Dementia and co-occurring chronic conditions: a systematic literature review to identify what is known and where are the gaps in the evidence?

OBJECTIVE: The challenges posed by people living with multiple chronic conditions are unique for people with dementia and other significant cognitive impairment. There have been recent calls to action to review the existing literature on co-occurring chronic conditions and dementia in order to better understand the effect of cognitive impairment on disease management, mobility, and mortality. METHODS: This systematic literature review searched PubMed databases through 2011 (updated in 2016) using key constructs of older adults, moderate-to-severe cognitive impairment (both diagnosed and undiagnosed dementia), and chronic conditions. Reviewers assessed papers for eligibility and extracted key data from each included manuscript. An independent expert panel rated the strength and quality of evidence and prioritized gaps for future study. RESULTS: Four thousand thirty-three articles were identified, of which 147 met criteria for review. We found that moderate-to-severe cognitive impairment increased risks of mortality, was associated with prolonged institutional stays, and decreased function in persons with multiple chronic conditions. There was no relationship between significant cognitive impairment and use of cardiovascular or hypertensive medications for persons with these comorbidities. Prioritized areas for future research include hospitalizations, disease-specific outcomes, diabetes, chronic pain, cardiovascular disease, depression, falls, stroke, and multiple chronic conditions. CONCLUSIONS: This review summarizes that living with significant cognitive impairment or dementia negatively impacts mortality, institutionalization, and functional outcomes for people living with multiple chronic conditions. Our findings suggest that chronic-disease management interventions will need to address co-occurring cognitive impairment. Copyright © 2017 John Wiley & Sons, Ltd.

Mental health differences between men and women caregivers, BRFSS 2009.

This study uses data from the 2009 Behavioral Risk Factors Surveillance System (BRFSS) to examine differences between male and female caregivers by demographics, health-related quality of life (HRQOL), and the effect of social support on HRQOL. Roughly two-thirds of caregivers were women, and demographic characteristics differed among men and women caregivers. Women caregivers reported significantly more mentally and physically unhealthy days than men, but there were no differences between men and women in general health or life satisfaction. Men were significantly more likely to report that they rarely or never received social support. Despite this, the effect of social support on HRQOL was stronger in men than in women. Implications of these findings for caregiver support programs are discussed.

A systematic review of intervention studies to prevent hospitalizations of community-dwelling older adults with dementia.

OBJECTIVES: To conduct a systematic literature review to determine if there were any intervention strategies that had any measurable effect on acute-care hospitalizations among community-dwelling adults with dementia. DESIGN: Studies were identified by a professional research librarian and content experts. SETTING: Community dwelling. PARTICIPANTS: Participants were diagnosed with dementia, severity ranging from mild to severe, and were recruited from health care and community agencies. MEASUREMENTS: A study met the inclusion criteria if it: (a) was published in English; (b) included a control or comparison group; (c) published outcome data from the intervention under study; (d) reported hospitalization as one of the outcomes; (e) included community-dwelling older adults; and (f) enrolled participants with dementia. Ten studies met all inclusion criteria. RESULTS: Of the 10 studies included, most assessed health services use (ie, hospitalizations) as a secondary outcome. Participants were recruited from a range of health care and community agencies, and most were diagnosed with dementia with severity ratings ranging from mild to severe. Most intervention strategies consisted of face-to-face assessments of the persons living with dementia, their caregivers, and the development and implementation of a care plan. A significant reduction in hospital admissions was not found in any of the included studies, although 1 study did observe a reduction in hospital days. CONCLUSIONS: The majority of studies included hospitalizations as a secondary outcome. Only 1 intervention was found to have an effect on hospitalizations. Future work would benefit from strategies specifically designed to reduce and prevent acute hospitalizations in persons with dementia.

Polling places, pharmacies, and public health: Vote & Vax 2012.

US national elections, which draw sizable numbers of older voters, take place during flu-shot season and represent an untapped opportunity for large-scale delivery of vaccinations. In 2012, Vote & Vax deployed a total of 1585 clinics in 48 states; Washington, DC; Guam; Puerto Rico; and the US Virgin Islands. Approximately 934 clinics were located in pharmacies, and 651 were near polling places. Polling place clinics delivered significantly more vaccines than did pharmacies (5710 vs 3669). The delivery of vaccines was estimated at 9379, and approximately 45% of the recipients identified their race/ethnicity as African American or Hispanic. More than half of the White Vote & Vax recipients and more than two thirds of the non-White recipients were not regular flu shot recipients.

Public perceptions about risk and protective factors for cognitive health and impairment: a review of the literature.

BACKGROUND: Preventing and/or delaying cognitive impairment is a public health priority. To increase awareness of and participation in behaviors that may help maintain cognitive function or reduce risk of impairment, we need to understand public perceptions about risk and protective factors. METHODS: We conducted a scoping review of studies examining the public's perceptions about risk and protective factors related to cognitive health and impairment published since the 2007 National Public Health Road Map to Maintaining Cognitive Health. RESULTS: A search of five databases yielded 1,115 documents published between June 2007 and December 2013. Initial review of abstracts identified 90 potentially eligible studies. After full-article review, 30 met inclusion criteria; four additional articles identified in reference lists also met inclusion criteria. Of the 34, 16 studies addressed Alzheimer's disease (AD) specifically, 15 dementia broadly, 5 mild to moderate cognitive impairment, and 8 normal functioning, with some content overlap. Across studies, respondents reported genetics (n = 14 studies), older age (n = 8), stress (n = 7), brain/head injury (n = 6), and mental illness/brain disease (n = 6) as perceived risk factors for AD and dementia. Protective factors most commonly identified for maintaining cognitive health were intellectual/mental stimulation (n = 13), physical activity (n = 12), healthy diet (n = 10), and social/leisure activities (n = 10). CONCLUSIONS: Studies identified genetics and older age as key perceived risk factors more so than behaviors such as smoking. Individuals perceived that numerous lifestyle factors (e.g. intellectual stimulation, physical activity) could protect against cognitive impairment, AD, and/or dementia. Results can inform national and international education efforts about AD and other dementias.

Proxy reports about household members with increased confusion or memory loss, 2011 Behavioral Risk Factor Surveillance System.

To provide information about the effects of increased confusion or memory loss (ICML) in households in the United States, we describe primary respondents' reports (proxy reports) about another person in their household experiencing ICML, using 2011 Behavioral Risk Factor Surveillance System (BRFSS) data. We used proxy reports on type of assistance needed, effects on functioning in daily activities, and whether confusion or memory was discussed with a health care professional, stratifying by age of the household member with ICML (18-50 y vs ≥65 y). About 3% (n = 3,075 households) of primary respondents reported living with a household member with ICML; 75% of these household members needed some type of assistance, and nearly 60% had discussed ICML with a health care professional. Collecting proxy data about individuals in households may help paint a clearer picture of the characteristics of those experiencing cognitive decline and the potential needs of individuals and families.

Increased confusion and memory loss in households, 2011 Behavioral Risk Factor Surveillance System.

Using data from the 2011 Behavioral Risk Factor Surveillance System (BRFSS), we examined households in 13 states (N = 81,012) in which the respondent or another adult household member experienced increased confusion or memory loss (ICML) in the preceding 12 months. A total of 12.6% of households reported at least 1 adult who experienced ICML, and in 5.4% of households all adults experienced ICML. Based on these results, an estimated 4 million households in these 13 states have a member with ICML, potentially affecting more than 10 million people. This study can inform public health communication campaigns aimed at increasing awareness of the signs and symptoms of cognitive decline and augment community planning efforts so that the needs of households in which 1 or more adults has cognitive decline are considered.

Using Social Network Analysis to Assess Mentorship and Collaboration in a Public Health Network.

INTRODUCTION: Addressing chronic disease burden requires the creation of collaborative networks to promote systemic changes and engage stakeholders. Although many such networks exist, they are rarely assessed with tools that account for their complexity. This study examined the structure of mentorship and collaboration relationships among members of the Healthy Aging Research Network (HAN) using social network analysis (SNA). METHODS: We invited 97 HAN members and partners to complete an online social network survey that included closed-ended questions about HAN-specific mentorship and collaboration during the previous 12 months. Collaboration was measured by examining the activity of the network on 6 types of products: published articles, in-progress manuscripts, grant applications, tools, research projects, and presentations. We computed network-level measures such as density, number of components, and centralization to assess the cohesiveness of the network. RESULTS: Sixty-three respondents completed the survey (response rate, 65%). Responses, which included information about collaboration with nonrespondents, suggested that 74% of HAN members were connected through mentorship ties and that all 97 members were connected through at least one form of collaboration. Mentorship and collaboration ties were present both within and across boundaries of HAN member organizations. CONCLUSION: SNA of public health collaborative networks provides understanding about the structure of relationships that are formed as a result of participation in network activities. This approach may offer members and funders a way to assess the impact of such networks that goes beyond simply measuring products and participation at the individual level.

Demographic and health status differences among people aged 45 or older with and without functional difficulties related to increased confusion or memory loss, 2011 Behavioral Risk Factor Surveillance System.

We examined the demographic and health characteristics of people aged 45 years or older in 21 states with self-reported increased confusion or memory loss (ICML) (n = 10,583) by whether or not they also reported functional difficulties related to ICML. We used data from the 2011 Behavioral Risk Factor Surveillance System optional module on impact of cognitive impairment. After adjusting for demographic differences, we found that respondents with ICML and functional difficulties were significantly more likely than those with ICML and no functional difficulties to report frequent poor physical health, frequent poor mental health, limited activity due to poor physical or mental health, and a need for more help. Further understanding of the implications for long-term services and supports is needed.

Falls and fall injuries among adults with arthritis--United States, 2012.

Falls are the leading cause of injury-related morbidity and mortality among older adults, with more than one in three older adults falling each year, resulting in direct medical costs of nearly $30 billion. Some of the major consequences of falls among older adults are hip fractures, brain injuries, decline in functional abilities, and reductions in social and physical activities. Although the burden of falls among older adults is well-documented, research suggests that falls and fall injuries are also common among middle-aged adults. One risk factor for falling is poor neuromuscular function (i.e., gait speed and balance), which is common among persons with arthritis. In the United States, the prevalence of arthritis is highest among middle-aged adults (aged 45-64 years) (30.2%) and older adults (aged ≥65 years) (49.7%), and these populations account for 52% of U.S. adults. Moreover, arthritis is the most common cause of disability. To examine the prevalence of falls among middle-aged and older adults with arthritis in different states/territories, CDC analyzed data from the 2012 Behavioral Risk Factor Surveillance System (BRFSS) to assess the state-specific prevalence of having fallen and having experienced a fall injury in the past 12 months among adults aged ≥45 years with and without doctor-diagnosed arthritis. This report summarizes the results of that analysis, which found that for all 50 states and the District of Columbia (DC), the prevalence of any fall (one or more), two or more falls, and fall injuries in the past 12 months was significantly higher among adults with arthritis compared with those without arthritis. The prevalence of falls and fall injuries is high among adults with arthritis but can be addressed through greater dissemination of arthritis management and fall prevention programs in clinical and community practice.

Expanding efforts to address Alzheimer's disease: the Healthy Brain Initiative.

The growing burden of Alzheimer's disease underscores the importance of enhancing current public health efforts to address dementia. Public health organizations and entities have substantial opportunities to contribute to efforts underway and to add innovations to the field. The Alzheimer's Association and the Centers for Disease Control and Prevention worked with a 15-member leadership committee and hundreds of stakeholders to create The Healthy Brain Initiative: The Public Health Road Map for State and National Partnerships, 2013-2018 (Road Map). The actions in the Road Map provide a foundation for the public health community to anticipate and respond to emerging innovations and developments. It will be a challenge to harness the increasingly complex nature of public- and private-sector collaborations. We must strengthen the capacity of public health agencies, leverage partnerships, and find new ways to integrate cognitive functioning into public health efforts.

Strategic priorities to increase use of clinical preventive services among older US adults.

The objective of this project was to obtain professionals' perceptions of system-level strategies with potential to increase use of clinical preventive services (CPS) among adults aged 50 years or older through community settings. Public health, aging services, and medical professionals participated in guided discussions and a modified Delphi process. Priority strategies, determined on the basis of a 70% or higher a priori agreement level, included enhancing community capacity; promoting the design of health information technologies to exchange data between clinical and community settings; promoting care coordination; broadening scope of practice; providing incentives to employers; and eliminating cost-sharing. Findings provide insights about preferences for system-level strategies that align with national and state initiatives to increase CPS use.

Environments for healthy aging: linking prevention research and public health practice.

Safe and well-designed community environments support healthful behaviors that help prevent chronic conditions and unintentional injuries and enable older adults to be active and engaged in community life for as long as possible. We describe the work of the Healthy Aging Research Network (HAN) and partners over the past decade to better understand place-based determinants of health and translate that knowledge to real-world practice, with a focus on environmental strategies. Using key components of the Knowledge to Action framework, we document the importance of a sustained, multidisciplinary, collaborative approach and ongoing interaction between researchers and communities. We share examples of practical tools and strategies designed to engage and support critical sectors with the potential to enhance the health and well-being of older adults and their communities. We conclude with a description of lessons learned in facilitating the translation of prevention research into practice.

Beliefs and communication practices regarding cognitive functioning among consumers and primary care providers in the United States, 2009.

INTRODUCTION: Limited research has examined primary care providers' communication with patients about maintaining cognitive functioning. Our study's objective was to compare the perceptions of consumers and primary care providers related to beliefs and communication practices about lifestyle behaviors beneficial for overall health and for maintaining cognitive functioning. METHODS: In 2009, we submitted 10 questions to Porter Novelli's HealthStyles survey and 6 questions to their DocStyles survey. We compared consumers' (n = 4,728) and providers' (n = 1,250) beliefs, practices, and information sources related to maintaining health and cognitive functioning. We made comparisons using nonparametric statistics. RESULTS: Approximately 76% of consumers considered their health to be good or very good; 73.4% were concerned or very concerned about the possibility that their memory may worsen with age. Women were significantly more concerned than men, and white consumers were more concerned than black and Hispanic consumers. Consumers reported they believed that intellectual stimulation (86.6%), physical activity (82.6%), and healthful diet (82.5%) prevented or delayed cognitive impairment. Providers reported advising patients to reduce cognitive impairment risk through physical activity (85.9%), intellectual stimulation (80.3%), and social involvement (67.4%). Few consumers (7.8%) reported receiving this information from providers but reported learning about strategies to maintain memory, primarily from television (50.1%), magazines (44.1%), and newspapers (33.7%). CONCLUSION: Providers reported advising patients about how to reduce risks of cognitive impairment. Consumers reported receiving this information from other sources. Findings suggest a need to examine and assess media messages and to better understand patient-provider communication about cognitive functioning.

Adult caregivers in the United States: characteristics and differences in well-being, by caregiver age and caregiving status.

We examined the characteristics of adults providing regular care or assistance to friends or family members who have health problems, long-term illnesses, or disabilities (ie, caregivers). We used data from the 2009 Behavioral Risk Factor Surveillance System (BRFSS) to examine caregiver characteristics, by age and caregiving status, and compare these characteristics with those of noncaregivers. Approximately 24.7% (95% confidence interval, 24.4%-25.0%) of respondents were caregivers. Compared with younger caregivers, older caregivers reported more fair or poor health and physical distress but more satisfaction with life and lower mental distress. Understanding the characteristics of caregivers can help enhance strategies that support their role in providing long-term care.

Seeking best practices: a conceptual framework for planning and improving evidence-based practices.

How can we encourage ongoing development, refinement, and evaluation of practices to identify and build an evidence base for best practices? On the basis of a review of the literature and expert input, we worked iteratively to create a framework with 2 interrelated components. The first - public health impact - consists of 5 elements: effectiveness, reach, feasibility, sustainability, and transferability. The second - quality of evidence - consists of 4 levels, ranging from weak to rigorous. At the intersection of public health impact and quality of evidence, a continuum of evidence-based practice emerges, representing the ongoing development of knowledge across 4 stages: emerging, promising, leading, and best. This conceptual framework brings together important aspects of impact and quality to provide a common lexicon and criteria for assessing and strengthening public health practice. We hope this work will invite and advance dialogue among public health practitioners and decision makers to build and strengthen a diverse evidence base for public health programs and strategies.

Examining external validity in efficacy and secondary articles of home-based depression care management interventions for older adults.

INTRODUCTION: Information on external validity enables public health practitioners to generalize conclusions about an intervention to future or different conditions and is critical to moving research into practice. Prior reviews examining external validity focused on efficacy publications only. Our objective was to determine the extent to which secondary articles could enhance information about external validity presented in efficacy studies. METHODS: We identified a group of interventions recommended by the Guide to Community Preventive Services for home-based depression care management for older adults. We searched online databases for secondary articles using a list of the study authors' names and study acronyms. Five articles were ineligible (intervention was not effective or articles lacked data on external validity) and 14 articles were eligible and reviewed (6 efficacy and 8 secondary articles). We examined 15 elements of external validity based on 4 of the 5 dimensions of the RE-AIM framework: reach, adoption, implementation, and maintenance. RESULTS: The 6 efficacy studies documented 1 or more elements of reach and implementation, and 5 studies included 1 or more elements of maintenance. Secondary articles included 4 to 9 elements on external validity and addressed 1 to 5 unique elements of external validity not reported in the efficacy publications. CONCLUSION: Secondary articles enrich the amount of information about external validity and may be published years before or after the efficacy publication. Reviewing only primary publications of efficacy trials may provide a limited view of external validity, at least for publications describing home-based depression care management.

Using a concept map as a tool for strategic planning: The Healthy Brain Initiative.

Concept mapping is a tool to assist in strategic planning that allows planners to work through a sequence of phases to produce a conceptual framework. Although several studies describe how concept mapping is applied to various public health problems, the flexibility of the methods used in each phase of the process is often overlooked. If practitioners were more aware of the flexibility, more public health endeavors could benefit from using concept mapping as a tool for strategic planning. The objective of this article is to describe how the 6 concept-mapping phases originally outlined by William Trochim guided our strategic planning process and how we adjusted the specific methods in the first 2 phases to meet the specialized needs and requirements to create The Healthy Brain Initiative: A National Public Health Road Map to Maintaining Cognitive Health. In the first stage (phases 1 and 2 of concept mapping), we formed a steering committee, convened 4 work groups over a period of 3 months, and generated an initial set of 42 action items grounded in science. In the second stage (phases 3 and 4), we engaged stakeholders in sorting and rating the action items and constructed a series of concept maps. In the third and final stage (phases 5 and 6), we examined and refined the action items and generated a final concept map consisting of 44 action items. We then selected the top 10 action items, and in 2007, we published The Healthy Brain Initiative: A National Public Health Road Map to Maintaining Cognitive Health, which represents the strategic plan for The Healthy Brain Initiative.

Changes in mental well-being in the transition to late life: findings from MIDUS I and II.

The number of adults aged 65 years and older is increasing rapidly, creating public health challenges. We used data from the 1995 and 2005 national surveys of Midlife in the United States (MIDUS) to compare changes in mental well-being of participants (n = 1007) of 3 age cohorts (ages 45-54 years, 55-64 years, and 65-74 years in 1995). Older adults experienced a slight decline in mental well-being not seen among younger participants and not explained by demographic variables, physical ailments, mental illnesses, or chronic conditions.

Engaging communication experts in a Delphi process to identify patient behaviors that could enhance communication in medical encounters.

BACKGROUND: The communication literature currently focuses primarily on improving physicians' verbal and non-verbal behaviors during the medical interview. The Four Habits Model is a teaching and research framework for physician communication that is based on evidence linking specific communication behaviors with processes and outcomes of care. The Model conceptualizes basic communication tasks as "Habits" and describes the sequence of physician communication behaviors during the clinical encounter associated with improved outcomes. Using the Four Habits Model as a starting point, we asked communication experts to identify the verbal communication behaviors of patients that are important in outpatient encounters. METHODS: We conducted a 4-round Delphi process with 17 international experts in communication research, medical education, and health care delivery. All rounds were conducted via the internet. In round 1, experts reviewed a list of proposed patient verbal communication behaviors within the Four Habits Model framework. The proposed patient verbal communication behaviors were identified based on a review of the communication literature. The experts could: approve the proposed list; add new behaviors; or modify behaviors. In rounds 2, 3, and 4, they rated each behavior for its fit (agree or disagree) with a particular habit. After each round, we calculated the percent agreement for each behavior and provided these data in the next round. Behaviors receiving more than 70% of experts' votes (either agree or disagree) were considered as achieving consensus. RESULTS: Of the 14 originally-proposed patient verbal communication behaviors, the experts modified all but 2, and they added 20 behaviors to the Model in round 1. In round 2, they were presented with 59 behaviors and 14 options to remove specific behaviors for rating. After 3 rounds of rating, the experts retained 22 behaviors. This set included behaviors such as asking questions, expressing preferences, and summarizing information. CONCLUSION: The process identified communication tasks and verbal communication behaviors for patients similar to those outlined for physicians in the Four Habits Model. This represents an important step in building a single model that can be applied to teaching patients and physicians the communication skills associated with improved satisfaction and positive outcomes of care.