D-CARE: The Dementia Care Study: Design of a Pragmatic Trial of the Effectiveness and Cost Effectiveness of Health System-Based Versus Community-Based Dementia Care Versus Usual Dementia Care.

BACKGROUND/OBJECTIVES: Although several approaches have been developed to provide comprehensive care for persons living with dementia (PWD) and their family or friend caregivers, the relative effectiveness and cost effectiveness of community-based dementia care (CBDC) versus health system-based dementia care (CBDC) and the effectiveness of both approaches compared with usual care (UC) are unknown. DESIGN: Pragmatic randomized three-arm superiority trial. The unit of randomization is the PWD/caregiver dyad. SETTING: Four clinical trial sites (CTSs) based in academic and clinical health systems. PARTICIPANTS: A total of 2,150 English- or Spanish-speaking PWD who are not receiving hospice or residing in a nursing home and their caregivers. INTERVENTIONS: Eighteen months of (1) HSDC provided by a nurse practitioner or physician's assistant dementia care specialist who works within the health system, or (2) CBDC provided by a social worker or nurse care consultant who works at a community-based organization, or (3) UC with as needed referral to the Alzheimer's Association Helpline. MEASUREMENTS: Primary outcomes: PWD behavioral symptoms and caregiver distress as measured by the Neuropsychiatric Inventory Questionnaire (NPI-Q) Severity and Modified Caregiver Strain Index scales. SECONDARY OUTCOMES: NPI-Q Distress, caregiver unmet needs and confidence, and caregiver depressive symptoms. Tertiary outcomes: PWD long-term nursing home placement rates, caregiver-reported PWD functional status, cognition, goal attainment, "time spent at home," Dementia Burden Scale-Caregiver, a composite measure of clinical benefit, Quality of Life of persons with dementia, Positive Aspects of Caregiving, and cost effectiveness using intervention costs and Medicare claims. RESULTS: The results will be reported in the spring of 2024. CONCLUSION: D-CARE will address whether emphasis on clinical support and tighter integration with other medical services has greater benefit than emphasis on social support that is tied more closely to community resources. It will also assess the effectiveness of both interventions compared with UC and will evaluate the cost effectiveness of each intervention.

Taking Care of the Dyad: Frequency of Caregiver Assessment Among Veterans with Dementia.

OBJECTIVES: This study assessed frequency of caregiver identification and needs of a sample of persons with dementia (PWDs) and their caregivers to determine whether needs were addressed and whether documentation increased with growing levels of self-reported relationship problems and burden. DESIGN: Cross-sectional design using data from electronic medical record (EMR) review and baseline research assessments (Burden Interview and Mutuality Scale). Items from a caregiver assessment tool were used to identify documentation of important factors in clinical guidelines. SETTING: Michael E. Debakey VA Medical Center, Houston, TX. PARTICIPANTS: A total of 211 PWDs from a randomized controlled trial testing a psychosocial intervention for preventing aggression in PWDs. MEASUREMENTS: EMRs for 12 months before participation in the original study were abstracted, using a tool created by the authors to assess documentation of information deemed important to caregiver assessment in clinical guidelines (eg, caregiver needs, caregiver well-being, and caregiving context). The first two authors reviewed the EMRs, adjusting the tool, based on questions that arose. RESULTS: Of 211 EMRs of PWDs reviewed, 177 (89%) identified caregivers. Of these, 88% identified the caregiver by name or relation to the PWD, 28% assessed caregiver well-being, and 41% assessed caregiver needs. All EMRs assessing caregiver needs showed provision of caregiver support (including psychoeducation, skills training, or referrals for additional aid). Levels of self-reported caregiver burden were not associated with documentation of assessment; however, higher levels of self-reported relationship problems were positively associated with increased caregiver contact documentation and negatively associated with caregiver need documentation and Alzheimer Association referrals. CONCLUSION: Healthcare providers identified caregivers in most of the sample, but less than 50% assessed their well-being and needs. J Am Geriatr Soc 67:1604-1609, 2019.

Mental Health Services for Older Adults: Creating a System That Tells the Story.

In 2004, voters in California approved Proposition 63 for passage of the Mental Health Services Act (MHSA). From that time until 2014, over $13 billion in the state's tax revenue was allocated for public mental health services. There is very little information available to answer critical questions such as these: How much of this amount was spent in the interests of older adult mental health? What benefits were gained from services delivered to older adults? This policy brief promotes recommendations for specific age-relevant indicator utilization and for an expanded system of uniform and transparent data for all types of MHSA-funded programs. These two policy directions are necessary in order to document the older adult mental health care services provided and to track outcomes at the state level for MHSA programs. A third recommendation centers on assuring that the mental health workforce is prepared to utilize and report age-relevant data indicators.

Expanding the geriatric mental health workforce through utilization of non-licensed providers.

OBJECTIVES: We evaluate policy and practice strategies for bolstering the geriatric mental healthcare workforce and describe costs and considerations of implementing one approach. METHOD: Narrative overview of the literature and policy retrieved from searches of databases, hand searches, and authoritative texts. We identified three proposed strategies to increase the geriatric mental healthcare workforce: (1) production of more geriatric mental health providers; (2) team-based care; and (3) non-licensed providers. We evaluate each in terms of challenges and potential and provide estimates of costs, policy, and practice considerations for training, employing, and supervising non-licensed mental health providers. RESULTS: Use of non-licensed providers is key to reforms needed to allow a more older adults to access necessary mental healthcare. Licensed and non-licensed providers have achieved similar improvements for generalized anxiety disorder among patients, although non-licensed providers did so at a lower cost. CONCLUSION: Supervised non-licensed providers can extend the reach of licensed providers for specific mental health conditions, resulting in lower costs and increased number of patients treated. Although several barriers to implementation exist, policy and infrastructure changes that may support this type of care delivery model are emerging from reforms in financing and associated delivery initiatives created by the Affordable Care Act.

A break-even analysis for dementia care collaboration: Partners in Dementia Care.

BACKGROUND: Dementia is a costly disease. People with dementia, their families, and their friends are affected on personal, emotional, and financial levels. Prior work has shown that the "Partners in Dementia Care" (PDC) intervention addresses unmet needs and improves psychosocial outcomes and satisfaction with care. OBJECTIVE: We examined whether PDC reduced direct Veterans Health Administration (VHA) health care costs compared with usual care. DESIGN: This study was a cost analysis of the PDC intervention in a 30-month trial involving five VHA medical centers. PARTICIPANTS: Study subjects were veterans (N = 434) 50 years of age and older with dementia and their caregivers at two intervention (N = 269) and three comparison sites (N = 165). INTERVENTIONS: PDC is a telephone-based care coordination and support service for veterans with dementia and their caregivers, delivered through partnerships between VHA medical centers and local Alzheimer's Association chapters. MAIN MEASURES: We tested for differences in total VHA health care costs, including hospital, emergency department, nursing home, outpatient, and pharmacy costs, as well as program costs for intervention participants. Covariates included caregiver reports of veterans' cognitive impairment, behavior problems, and personal care dependencies. We used linear mixed model regression to model change in log total cost post-baseline over a 1-year follow-up period. KEY RESULTS: Intervention participants showed higher VHA costs than usual-care participants both before and after the intervention but did not differ significantly regarding change in log costs from pre- to post-baseline periods. Pre-baseline log cost (p ≤ 0.001), baseline cognitive impairment (p ≤ 0.05), number of personal care dependencies (p ≤ 0.01), and VA service priority (p ≤ 0.01) all predicted change in log total cost. CONCLUSIONS: These analyses show that PDC meets veterans' needs without significantly increasing VHA health care costs. PDC addresses the priority area of care coordination in the National Plan to Address Alzheimer's Disease, offering a low-cost, structured, protocol-driven, evidence-based method for effectively delivering care coordination.

Using urinary biomarkers to evaluate polycyclic aromatic hydrocarbon exposure in 126 preschool children in Ohio.

Limited data exist on exposures of young children to polycyclic aromatic hydrocarbons (PAHs) in the United States (US). The urinary metabolite of pyrene, 1-hydroxypyrene (1-OHPyr), is widely used as a biomarker of total PAH exposure. Our objectives were to quantify urinary 1-OHPyr levels in 126 preschool children over a 48-h period and to examine associations between selected sociodemographic/lifestyle factors and urinary 1-OHPyr levels. Monitoring was performed at 126 homes and 16 daycares in Ohio in 2001, and questionnaires and urine samples were collected. The median urinary 1-OHPyr level was 0.33 ng/mL. In a multiple regression model, sampling season (p = 0.0001) and natural log (ln)-transformed creatinine concentration (p = 0.0006) were highly significant predictors of ln-transformed 1-OH-Pyr concentration; cooking appliance type (p = 0.096) was a marginally significant predictor of ln(1-OHPyr). These children had higher median urinary 1-OHPyr levels compared to other US children (≤ 0.15 ng/mL) in previously published studies, which suggests possible geographical differences in PAH exposure.

Characteristics of Depressed Caregivers of Veterans With Dementia.

This study examined the characteristics of caregivers and persons with dementia (PWD) to determine their association with caregiver depression. Participants included 508 PWD (veterans) and 486 caregivers from Boston, Houston, Providence, Beaumont (Texas), and Oklahoma City, identified from diagnoses from medical records and recruited from February 2007 to July 2009, for a larger study evaluating Partners in Dementia Care, a care-coordination intervention. Characteristics evaluated for PWD included activities of daily living, instrumental activities of daily living, cognitive impairment, and disruptive behavior. Caregiver characteristics evaluated included caregiver unmet needs, support-service use, and number of informal helpers. Caregiver depression was measured using the Iowa form 11-item Center for Epidemiologic Studies Depression Scale. Depressed caregivers reported significantly more unmet needs than the nondepressed caregivers. Depressed caregivers also reported a high frequency of disruptive behavior in their PWD. Caregiver perceptions of unmet needs may be an important target for intervention.

Caregiver outcomes of partners in dementia care: effect of a care coordination program for veterans with dementia and their family members and friends.

The objective is to test the effectiveness of Partners in Dementia Care (PDC), a care-coordination program that integrates and improves access to medical and nonmedical services, while strengthening the informal care network and providing information, coaching, and emotional support. PDC was delivered via a partnership between Veterans Affairs (VA) Medical Centers (VAMCs) and Alzheimer's Association chapters, for caregivers of veterans with dementia living in the community and receiving primary care from the VA. The initial sample was 486 caregivers of 508 veterans with diagnosed dementia. Outcomes were evaluated for 394 and 324 caregivers who completed 6- and 12- month follow-up, respectively. PDC had a standardized protocol that included assessment and reassessment, action planning, and ongoing monitoring. It was delivered by telephone and e-mail for cost efficiency and the ability to handle caseloads of 100 to 125. Care coordinators from VAMCs and Alzheimer's Association chapters worked as a team using a shared computerized record. A variety of caregiver outcomes was measured after 6 and 12 months. Intervention group caregivers had significant improvements in outcomes representing unmet needs, three types of caregiver strains, depression, and two support resources. Most improvements were evident after 6 months, with more-limited improvements from Months 6 to 12. Some outcomes improved for all caregivers, whereas some improved for caregivers experiencing more initial difficulties or caring for veterans with more-severe impairments. PDC is a promising model that improves linkages between healthcare services and community services, which is a goal of several new national initiatives such as the National Plan to Address Alzheimer's Disease and a proposed amendment to the Older Americans Act.

An educational program to assist clinicians in identifying elder investment fraud and financial exploitation.

Due to age-related factors and illnesses, older adults may become vulnerable to elder investment fraud and financial exploitation (EIFFE). The authors describe the development and preliminary evaluation of an educational program to raise awareness and assist clinicians in identifying older adults at risk. Participants (n = 127) gave high ratings for the program, which includes a presentation, clinician pocket guide, and patient education brochure. Thirty-five respondents returned a completed questionnaire at the 6-month follow-up, with 69% (n = 24) of those indicating use of the program materials in practice and also reporting having identified 25 patients they felt were vulnerable to EIFFE. These findings demonstrate the value of providing education and practical tools to enhance clinic-based screening of this underappreciated but prevalent problem.

Establishing community partnerships to support late-life anxiety research: lessons learned from the Calmer Life project.

OBJECTIVES: This article outlines the development of the Calmer Life project, a partnership established between researchers and faith-based and social service organizations to examine the effectiveness of cognitive behavioral therapy (CBT) incorporating religious/spiritual components for older African Americans in low-income communities. METHOD: The program was designed to bypass several barriers to delivery of CBT within the specified community; it allows multimodal delivery (in person or by telephone) that occurs outside traditional mental health settings through faith-based organizations and neighborhood community centers. It includes religion/spirituality as an element, dependent upon the preference of the participant, and is modular, so that people can select the skills they wish to learn. Established relationships within the community were built upon, and initial meetings were held in community settings, allowing feedback from community organizations. RESULTS: This ongoing program is functioning successfully and has strengthened relationships with community partners and facilitated increased availability of education and services in the community. The lessons learned in establishing these partnerships are outlined. CONCLUSIONS: The growth of effectiveness research for late-life anxiety treatments in underserved minority populations requires development of functional partnerships between academic institutions and community stakeholders, along with treatment modifications to effectively address barriers faced by these consumers. The Calmer Life project may serve as a model.

Utilization of legal and financial services of partners in dementia care study.

Financial and legal services are unique needs of persons with dementia and their caregivers. This study examines their need for legal and financial assistance and the kinds of legal and financial services provided within Partners in Dementia Care, a telephone-based, care coordination and support service intervention delivered through a partnership between Veterans Affairs (VA) medical centers and local Alzheimer's Association chapters. Based on comprehensive assessment, and needs prioritization, care coordinators collaboratively planned action steps (specific behavioral tasks) with each caregiver/person with dementia to address the dyad's identified unmet needs. Results show that 51 (54.8%) of 93 dyads reported a need for legal and financial services. Action steps related to legal and financial need included education or assistance with legal services (27.27%), nonhealth-related financial benefits (32.32%), health-related financial benefits (21.21%), financial management/planning (9.09%), and financial support (10.1%). Comparable numbers of action steps were directed to VA (41.4%) and non-VA (58.6%) services.

Healthy IDEAS: implementation of a depression program through community-based case management.

PURPOSE: Healthy IDEAS (HIDEAS; IDEAS stands for Identifying Depression, Empowering Activities for Seniors) is an evidence-based depression program addressing commonly recognized barriers to mental health care for older adults. The purpose of this study was to describe the implementation of HIDEAS and assess its feasibility. DESIGN AND METHODS: Three community agencies implemented the program with 94 eligible older adults who were identified from 348 screened older adults. We assessed program implementation by using the Core Implementation Component framework, using a client-tracking database, written survey of case managers, focus-group interview with coaches, and agency and project progress reports. RESULTS: We identified several challenges: clients' reluctance to acknowledge depressive symptoms and difficulty in engaging in behavioral changes; differences among case managers' mental health knowledge, skills, and "buy-in" and difficulty managing limited time; and differences in agency culture that foster in-agency supervision. IMPLICATIONS: Successful adoption and sustainability of HIDEAS are more likely when essential elements of the Core Implementation Component framework are addressed to bring about behavioral changes at all treatment-implementation levels-clients, practitioners, and organizations.