Comparison of Mini-Mental State Examination and Montreal Cognitive Assessment Ratings Across Levels of Parkinson's Disease Severity.

BACKGROUND: Cognitive impairment (CI) is common in Parkinson's disease (PD) and an important cause of disability. Screening facilitates early detection of CI and has implications for management. Preclinical disability is when patients have functional limitations but maintain independence through compensatory measures. OBJECTIVE: The objective of this study was to investigate the relationship between scores on the Mini-Mental State Examination (MMSE) and Montreal Cognitive Assessment (MoCA) with levels of PD severity and disability. METHODS: PD patients (n = 2,234) in a large observational study were stratified by disease severity, based on Total Unified Parkinson's Disease Rating Scale (Total UPDRS) and Hoehn and Yahr (HY) stage. Using MMSE (n = 1,184) or MoCA (n = 1,050) and basic (ADL) and instrumental activities of daily living (IADL) scales for disability, linear regression analysis examined associations between cognitive status and disability. RESULTS: Cognition and disability were highly correlated, with the strongest correlation between IADL and MoCA. Only 16.0% of mean MMSE scores were below threshold for CI (28) and only in advanced PD (Total UPDRS 60+, HY≥3). MoCA scores fell below CI threshold (26) in 66.2% of the sample and earlier in disease (Total UPDRS 30+, HY≥2), corresponding with impairments in ADLs. CONCLUSION: In a large clinical dataset, a small fraction of MMSE scores fell below cutoff for CI, reinforcing that MMSE is an insensitive screening tool in PD. MoCA scores indicated CI earlier in disease and coincided with disability. This study shows that MoCA, but not MMSE is sensitive to the emergence of early cognitive impairment in PD and correlates with the concomitant onset of disability.

Mobile Technology Care Coordination of Long-Term Services and Support: Cluster Randomized Clinical Trial.

The purpose of the study was to assess whether the effects of a mobile predictive intervention used by Service Coordinators (SCs) reduce hospital utilization in a Medicaid Long-Term Services and Supports (LTSS) population in Baltimore city during a 5-month intervention. SC participants (n = 11) were recruited to treatment or control groups. LTSS clients (n = 420) followed their SC randomization assignment. Utilization data were obtained from the Maryland Chesapeake Regional Information System for our Patients (CRISP) Health Information Exchange (HIE) system and linked to service coordination records. Study groups were similar in age, gender, race, and years receiving LTSS. SCs' satisfaction with use of the mobile tool was surveyed. SC perceptions were neutral (mean scores ranged from 2.3 to 3.3 on a 5-point scale). No significant differences between groups were observed for all utilization metrics. The mobile technology software system used in this study did not improve health care utilization for a LTSS population needing ongoing clinical and social services coordinated care.

Discordance Between Physician Assessment and Patient-Reported Depressive Symptoms in Parkinson Disease.

OBJECTIVE: To assess concordance between physician assessment and patient-reported symptoms when screening for depression in Parkinson disease (dPD). BACKGROUND: Depression in Parkinson disease is highly prevalent (∼40%) and has a significant impact on quality of life and disability, yet physician recognition and treatment remain inadequate. METHODS: One thousand seventy-six patients with PD completed the Brief Symptom Inventory-18 (BSI-18), a screening questionnaire for psychiatric symptoms, which was compared to item #3 (depression) on the Unified Parkinson's Disease Rating Scale (UPDRS). RESULTS: The mean BSI-18 depression score was 51.4 (9.7). Of the 170 (16%) patients screening positive for dPD on the BSI-18, 104 (61%) were not recognized as depressed by neurologists on the UPDRS. Factors associated with lower neurologist recognition included male gender, better mental health quality of life, and lack of antidepressant use. CONCLUSION: More than 60% of patients screening positive for depression on self-report were not recognized by neurologists on the UPDRS. A patient-reported screening tool for depression may improve recognition and management of dPD.

Assessment of the psychometrics of a PROMIS item bank: self-efficacy for managing daily activities.

PURPOSE: The aim of this study is to investigate the psychometrics of the Patient-Reported Outcomes Measurement Information System self-efficacy for managing daily activities item bank. METHODS: The item pool was field tested on a sample of 1087 participants via internet (n = 250) and in-clinic (n = 837) surveys. All participants reported having at least one chronic health condition. The 35 item pool was investigated for dimensionality (confirmatory factor analyses, CFA and exploratory factor analysis, EFA), item-total correlations, local independence, precision, and differential item functioning (DIF) across gender, race, ethnicity, age groups, data collection modes, and neurological chronic conditions (McFadden Pseudo R (2) less than 10 %). RESULTS: The item pool met two of the four CFA fit criteria (CFI = 0.952 and SRMR = 0.07). EFA analysis found a dominant first factor (eigenvalue = 24.34) and the ratio of first to second eigenvalue was 12.4. The item pool demonstrated good item-total correlations (0.59-0.85) and acceptable internal consistency (Cronbach's alpha = 0.97). The item pool maintained its precision (reliability over 0.90) across a wide range of theta (3.70), and there was no significant DIF. CONCLUSION: The findings indicated the item pool has sound psychometric properties and the test items are eligible for development of computerized adaptive testing and short forms.

Racial and socioeconomic disparities in parkinsonism.

OBJECTIVE: To assess potential racial and socioeconomic disparities in patients with parkinsonism treated at a tertiary Movement Disorders Center. METHODS: Patients with parkinsonism were evaluated for demographics (age, race, annual income, and educational level), medical comorbidities, medication regimen, disability (Older Americans Resources and Services subscale), presence of Parkinson disease, and disease severity (Unified Parkinson Disease Rating Scale). Disability and disease severity measures were compared by race, income, and educational level using analysis of variance for continuous variables and χ(2) tests for dichotomous variables. RESULTS: The sample included 1159 patients with parkinsonism (93.4% white, 6.1% African American, 61.2% who earned more than $50,000 annually, 62.7% who completed college, and 79.2% with a diagnosis of Parkinson disease). Cross-sectional analyses by race, income, and educational level showed greater disability and disease severity in African American compared with white patients (African American vs white Older Americans Resources and Services subscale total score, 29.8 vs 25.3, P = .005; Unified Parkinson's Disease Rating Scale total score, 53.0 vs 42.8; P < .001). African Americans were less likely to be prescribed dopaminergic medications, particularly newer agents (African Americans 20.6% vs whites: 41.1%; P = .01). Lower income and lower educational level were independently associated with greater disease severity and disability (P < .003). CONCLUSION: Racial and socioeconomic disparities exist among patients with parkinsonism being treated at a tertiary Movement Disorders Center. African Americans and those with lower socioeconomic status have greater disease severity and disability than whites. These disparities may be because of problems in diagnosis, access to care, physician referrals, and patient attitudes regarding the appropriate threshold for seeking treatment at a specialized center. Understanding and correction of these disparities may improve outcomes.

The impact of anemia on nursing home residents.

The purpose of this secondary data analysis was to describe the prevalence and treatment of anemia and test the impact of anemia on physical and psychosocial outcomes at baseline and following restorative care interventions. A total of 451 residents from 12 nursing homes participated in this study. The average age of the participants was 83.74 (SD = 8.24), the majority were female (79%), White (66%), and unmarried (90%). A total of 245 (54%) residents were anemic, and 66% were treated with at least one medication. Physical performance was worse in those with anemia, and those with anemia associated with chronic kidney disease had lower self-efficacy and outcome expectations for functional activities than those without anemia. There was no time by treatment interaction between those with and without anemia. The findings provide some additional support for the prevalence of anemia and suggest that those with anemia associated with chronic kidney disease are less motivated to engage in functional activities.

The role of nursing home admission and dementia status on care for diabetes mellitus.

OBJECTIVES: To study the role of nursing home (NH) admission and dementia status on the provision of five procedures related to diabetes mellitus. DESIGN: Retrospective cohort study using data from a large prospective study in which an expert panel determined the prevalence of dementia. SETTING: Fifty-nine Maryland NHs. PARTICIPANTS: Three hundred ninety-nine new admission NH patients with diabetes mellitus. MEASUREMENTS: Medicare administrative claims records matched to the NH medical record data were used to measure procedures related to diabetes mellitus received in the year before NH admission and up to a year after admission (and before discharge). Procedures included glycosylated hemoglobin, fasting blood glucose, dilated eye examination, lipid profile, and serum creatinine. RESULTS: For all but dilated eye examinations, higher rates of procedures related to diabetes mellitus were seen in the year after NH admission than in the year before. Residents without dementia received more procedures than those with dementia, although this was somewhat attenuated after controlling for demographic, health, and healthcare utilization variables. Persons without dementia experience greater increases in procedure rates after admission than those with dementia. CONCLUSION: The structured environment of care provided by the NH may positively affect monitoring procedures provided to elderly persons with diabetes mellitus, especially those without dementia. Medical decisions related to the risks and benefits of intensive treatment for diabetes mellitus to patients of varying frailty and expected longevity may lead to lower rates of procedures for residents with dementia.

Discussion as a factor in racial disparity in advance directive completion at nursing home admission.

Studies have consistently shown racial disparities in advance directive completion for nursing home residents but have not examined whether this disparity is due to differences in interactions with healthcare providers. This study had two aims: to determine whether the racial disparity in advance directive completion by nursing home residents is related to differences in discussion of treatment restrictions with healthcare providers and to examine whether there is a racial disparity in perceptions of residents' significant others that additional discussions would be helpful. Participants were 2,171 white or black (16% of sample) residents newly admitted to 59 nursing homes. Data were collected from structured interviews with residents' significant others and review of nursing home charts. Questions included whether advance directives were completed, whether treatment restrictions were discussed with the resident or family, and whether more discussion would have been helpful. Frequencies according to race were determined for each question; P-values and logistic regression models were obtained. Black residents were less likely to have completed any advance directives (P<.001), and they (P<.001) and their family members (P<.001) were less likely than whites to have discussed treatment restrictions with healthcare providers. Logistic regression models indicated that disparity in treatment restrictions narrowed when these discussions occurred. Significant others of black residents were more likely than those of white residents to consider further discussion helpful (P<.001), especially with physicians. Racial disparity in treatment restrictions may be due in part to a difference in discussion with healthcare providers; increasing discussion may narrow this disparity.

Differences in services provided by hospices based on home health agency certification status.

BACKGROUND: Similar patient populations and favorable regulations have led many home health agencies to become Medicare and/or Medicaid certified as hospice agencies (mixed), but home health and hospice programs differ in focus and scope. Little research has been performed examining the differences between mixed hospices and those agencies only certified as hospices (nonmixed). OBJECTIVES: To describe the differences in agency characteristics between mixed and nonmixed agencies; and to compare frequencies of service provision by mixed and nonmixed agencies. RESEARCH DESIGN: Cross-sectional study using data from the 2000 National Home and Hospice Care Survey. SUBJECTS: A total of 760 Medicare and/or Medicaid certified hospice agencies providing services during the survey, including 393 mixed agencies (52% of sample) and 367 nonmixed hospices. MEASURES: Survey responses by administrators about services provided by agency. RESULTS: Nonmixed agencies were significantly more likely than mixed agencies to provide many types of services, including: volunteers [96.1% vs. 77.4%, respectively; odds ratio (OR): 7.27; 95% confidence interval (CI): 5.26-10.05], social services (96.1% vs. 93.5%; OR: 1.70; 95% CI: 1.20-2.40), spiritual care (95.1% vs. 77.8%; OR: 5.53; 95% CI: 4.13-7.41), bereavement care (93.5% vs. 79.8%; OR: 3.63; 95% CI: 2.80-4.72), counseling (89.5% vs. 70.2%; OR: 3.62; 95% CI: 2.92-4.48), and physician services (87.2% vs. 52.0%; OR: 6.30; 95% CI: 5.18-7.66). In logistic regression models, these differences remained significant after adjustment for census region, operation by a hospital, number of patients and number of hospice patients, and Medicare and Medicaid hospice certification status. CONCLUSIONS: Mixed agencies provide a narrower range of services to hospice patients than nonmixed agencies, including fewer services considered cornerstones of hospice treatment.

Sensitivity of nursing home cost comparisons to method of dementia diagnosis ascertainment.

This study compared the association of differing methods of dementia ascertainment, derived from multiple sources, with nursing home (NH) estimates of prevalence of dementia, length of stay, and costs an understudied issue. Subjects were 2050 new admissions to 59 Maryland NHs, from 1992 to 1995 followed longitudinally for 2 years. Dementia was ascertained at admission from charts, Medicare claims, and expert panel. Overall 59.5% of the sample had some indicator of dementia. The expert panel found a higher prevalence of dementia (48.0%) than chart review (36.9%) or Medicare claims (38.6%). Dementia cases had lower relative average per patient monthly costs, but longer NH length of stay compared to nondementia cases across all methods. The prevalence of dementia varied widely by method of ascertainment, and there was only moderate agreement across methods. However, lower costs for dementia among NH admissions are a robust finding across these methods.

A comparative study of physical performance measures in Parkinson's disease.

UNLABELLED: The objective of this study is to compare physical performance measures for their ability to discriminate between levels of disability and disease severity in Parkinson's disease (PD). Disability in PD is commonly assessed by patient self-report, which may be limited by patient insight. METHODS: Seventy-nine patients with PD were tested with seven performance measures: Physical Performance Test (PPT), modified Physical Performance Test (mPPT), Short Physical Performance Battery (SPPB), Performance Test of Activities of Daily Living (PADL), Berg Balance Scale (BBS), Timed Up and Go (TUG), and Functional Reach (FR). These measures were compared with patient-reported disability on the Older Americans Resource and Services Disability subscale (OARS) and disease severity on the Unified Parkinson's Disease Rating Scale (UPDRS). The performance measures were more sensitive to levels of disease severity than disability. Four measures discriminated across quartiles of disability (PPT, mPPT, BBS, TUG: P < 0.05), whereas all seven measures discriminated across quartiles of the Total UPDRS (PPT, mPPT, BBS, TUG, FR: P < 0.01; SPPB, PADL: P < 0.05). However, no measure consistently discriminated between subgroups with a range of early and advanced disease severity. The seven physical performance measures showed different profiles of strengths and weaknesses in assessing disability and disease severity. The results of this study will facilitate choosing performance measures for clinical care and clinical trials in PD.

Medicare expenditures for nursing home residents triaged to nursing home or hospital for acute infection.

OBJECTIVES: To compare Medicare payments of nursing home residents triaged to nursing home with those of nursing home residents triaged to the hospital for acute infection care. DESIGN: Observational study with propensity score matching. SETTING: Fifty-nine nursing homes in Maryland. PARTICIPANTS: Two thousand two hundred eighty-five individuals admitted to the 59 nursing homes and followed between 1992 and 1997. MEASUREMENTS: Demographic and clinical data were obtained from interviews and medical record review and linked to Medicare payment records. Incident infection was ascertained according to medical record review for new infectious diagnoses or prescription of antibiotics. Hospital triage was defined as hospital transfer within 3 days of infection onset. Hospital triage patients were paired with similar nursing home triage patients using propensity score matching. Medicare expenditures for triage groups were compared in 1997 dollars. RESULTS: Of 3,618 infection cases, 28% were genitourinary infections, 20% skin, 14% upper respiratory, 12% lower respiratory, 4% gastrointestinal, and 2% bloodstream. Two hundred fifty-six pairs of hospital and nursing home triage cases fulfilled matching criteria. Mean Medicare payments+/-standard deviation were $5,202+/-7,310 and $996+/-2,475 per case in the hospital and nursing home triage groups, respectively, for a mean difference of $4,206 (95% confidence interval=$3,260-5,151). Mean payments per case in the hospital triage group were $3,628 higher in inpatient expenditures, $482 higher in physician visit expenditures, $161 higher in emergency department expenditures, and $147 higher in skilled nursing day expenditures. CONCLUSION: Per-case Medicare expenditures are higher with hospital triage than for nursing home triage for nursing home residents with acute infection. This result may be used to estimate cost savings to Medicare of interventions designed to reduce hospital use by nursing home residents.

Nursing home characteristics related to medicare costs for residents with and without dementia.

OBJECTIVES: To evaluate the relationship of nursing home characteristics to Medicare costs overall and by dementia status. DESIGN: New admissions followed for 2 years. Setting. Random stratified sample of 55 Maryland nursing homes. PARTICIPANTS: Sample of 1257 residents. MEASURES: Records, interview, and observation. RESULTS: Medicare costs were lower in facilities that have a better environmental quality, hospice beds, and more food service workers; costs were higher in hospital-based facilities and those that have a higher Medicaid case mix, X-ray, and some specified types of staff. Across all characteristics, costs for residents with dementia were consistently two-thirds the cost of other residents. DISCUSSION: In terms of dementia status, resident characteristics drive Medicare costs, as opposed to facility characteristics. Using alternative residential settings for individuals with dementia may increase Medicare costs of nursing home residents and Medicare costs of residents with dementia who are cared for in settings less able to attend to medical needs.

Determinants and effects of nurse staffing intensity and skill mix in residential care/assisted living settings.

PURPOSE: Residential care/assisted living facilities have become an alternative to nursing homes for many individuals, yet little information exists about staffing in these settings and the effect of staffing. This study analyzed the intensity and skill mix of nursing staff using data from a four-state study, and their relationship to outcomes. DESIGN AND METHODS: We obtained longitudinal data for 1,894 residents of 170 residential care/assisted living facilities participating in the Collaborative Studies of Long-Term Care. Descriptive statistics assessed the levels of direct care staff (registered nurse, licensed practical nurse, personal care aide). Regression analyses evaluated the relationship between two staffing measures (intensity measured as care hours per resident and skill mix measured as the percentage of total care hours by licensed nurses), facility characteristics, and four health outcomes (mortality, nursing home transfer, hospitalization, and incident morbidity). RESULTS: Care hours per resident decreased with facility size (economies of scale) only for very small facilities and increased with dementia prevalence (case-mix effect). Licensed staff accounted for a greater proportion of total hours in nonprofit settings. Health outcomes did not vary by total care hours per resident, but hospitalization rates were significantly lower in facilities with higher proportions of skilled staff hours; this effect was stronger as dementia case mix increased. IMPLICATIONS: Current staffing levels for the outcomes analyzed meet most residents' needs. Reduced hospitalization in relation to greater use of licensed staff suggests that increased use of these workers might result in reductions in acute care expenditures.

Treatment of dementia in community-dwelling and institutionalized medicare beneficiaries.

OBJECTIVES: To establish nationally representative estimates of the use of agents to treat Alzheimer's disease and related dementias (ADRDs) and related behavioral symptoms in Medicare beneficiaries and to describe medication use according to residential status and other patient characteristics. DESIGN: Cross-sectional prevalence study. SETTING: Community and various long-term care (LTC) settings. PARTICIPANTS: Twelve thousand six hundred ninety-seven beneficiaries from the 2002 Medicare Current Beneficiary Survey (MCBS), of whom 11,593 were community dwelling and 1,104 resided in various LTC settings. MEASUREMENTS: ADRDs were identified according to International Classification of Diseases, Ninth Revision, codes in Medicare claims and self- and proxy reports. Medication use was derived from self-reports (community) and extracts of facility medication administration records (LTC). RESULTS: In 2002, an estimated 3.4 million Medicare beneficiaries were diagnosed with ADRDs (8.1%), of whom 58.9% resided in the community (prevalence rate=5.1%) and 41.1% resided in LTC facilities (prevalence rate=57.2%). Use of antidementia drugs was similar across settings, with 24.7% of subjects with dementia in the community and 26.3% of those in LTC receiving prescriptions for donepezil, galantamine, or rivastigmine. Use of haloperidol was comparable (and low) in both settings. Use of atypical antipsychotics, especially risperidone, olanzapine, and quetiapine, was much higher in LTC residents (21.0%, 11.9%, and 7.1%, respectively) than in the community (5.1%, 4.0%, and 2.3%). CONCLUSION: The prevalence of ADRDs in LTC settings is much larger than in the community, but there is little difference in the proportions receiving antidementia drugs, although LTC residents are more likely to be treated with atypical antipsychotics (risperidone, olanzapine, and quetiapine), presumably for behavioral symptoms.

Medication management assessment for older adults in the community.

PURPOSE: The purpose of this study was to describe the Medication Management Instrument for Deficiencies in the Elderly (MedMaIDE) and to provide results of reliability and validity testing. DESIGN AND METHODS: Participants were 50 older adults, aged 65 and older, who lived in the community, took at least one prescription medication, and were then self-medicating. Nonmedical study staff assessed participants in their homes at baseline and 1 week, and a study pharmacist conducted pill counts at baseline and 30 days. The MedMaIDE covers three domains important for ensuring medication compliance (knowledge of medications, how to take medications, and procurement) and yields a total deficiency score. We assessed test-retest and interrater reliability. We assessed validity by comparing the MedMaIDE deficiency scores to 30-day pill count compliance. RESULTS: The sample was mostly female (72%) and White (56%), with a mean age of 78. Participants were taking an average of 7 prescription drugs, with an average pill count compliance of 70%. The MedMaIDE had very good test-retest reliability (intraclass correlation coefficient [ICC] = 0.93) and good interrater reliability (ICC = 0.74). Internal consistency was also strong (Cronbach's alpha = .71). Comparing the MedMaIDE to the pill count with those who were compliant (>80%) versus those that were not, the agreement was 75%. The MedMaIDE was more highly specific and predictive of compliance compared to the pill count. IMPLICATIONS: The MedMaIDE appears to be a reliable and valid instrument for determining if an older adult has deficiencies in managing medications.

An empirical typology of residential care/assisted living based on a four-state study.

PURPOSE: Residential care/assisted living describes diverse facilities providing non-nursing home care to a heterogeneous group of primarily elderly residents. This article derives typologies of assisted living based on theoretically and practically grounded evidence. DESIGN AND METHODS: We obtained data from the Collaborative Studies of Long-Term Care, which examined 193 assisted living facilities in four states: Florida, Maryland, New Jersey, and North Carolina. By using mixture modeling, we derived typologies in five different ways, based on: structure; process; resident case-mix; structure and process; and structure, process, and resident case-mix. RESULTS: Although configurations of typologies varied as a function of criterion variables used, common themes emerged from different cluster solutions. A typology based on resident case-mix yielded a five-cluster solution, whereas a typology based on structure, process, and resident case-mix resulted in six distinct clusters. Medicaid case-mix/psychiatric illness and high resident impairment were two clusters identified by both strategies. IMPLICATIONS: Because of the wide variation in structure, residents, and services within assisted living facilities, typologies such as those described here may be useful in clinical practice, research, and policy. To the extent that public payment defines its own cluster, the potential for inequities in care merits careful attention.

Making a difference: nursing assistants' perspectives of restorative care nursing.

This article explores the experiences of nursing assistants who participated in the Res-Care Pilot Intervention. A qualitative study used a focus group methodology. An interview guide was used and data from focus groups were audiotaped and transcribed verbatim. A purposive sample of 13 nursing assistants participated in the focus groups. A total of 35 different codes were identified, and these were reduced to the following four themes: resident barriers to restorative care, facility or system barriers to restorative care, nursing assistant strategies, and system facilitators of restorative care. The study supports and adds to previous work that suggests that in order to successfully implement changes in care in nursing home settings the following issues should be addressed: real or perceived workload issues, poor communication with nursing, insufficient knowledge or education, lack of appropriate supplies, and insufficient administrative support. The findings may be used to revise the Res-Care Pilot Intervention and direct future implementation of programs in nursing home settings.

Mortality and adverse health events in newly admitted nursing home residents with and without dementia.

OBJECTIVES: To evaluate the association between dementia and mortality, adverse health events, and discharge disposition of newly admitted nursing home residents. It was hypothesized that residents with dementia would die at a higher rate and develop more adverse health events (e.g., infections, fevers, pressure ulcers, falls) than residents without dementia because of communication and self-care difficulties. DESIGN: An expert clinician panel diagnosed an admission cohort from a stratified random sample of 59 Maryland nursing homes, between 1992 and 1995. The cohort was followed for up to 2 years or until discharge. SETTING: Fifty-nine Maryland nursing homes. PARTICIPANTS: Two thousand one hundred fifty-three newly admitted residents aged 65 and older not having resided in a nursing home for 8 or more days in the previous year. MEASUREMENTS: Mortality, infection, fever, pressure ulcers, fractures, and discharge home. RESULTS: Residents with dementia had significantly lower overall rates of infection (relative risk (RR)=0.77, 95% confidence interval (CI)=0.70-0.85) and mortality (RR=0.61, 95% CI=0.53-0.71) than those without dementia, whereas rates of fever, pressure ulcers, and fractures were similar for the two groups. These results persisted when rates were adjusted for demographic characteristics, comorbid conditions, and functional status. During the first 90 days of the nursing home stay, residents with dementia had significantly lower rates of mortality if not admitted for rehabilitative care under a Medicare qualifying stay (RR=0.25, 95% CI=0.14-0.45), were less often discharged home (RR=0.33, 95% CI=0.28-0.38), and tended to have lower fever rates (RR=0.78, 95% CI=0.63-0.96) than residents without dementia. CONCLUSION: Newly admitted nursing home residents with dementia have a profile of health events that is distinct from that of residents without dementia, indicating that the two groups have different long-term care needs. Results suggest that further investigation of whether residents with dementia can be well managed in alternative residential settings would be valuable.

Medicare cost differences between nursing home patients admitted with and without dementia.

PURPOSE: Our objective in this study was to compare Medicare costs of treating older adults with and without dementia in nursing home settings. DESIGN AND METHODS: An expert panel established the dementia status of a stratified random sample of newly admitted residents in 59 Maryland nursing homes between 1992 and 1995. Medicare expenditures per-person month (PPM) were compared for 640 residents diagnosed with dementia and 636 with no dementia for 1 year preadmission and 2 years postadmission. Multivariate analysis with generalized estimating equations was used to identify the source of Medicare cost differentials between the two groups. RESULTS: Medicare expenditures peaked in the month immediately preceding admission and dropped to preadmission levels by the third month in a nursing home. Adjusted PPM costs postadmission for the dementia group as a whole were 79% (p < .001) of the Medicare costs of treating residents without dementia. For the subgroup of residents admitted without a Medicare qualified stay (MQS), those with dementia had Medicare costs of just 63% (p < .001) of those without dementia. Overall Medicare costs PPM were insignificantly different between the two groups admitted with a MQS. IMPLICATIONS: Whether nursing home residents are admitted with a MQS is the single most important factor in assessing treatment cost differentials between residents admitted with and without dementia. Failure to consider this factor may lead researchers and policy makers to misdirect their attention from the true source of the differential-dementia patients admitted without a qualifying stay.