Mortality in nursing home residents stratified according to subtype of dementia: a longitudinal study over three years.

BACKGROUND: There are several subtypes of dementia caused by different pathophysiology and with different clinical characteristics. Irrespective subtype, the disease is progressive, eventually leading to the need for care and supervision on a 24/7 basis, often provided in nursing homes (NH). The progression rate and course of the disease might vary according to subtype. The aim of this study was to explore whether the mortality rate for NH residents varied according to the subtype of dementia. METHODS: NH residents were followed from admission to NH over a period of 36 months or until death with annual follow-up examinations. Demographic and clinical data were collected. The diagnosis of dementia and its subtype at baseline (BL) were set according to international accepted criteria. Kaplan-Meier analysis was performed to estimate median survival time. A Cox regression model was estimated to assess the impact of dementia diagnosis and demographic and clinical variables on mortality. RESULTS: A total of 1349 participants were included. When compared to persons with Alzheimer's disease (AD), persons with frontotemporal dementia (FTD) and dementia with Lewy bodies or Parkinson's disease dementia (DLB/PDD) were younger and had more neuropsychiatric symptoms. Median survival for the total sample was 2.3 years (95% confidence interval: 2.2-2.5). When compared to persons with AD, having no dementia or unspecified dementia was associated with higher mortality, while we found similar mortality in other subtypes of dementia. Higher age, male gender, poorer general health, higher dependency in activities of daily living, and more affective symptoms were associated with higher mortality. CONCLUSION: Mortality did not differ across the subtypes of dementia, except in persons with unspecified dementia or without dementia, where we found a higher mortality. With a median survival of 2.3 years, NH residents are in the last stage of their lives and care and medical follow-up should focus on a palliative approach. However, identifying the subtype of dementia might help carers to better understand and address neuropsychiatric symptoms and to customize medical treatment.

A prolonged course of COVID-19 in a person with dementia. / Et langvarig covid-19-forløp hos en person med demens.

BACKGROUND: The course of COVID-19 may be particularly long-lasting in elderly patients. Caring for patients with dementia suffering from COVID-19 is challenging due to unclear symptom presentation, delirium, and maintaining isolation procedures. CASE PRESENTATION: A man in his sixties with dementia, hospitalised in a psychogeriatric ward, presented with mild upper respiratory tract symptoms and recovered within 24 hours. Ten days later he developed more severe symptoms. PCR test for SARS-CoV-2 was positive. Over the following two months his clinical state fluctuated, from almost symptom-free days to being bedridden and assessed as potentially terminal. After the initial positive test, he had three consecutive negative tests, before he again tested positive for SARS-CoV-2. Uncertainty as to whether the patient remained contagious resulted in isolation of the patient for over two months. INTERPRETATION: PCR testing of SARS-CoV-2 does not differentiate between intact virus and remnants thereof, and patients may test positive for a long time. This along with a fluctuating clinical course makes it difficult for clinicians to decide when to end isolation of COVID-19 patients.

Determinants of adherence to recommendations for depressed elderly patients in primary care: a multi-methods study.

OBJECTIVE: It is logical that tailoring implementation strategies to address identified determinants of adherence to clinical practice guidelines should improve adherence. This study aimed to identify and prioritize determinants of adherence to six recommendations for elderly patients with depression. DESIGN AND SETTING: Group and individual interviews and a survey were conducted in Norway. METHOD: Individual and group interviews with healthcare professionals and patients, and a mailed survey of healthcare professionals. A generic checklist of determinants of practice was used to categorize suggested determinants. PARTICIPANTS: Physicians and nurses from primary and specialist care, psychologists, researchers, and patients. MAIN OUTCOME MEASURES: Determinants of adherence to recommendations for depressed elderly patients in primary care. RESULTS: A total of 352 determinants were identified, of which 99 were prioritized. The most frequently identified factors had to do with dissemination of guidelines, general practitioners' time constraints, the low prioritization of elderly patients with depression, and the patients' or relatives' wish for medication. Approximately three-quarters of the determinants were from three of the seven domains in the generic checklist: individual healthcare professional factors, patient factors, and incentives and resources. The survey did not provide useful information due to a low response rate and a lack of responses to open-ended questions. IMPLICATIONS: The list of prioritized determinants can inform the design of interventions to implement recommendations for elderly patients with depression. The importance of the determinants that were identified may vary across communities, practices. and patients. Interventions that address important determinants are necessary to improve practice.

Unrecognised depression among older people: a cross-sectional study from Norwegian general practice.

BACKGROUND: Depression is common in old age and is associated with disability, increased mortality, and impairment from physical diseases. AIM: To estimate the prevalence of depression among older patients in Norwegian general practice, to evaluate the extent they talk about it during their consultation, whether it was previously known or suspected by their GP, and how frequently patients with depression visit their GP. DESIGN & SETTING: Cross-sectional study among patients and GPs at 18 primary care clinics in the south of Norway. METHOD: Patients aged ≥65 years who visited their GP were asked to complete the Patient Health Questionnaire-9 (PHQ-9). The GPs reported what kind of issues the patient presented at the consultation, if a current depression was known, and the consultation frequency. RESULTS: Forty-four (11.4%) of 383 patients reported moderate or severe depressive symptoms (PHQ-9 ≥10). Among the cases with data from both patient and GP (n = 369), 38 patients (10.3%) reported moderately depressive symptoms. Of these, only 12 (31.6%) mentioned psychological problems to their GP during their consultation; 12 (31.6%) with previous depression were neither known to the GP nor suspected of currently having depression; and 67.6% of them visited their GP ≥5 times a year. CONCLUSION: Older patients tend to speak little of their depression to the GP. Almost one in three older patients with moderate depressive symptoms were unrecognised by their GP. Older patients who frequently visit the GP should be suspected of potentially having mental health problems.

Current and Future Prevalence Estimates of Mild Cognitive Impairment, Dementia, and Its Subtypes in a Population-Based Sample of People 70 Years and Older in Norway: The HUNT Study.

BACKGROUND: Having accurate, up-to-date information on the epidemiology of mild cognitive impairment (MCI) and dementia is imperative. OBJECTIVE: To determine the prevalence of MCI and dementia in Norway using data from a large population-based study. METHODS: All people 70 + years of age, n = 19,403, in the fourth wave of the Trøndelag Health Study (HUNT4) were invited to participate in the study HUNT4 70 + . Trained health personnel assessed participants using cognitive tests at a field station, at homes, or at their nursing home. Interviewers also completed a structured carer questionnaire in regard to participants suspected of having dementia. Clinical experts made diagnoses according to DSM-5 criteria. We calculated prevalence weighing the data to ensure population representativeness. RESULTS: A total of 9,930 (51.2%) of the possible 19,403 people participated, and 9,663 of these had sufficient information for analysis. Standardized prevalence of dementia and MCI was 14.6% (95% confidence interval (CI) 13.9-15.4) and 35.3% (95% CI 34.3-36.4), respectively. Dementia was more prevalent in women and MCI more prevalent in men. The most prevalent dementia subtype was Alzheimer's disease (57%). By adding data collected from a study of persons < 70 years in the same region, we estimate that there are 101,118 persons with dementia in Norway in 2020, and this is projected to increase to 236,789 and 380,134 in 2050 and 2100, respectively. CONCLUSION: We found a higher prevalence of dementia and MCI than most previous studies. The present prevalence and future projections are vital for preparing for future challenges to the healthcare system and the entire society.

Single session educational programme for caregivers of psychogeriatric in-patients--results from a randomised controlled pilot study.

BACKGROUND: Family caregivers of patients with psychiatric or medical disorders are at risk of developing psychological distress. Studies including family caregivers of patients with dementia have shown that psychoeducative programmes reduce distress and postpone institutionalisation. Little is known about the effect of psychoeducation of relatives of psychogeriatric patients. The aim of this study was to investigate the effect of a single-session educational intervention of relatives of psychogeriatric in-patients. METHODS: A randomised controlled intervention study was carried out with 16 relatives in the intervention group and 14 in the control group. The intervention was carried out as a single session programme. Primary outcome measures were psychological well-being and depression as measured by means of General Health Questionnaire (GHQ-30), Impact of Event Scale (IES) and Geriatric Depression Scale (GDS). Outcome measures were performed at baseline, at discharge and at 3-month follow-up. RESULTS: Psychological distress was high. Daughters were more depressed and distressed than spouses. Patients' diagnoses did not seem to exert influence on the relatives' well-being. There was a significant worsening of psychological distress in the intervention group as measured by GHQ-30. CONCLUSIONS: The study is small and results must be interpreted with caution. Distress among relatives was high regardless of patient's diagnosis. The results of the intervention might lead us to conclude that single-session interventions towards this specific group of relatives do not improve psychological stress and might, in some aspects, even worsen it.

Examining the association between genetic liability for schizophrenia and psychotic symptoms in Alzheimer's disease.

Psychosis (delusions or hallucinations) in Alzheimer's disease (AD + P) occurs in up to 50% of individuals and is associated with significantly worse clinical outcomes. Atypical antipsychotics, first developed for schizophrenia, are commonly used in AD + P, suggesting shared mechanisms. Despite this implication, little empirical research has been conducted to examine whether there are mechanistic similarities between AD + P and schizophrenia. In this study, we tested whether polygenic risk score (PRS) for schizophrenia was associated with AD + P. Schizophrenia PRS was calculated using Psychiatric Genomics Consortium data at ten GWAS p value thresholds (PT) in 3111 AD cases from 11 cohort studies characterized for psychosis using validated, standardized tools. Association between PRS and AD + P status was tested by logistic regression in each cohort individually and the results meta-analyzed. The schizophrenia PRS was associated with AD + P at an optimum PT of 0.01. The strongest association was for delusions where a one standard deviation increase in PRS was associated with a 1.18-fold increased risk (95% CI: 1.06-1.3; p = 0.001). These new findings point towards psychosis in AD-and particularly delusions-sharing some genetic liability with schizophrenia and support a transdiagnostic view of psychotic symptoms across the lifespan.

A tailored intervention to implement guideline recommendations for elderly patients with depression in primary care: a pragmatic cluster randomised trial.

BACKGROUND: Elderly patients with depression are underdiagnosed, undertreated and run a high risk of a chronic course. General practitioners adhere to clinical practice guidelines to a limited degree. In the international research project Tailored Implementation for Chronic Diseases, we tested the effectiveness of tailored interventions to improve care for patients with chronic diseases. In Norway, we examined this approach to improve adherence to six guideline recommendations for elderly patients with depression targeting healthcare professionals, patients and administrators. METHODS: We conducted a cluster randomised trial in 80 Norwegian municipalities. We identified determinants of practice for six recommendations and subsequently tailored interventions to address these determinants. The interventions targeted healthcare professionals, administrators and patients and consisted of outreach visits, a website presenting the recommendations and the underlying evidence, tools to manage depression in the elderly and other web-based resources, including a continuous medical education course for general practitioners. The primary outcome was mean adherence to the recommendations. Secondary outcomes were improvement in depression symptoms as measured by patients and general practitioners. We offered outreach visits to all general practitioners and practice staff in the intervention municipalities. We used electronic software that extracted eligible patients from the general practitioners' lists. We collected data by interviewing general practitioners or sending them a questionnaire about their practice for four patients on their list and by sending a questionnaire to the patients. RESULTS: One hundred twenty-four of the 900 general practitioners (14 %) participated in the data collection, 51 in the intervention group and 73 in the control group. We interviewed 77 general practitioners, 47 general practitioners completed the questionnaire, and 134 patients responded to the questionnaire. Amongst the general practitioners who provided data, adherence to the recommendations was 1.6 percentage points higher in the intervention group than in the control group (95 % CI -6 to 9). CONCLUSIONS: The effectiveness of our tailored intervention to implement recommendations for elderly patients with depression in primary care is uncertain, due to the low response rate in the data collection. However, it is unlikely that the effect was large. It remains uncertain how best to improve adherence to evidence-based recommendations and thereby improve the quality of care for these patients. TRIAL REGISTRATION: ClinicalTrials.gov: NCT01913236 .

Tailoring interventions to implement recommendations for the treatment of elderly patients with depression: a qualitative study.

BACKGROUND: To improve adherence to evidence-based recommendations, it is logical to identify determinants of practice and tailor interventions to address these. We have previously prioritised six recommendations to improve treatment of elderly patients with depression, and identified determinants of adherence to these recommendations. The aim of this article is to describe how we tailored interventions to address the determinants for the implementation of the recommendations. METHODS: We drafted an intervention plan, based on the determinants we had identified in a previous study. We conducted six group interviews with representatives of health professionals (GPs and nurses), implementation researchers, quality improvement officers, professional and voluntary organisations and relatives of elderly patients with depression. We informed about the gap between evidence and practice for elderly patients with depression and presented the prioritised determinants that applied to each recommendation. Participants brainstormed individually and then in groups, suggesting interventions to address the determinants. We then presented evidence on the effectiveness of strategies for implementing depression guidelines. We asked the groups to prioritise the suggested interventions considering the perceived impact of determinants and of interventions, the research evidence underlying the interventions, feasibility and cost. We audiotaped and transcribed the interviews and applied a five step framework for our analysis. We created a logic model with links between the determinants, the interventions, and the targeted improvements in adherence. RESULTS: Six groups with 29 individuals provided 379 suggestions for interventions. Most suggestions could be fit within the drafted plan, but the groups provided important amendments or additions. We sorted the interventions into six categories: resources for municipalities to develop a collaborative care plan, resources for health professionals, resources for patients and their relatives, outreach visits, educational and web-based tools. Some interventions addressed one determinant, while other interventions addressed several determinants. CONCLUSIONS: It was feasible and helpful to use group interviews and combine open and structured approaches to identify interventions that addressed prioritised determinants to adherence to the recommendations. This approach generated a large number of suggested interventions. We had to prioritise to tailor the interventions strategies.

Tailored interventions to implement recommendations for elderly patients with depression in primary care: a study protocol for a pragmatic cluster randomised controlled trial.

BACKGROUND: The prevalence of depression is high and the elderly have an increased risk of developing chronic course. International data suggest that depression in the elderly is under-recognised, the latency before clinicians provide a treatment plan is longer and elderly patients with depression are not offered psychotherapy to the same degree as younger patients. Although recommendations for the treatment of elderly patients with depression exist, health-care professionals adhere to these recommendations to a limited degree only. We conducted a systematic review to identify recommendations for managing depression in the elderly and prioritised six recommendations. We identified and prioritised the determinants of practice related to the implementation of these recommendations in primary care, and subsequently discussed and prioritised interventions to address the identified determinants. The objective of this study is to evaluate the effectiveness of these tailored interventions for the six recommendations for the management of elderly patients with depression in primary care. METHODS/DESIGN: We will conduct a pragmatic cluster randomised trial comparing the implementation of the six recommendations using tailored interventions with usual care. We will randomise 80 municipalities into one of two groups: an intervention group, to which we will deliver tailored interventions to implement the six recommendations, and a control group, to which we will not deliver any intervention. We will randomise municipalities rather than patients, individual clinicians or practices, because we will deliver the intervention for the first three recommendations at the municipal level and we want to minimise the risk of contamination across GP practices for the other three recommendations. The primary outcome is the proportion of actions taken by GPs that are consistent with the recommendations. DISCUSSION: This trial will investigate whether a tailored implementation approach is an effective strategy for improving collaborative care in the municipalities and health-care professionals' practice towards elderly patients with depression in primary care. The effectiveness evaluation described in this protocol will be accompanied with a process evaluation exploring why and how the interventions were effective or ineffective. TRIAL REGISTRATION: ClinicalTrials.gov: NCT01913236.

Tailored Implementation for Chronic Diseases (TICD): a protocol for process evaluation in cluster randomized controlled trials in five European countries.

BACKGROUND: In the 'Tailored Implementation for Chronic Diseases (TICD)' project, five tailored implementation programs to improve healthcare delivery in different chronic conditions have been developed. These programs will be evaluated in distinct cluster-randomized controlled trials. This protocol describes the process evaluation across these trials, which aims to identify determinants of change in chronic illness care, to examine the validity of the tailoring methods that were applied, and to analyze the association of implementation activities and the effectiveness of the program. METHODS: A multilevel approach was used to develop five tailored implementation interventions. In order to guide the process evaluation in five distinct trials, the study protocols for the cluster randomized trials and the related process evaluations were developed simultaneously and iteratively. RESULTS: The process evaluation comprises three main components: a structured survey with health professionals in the trials, semi-structured interviews with a purposeful sample of this study population, and standardized documentation of organizational practice characteristics. Norway will only conduct the qualitative part of the analysis because the survey and documentation of practice characteristics are considered to be not feasible. The evaluation is guided by 'logic models' of the implementation programs: frameworks that specify the linkages between the strategies used, the determinants addressed by tailoring, and the anticipated outcomes. Standardization of measures across trials is sought to facilitate analysis of aggregated data from the trials. CONCLUSIONS: This process evaluation will need to find a balance between standardization of methods across trials and the tailoring of measures to the specificities of each trial.

Tailored implementation of evidence-based practice for patients with chronic diseases.

BACKGROUND: When designing interventions and policies to implement evidence based healthcare, tailoring strategies to the targeted individuals and organizations has been recommended. We aimed to gather insights into the ideas of a variety of people for implementing evidence-based practice for patients with chronic diseases, which were generated in five European countries. METHODS: A qualitative study in five countries (Germany, Netherlands, Norway, Poland, United Kingdom) was done, involving overall 115 individuals. A purposeful sample of four categories of stakeholders (healthcare professionals, quality improvement officers, healthcare purchasers and authorities, and health researchers) was involved in group interviews in each of the countries to generate items for improving healthcare in different chronic conditions per country: chronic obstructive pulmonary disease, cardiovascular disease, depression in elderly people, multi-morbidity, obesity. A disease-specific standardized list of determinants of practice in these conditions provided the starting point for these groups. The content of the suggested items was categorized in a pre-defined framework of 7 domains and specific themes in the items were identified within each domain. RESULTS: The 115 individuals involved in the study generated 812 items, of which 586 addressed determinants of practice. These largely mapped onto three domains: individual health professional factors, patient factors, and professional interactions. Few items addressed guideline factors, incentives and resources, capacity of organizational change, or social, political and legal factors. The relative numbers of items in the different domains were largely similar across stakeholder categories within each of the countries. The analysis identified 29 specific themes in the suggested items across countries. CONCLUSION: The type of suggestions for improving healthcare practice was largely similar across different stakeholder groups, mainly addressing healthcare professionals, patient factors and professional interactions. As this study is one of the first of its kind, it is important that more research is done on tailored implementation strategies.

Stakeholders' contributions to tailored implementation programs: an observational study of group interview methods.

BACKGROUND: Tailored strategies to implement evidence-based practice can be generated in several ways. In this study, we explored the usefulness of group interviews for generating these strategies, focused on improving healthcare for patients with chronic diseases. METHODS: Participants included at least four categories of stakeholders (researchers, quality officers, health professionals, and external stakeholders) in five countries. Interviews comprised brainstorming followed by a structured interview and focused on different chronic conditions in each country. We compared the numbers and types of strategies between stakeholder categories and between interview phases. We also determined which strategies were actually used in tailored intervention programs. RESULTS: In total, 127 individuals participated in 25 group interviews across five countries. Brainstorming generated 8 to 120 strategies per group; structured interviews added 0 to 55 strategies. Healthcare professionals and researchers provided the largest numbers of strategies. The type of strategies for improving healthcare practice did not differ systematically between stakeholder groups in four of the five countries. In three out of five countries, all components of the chosen intervention programs were mentioned by the group of researchers. CONCLUSIONS: Group interviews with different stakeholder categories produced many strategies for tailored implementation of evidence-based practice, of which the content was largely similar across stakeholder categories.

Identifying determinants of care for tailoring implementation in chronic diseases: an evaluation of different methods.

BACKGROUND: The tailoring of implementation interventions includes the identification of the determinants of, or barriers to, healthcare practice. Different methods for identifying determinants have been used in implementation projects, but which methods are most appropriate to use is unknown. METHODS: The study was undertaken in five European countries, recommendations for a different chronic condition being addressed in each country: Germany (polypharmacy in multimorbid patients); the Netherlands (cardiovascular risk management); Norway (depression in the elderly); Poland (chronic obstructive pulmonary disease--COPD); and the United Kingdom (UK) (obesity). Using samples of professionals and patients in each country, three methods were compared directly: brainstorming amongst health professionals, interviews of health professionals, and interviews of patients. The additional value of discussion structured through reference to a checklist of determinants in addition to brainstorming, and determinants identified by open questions in a questionnaire survey, were investigated separately. The questionnaire, which included closed questions derived from a checklist of determinants, was administered to samples of health professionals in each country. Determinants were classified according to whether it was likely that they would inform the design of an implementation intervention (defined as plausibly important determinants). RESULTS: A total of 601 determinants judged to be plausibly important were identified. An additional 609 determinants were judged to be unlikely to inform an implementation intervention, and were classified as not plausibly important. Brainstorming identified 194 of the plausibly important determinants, health professional interviews 152, patient interviews 63, and open questions 48. Structured group discussion identified 144 plausibly important determinants in addition to those already identified by brainstorming. CONCLUSIONS: Systematic methods can lead to the identification of large numbers of determinants. Tailoring will usually include a process to decide, from all the determinants that are identified, those to be addressed by implementation interventions. There is no best buy of methods to identify determinants, and a combination should be used, depending on the topic and setting. Brainstorming is a simple, low cost method that could be relevant to many tailored implementation projects.

The validity of the Montgomery-Aasberg depression rating scale as a screening tool for depression in later life.

BACKGROUND: The aims of the study were to examine the validity of the MADRS and to compare it with the validity of the Cornell Scale for Depression in Dementia (CSDD). METHODS: We included 140 patients without dementia, with mean age 81.5 (sd 7.7) years. Trained psychiatric nurses interviewed all of them using the MADRS. In addition, for 70 patients caregivers were interviewed using the CSDD. A psychiatrist who had no access to the MADRS or the CSDD results made a diagnosis of depression according to the DSM-IV criteria for major depression, and the ICD-10 criteria was also applied for the 70 patients assessed with the CSDD. RESULTS: Twenty-two out of the 140 had depression according to the DSM IV criteria, whereas 25 out of 70 had depression according to the ICD-10 criteria. The area under the curve (auc) in a receiver operating characteristic analysis was 0.86 (95% CI 0.79-0.93) for the MADRS using the DSM-IV criteria. The best cut-off point was 16/17 with sensitivity of 0.80 and specificity of 0.82. The AUC for the CSDD was 0.83 (95% CI 0.71-0.95). The recommended cut-off score on the CSDD of 7/8 was valid but not the best in this study. LIMITATIONS: The patients were diagnosed with a diagnosis of depression by only one psychiatrist, and the procedures in the two centres were not exactly the same. CONCLUSIONS: The MADRS has good discriminating power to detect depression in elderly persons and should be preferred to the CSDD for use with persons without dementia.