fall prevention among older adults.

Missed or Delayed Medical Care Appointments by Older Users of Nonemergency Medical Transportation.

PURPOSE OF THE STUDY: This study identified factors associated with canceling nonemergency medical transportation appointments among older adult Medicaid patients. DESIGN AND METHODS: Data from 125,913 trips for 2,913 Delaware clients were examined. Mediation analyses, as well as, multivariate logistic regressions were conducted. RESULTS: Over half of canceled trips were attributed to client reasons (e.g., no show, refusal). Client characteristics (e.g., race, sex, functional status) were associated with cancelations; however, these differed based on the cancelation reason. Regularly scheduled trips were less likely to be canceled. IMPLICATIONS: The evolving American health care system may increase service availability. Additional policies can improve service accessibility and overcome utilization barriers.

The instructional impact of the American Medical Association's Older Drivers Project online curriculum.

The Older Drivers Project (ODP) of the American Medical Association has provided evidence-based training for clinicians since 2003. More than 10,000 physicians and other professionals have been trained via an authoritative manual, the Physician's Guide to Assessing & Counseling Older Drivers, and an associated continuing medical education five-module curriculum offered formally by multidisciplinary teams from 12 U.S. States from 2003 to 2008. An hour-long, online version was piloted with medical residents and physicians (N = 259) from six academic and physician office sites from 2010 to 2011. Pre/postsurveys were completed. Most rated the curriculum of high quality and relevant to their practice. A majority (88%) reported learning a new technique or tool, and 89% stated an intention to incorporate new learning into their daily clinical practice. More than one half (62%) reported increased confidence in addressing driving. This transition from in-person to online instruction will allow the ODP to reach many more clinicians, at all levels of training, in the years to come.

Personal derived health information: a foundation to preparing the United States for disasters and public health emergencies.

BACKGROUND: In the days following a disaster/public health emergency, there is great effort to ensure that everyone receives appropriate care and lives are saved. However, evacuees following a disaster/public health emergency often lack access to personal health information that is vital to receive or maintain quality care. Delayed treatment and interruptions of medication regimens often contribute to excess morbidity and mortality following a disaster/public health emergency. This study sought to define a set of minimum health information elements that can be maintained in a personal health record (PHR) and given to first responders/receivers within the first 96 hours of a disaster/public health response to improve clinical health outcomes. METHODS: A mixed methods approach of qualitative and quantitative data gathering and analyses was completed. Expert panel members (n = 116) and existing health information elements were sampled for this study; 55% (n = 64) of expert panel members had clinical credentials and determined the health information. From an initial set of 6 sources, a step-wise process using a Likert scale survey and thematic data analyses, including interrater reliability and validity checks, produced a set of minimum health information elements. RESULTS: The results identified 30 essential elements from 676 existing health information elements, a reduction of approximately 95%. The elements were grouped into 7 domains: identification, emergency contact, health care contact, health profile -past medical history, medication, major allergies/diet restrictions, and family information. CONCLUSIONS: Leading experts in clinical disaster preparedness identified a set of minimum health information elements that first responders/receivers must have to ensure appropriate and timely care. If this set of elements is used as the fundamental information for a PHR, and automatically updated and validated during clinical encounters and medication changes, it is conceivable that following large-scale disasters clinical outcomes may be improved and more lives may be saved.

The American Medical Association Older Driver Curriculum for health professionals: changes in trainee confidence, attitudes, and practice behavior.

Few gerontology and geriatrics professionals receive training in driver fitness evaluation, state reporting of unfit drivers, or transportation mobility planning yet are often asked to address these concerns in the provision of care to older adults. The American Medical Association (AMA) developed an evidence-based, multi-media Curriculum to promote basic competences. This study evaluated reported changes in practice behaviors 3 months posttraining in 693 professionals trained via the AMA approach. Eight Teaching Teams, designated and trained by AMA staff, offered 22 training sessions across the United States in 2006 to 2007. Trainees (67% female; mean age 46) completed a pretest questionnaire and a posttest administered by mail. Physicians were the largest professional group (32%). Although many trainees acknowledged having conversations with patients about driving at pretest, few endorsed utilizing specific techniques recommended by the AMA prior to this training. The posttest response rate was 34% (n = 235). Significant improvements in reported attitudes, confidence, and practices were found across measured items. In particular, posttest data indicated new adoption of in-office screening techniques, chart documentation of driver safety concerns, and transportation alternative planning strategies. Findings suggest that a well-designed, one-time continuing education intervention can enhance health professional confidence and clinical practice concerning driver fitness evaluation and mobility planning. Targeted dissemination of this Curriculum (in-person and online) will allow more to benefit in the future.

Development of geriatric competencies for emergency medicine residents using an expert consensus process.

BACKGROUND: The emergency department (ED) visit rate for older patients exceeds that of all age groups other than infants. The aging population will increase elder ED patient utilization to 35% to 60% of all visits. Older patients can have complex clinical presentations and be resource-intensive. Evidence indicates that emergency physicians fail to provide consistent high-quality care for elder ED patients, resulting in poor clinical outcomes. OBJECTIVES: The objective was to develop a consensus document, "Geriatric Competencies for Emergency Medicine Residents," by identified experts. This is a minimum set of behaviorally based performance standards that all residents should be able to demonstrate by completion of their residency training. METHODS: This consensus-based process utilized an inductive, qualitative, multiphase method to determine the minimum geriatric competencies needed by emergency medicine (EM) residents. Assessments of face validity and reliability were used throughout the project. RESULTS: In Phase I, participants (n=363) identified 12 domains and 300 potential competencies. In Phase II, an expert panel (n=24) clustered the Phase I responses, resulting in eight domains and 72 competencies. In Phase III, the expert panel reduced the competencies to 26. In Phase IV, analysis of face validity and reliability yielded a 100% consensus for eight domains and 26 competencies. The domains identified were atypical presentation of disease; trauma, including falls; cognitive and behavioral disorders; emergent intervention modifications; medication management; transitions of care; pain management and palliative care; and effect of comorbid conditions. CONCLUSIONS: The Geriatric Competencies for EM Residents is a consensus document that can form the basis for EM residency curricula and assessment to meet the demands of our aging population.

State mental health policy: implementation of computerized medication prescribing algorithms in a community mental health system.

This column describes a Michigan initiative to implement medication prescribing algorithms for schizophrenia, bipolar disorder, and major depression. The algorithms were incorporated into the electronic medical records system of a four-county community mental health system. Guideline adherence of 30 providers who treated nearly 3,000 patients was measured at mid- and endpoints of the first year. They were adherent for about a third of their patients in the first six months (32%) and more than half in the second (52%). Scores on scales measuring providers' perceptions of algorithm ease of use and usefulness were in the midrange at both time points.

Sixteen-year predictors of substance use disorder diagnoses for patients with mental health disorders.

Individuals with substance use disorders (SUDs). including co-occurring disorders, are among the highest-risk populations for medical and psychiatric rehospitalizations, and are often underdiagnosed at initial hospitalization. This study examined predictors for these individuals at baseline hospitalization and subsequent rehospitalizations. Three groups were compared from a sample of individuals admitted to inpatient psychiatry (1982 to 1987) with at least one rehospitalization within a 16-year period. Multivariate logistical regressions were used to determine associations with predictor variables. The data showed that individuals' diagnosed with a SUD after baseline hospitalization were more likely to have more medical hospitalizations and to be diagnosed with schizophrenia compared to those who were diagnosed with a SUD, including co-occurring disorders, at baseline. The results of this study indicate the importance of substance use screening to enhance service resources and treatment outcomes for medically and psychiatrically complex populations.

Improving integrated general medical and mental health services in community-based practices.

The historical fragmentation of physical and mental health services has impeded efforts to improve quality and outcomes of care for persons with mental disorders. However, there is little information on effective strategies that might reduce fragmentation and improve integrated services within non-academic, community-based healthcare settings. Twenty-three practices from across the U.S. participated in a learning community meeting designed to identify barriers to integrated care and strategies for reducing such barriers. Barriers were initially identified based on a quantitative survey of organizational factors. Focus groups were used to elaborate on barriers to integrated care and to identify strategies for reducing barriers that are feasible in community-based settings. Participants identified key barriers, including administrative (e.g., lack of common medical records for mental health and general medical conditions), financial (e.g., lack of reimbursement codes to bill for mental health and general medical care in the same setting), and clinical (e.g., lack of an integrated care protocol). Top strategies recommended by participants included templates (i.e., for memoranda of understanding) to allow providers to work across practice settings, increased medical record security to enable a common medical record between mental health and general medical care, working with state Medicaid agencies to establish integrated care reimbursement codes, and guidance in establishing workflows between different providers (i.e., avoid duplication of tasks). Strategies to overcome barriers to integrated care may require cooperation across different organizational levels, including administrators, providers, and health care payers in order for integrated care to be established and sustained over time.

Reinstitutionalization following psychiatric discharge among VA patients with serious mental illness: a national longitudinal study.

Patterns of reinstitutionalization following psychiatric hospitalization for individuals with serious mental illnesses (SMI) vary by medical and psychiatric health care settings. This report presents rates of reinstitutionalization across care settings for 35,527 patients following psychiatric discharge in the Department of Veterans Affairs (VA) health system, a national health care system. Over a 7-year follow-up period, 30,417 patients (86%) were reinstitutionalized. Among these patients, 73% were initially reinstitutionalized to inpatient psychiatric settings. Homelessness, medical morbidity, and substance use were associated with increased risks for reinstitutionalization. Despite the VA's increased emphasis on outpatient services delivery, the vast majority of patients experienced reinstitutionalization in the follow-up period. Study findings may inform efforts to refine psychiatric and medical assessment for service delivery for this vulnerable population.