Caregiver Stress and the Patient With Dementia.

Informal caregivers (often, but not exclusively, family members) are essential to the clinical care of a patient with dementia. Most caregivers are untrained and unpaid. As a result, caregivers often experience stress caused by the caregiving experience; they are the "invisible second patients" in dementia care. Clinicians can help caregivers by supporting them in their role and by referring them to additional resources for support.

Quality measurement: It's here to stay.

The Centers for Medicare and Medicaid Services (CMS) is shifting from volume-based to value-based reimbursement of health care services. Measuring the value of health care requires measurement of quality and cost. We provide an overview of quality measurement and review a well-known and widely used conceptual model for assessing quality: structure, process, and outcome. We highlight the advantages and disadvantages of using these types of metrics. We then use this conceptual model to describe prominent CMS programs such as the Physician Quality Reporting System, Physician Compare Web site, and the Medicare Shared Savings Plan. We highlight 2 recent trends: the increasing use of outcome measures to supplement process measures and the public reporting of quality.

Practical steps for implementing quality measurement in practice.

All neurologists must begin incorporating quality measurement and quality improvement into their practice. Efforts to pay physicians based on the quality of their care and patient outcomes moves quality measurement beyond reporting to satisfy regulatory requirements and pushes physicians to select and use quality measures to improve patient outcomes and patient experience. This article provides practical steps and proposes considerations for neurologic practices advancing quality measurement and improvement.

Clinical significance in dementia research: a review of the literature.

Clinical research traditionally relies on measures of statistical significance to assess the strength of evidence while less attention is paid to the practical import of the results. The objective of this study was to provide a critical overview of the current approaches to measuring clinical significance in dementia research and to provide suggestions for future research. A systematic search was conducted of Medline and Embase for original, English-language, peer-reviewed articles published before July 2012. A total of 18 articles met the inclusion criteria, of which 13 used multiple approaches to measure clinical significance. In all, 5 articles used expert opinion as anchors; 4 also used distribution-based approaches. In all, 8 articles used Goal Attainment Scaling; 7 of these also relied on clinician-based impressions of change. Another 3 articles used only clinical global impressions of change, 1 article used changes in symptomatology, and another used the value from literature.

Quality improvement in neurology: dementia management quality measures.

Professional and advocacy organizations have long urged that dementia should be recognized and properly diagnosed. With the passage of the National Alzheimer's Project Act in 2011, an Advisory Council for Alzheimer's Research, Care, and Services was convened to advise the Department of Health and Human Services. In May 2012, the Council produced the first National Plan to address Alzheimer's disease, and prominent in its recommendations is a call for quality measures suitable for evaluating and tracking dementia care in clinical settings. Although other efforts have been made to set dementia care quality standards, such as those pioneered by RAND in its series Assessing Care of Vulnerable Elders (ACOVE), practitioners, healthcare systems, and insurers have not widely embraced implementation. This executive summary (full manuscript available at www.neurology.org) reports on a new measurement set for dementia management developed by an interdisciplinary Dementia Measures Work Group (DWG) representing the major national organizations and advocacy organizations concerned with the care of individuals with dementia. The American Academy of Neurology (AAN), the American Geriatrics Society, the American Medical Directors Association, the American Psychiatric Association, and the American Medical Association-convened Physician Consortium for Performance Improvement led this effort. The ACOVE measures and the measurement set described here apply to individuals whose dementia has already been identified and properly diagnosed. Although similar in concept to ACOVE, the DWG measurement set differs in several important ways; it includes all stages of dementia in a single measure set, calls for the use of functional staging in planning care, prompts the use of validated instruments in patient and caregiver assessment and intervention, highlights the relevance of using palliative care concepts to guide care before the advanced stages of illness, and provides evidence-based support for its recommendations and guidance on the selection of instruments useful in tracking patient-centered outcomes. It also specifies annual reassessment and updating of interventions and care plans for dementia-related problems that affect families and other caregivers as well as individuals with dementia. Here, a brief synopsis of why major reforms in healthcare design and delivery are needed to achieve substantive improvements in the quality of care is first provided, and then the final measures approved for publication, dissemination, and implementation are listed.

Quality improvement in neurology: dementia management quality measures (executive summary).

This article represents the efforts of an interdisciplinary work group, the Dementia Measures Work Group (DWG), composed of representatives of diverse national organizations who convened specifically to define optimal standards of dementia care for individual practitioners as well as multidisciplinary teams. The DWG measurement set includes all stages of dementia in a single measure set, calls for the use of functional staging in planning care, prompts the use of validated instruments in patient and caregiver assessment and intervention, highlights the relevance of using palliative care concepts to guide care prior to the advanced stages of illness, and provides evidence-based support for its recommendations and guidance on the selection of instruments for tracking patient-centered outcomes. In addition, it specifies annual reassessment and updating of interventions and care plans for dementia-related problems that affect families and other caregivers as well as patients.

Quality measures for neurologists: Financial and practice implications.

Measuring and reporting health care quality is increasingly becoming part of clinical practice and reimbursement for specialists, including neurologists. The goal is to improve the value of care. Current major programs tie quality measurements to reimbursement, including programs from the Centers for Medicare and Medicaid Services: the Physician Quality Reporting System, the Electronic Health Record Incentive Program (and Meaningful Use), and Accountable Care Organizations. Many specialty boards, including the American Board of Psychiatry and Neurology, now require clinical practice quality measurements for maintenance of certification. Practitioners may find these programs confusing, overlapping, burdensome, and not clearly relevant to promoting better patient care. Yet, integrating quality metrics into practice has entered the mainstream and is increasingly tied to reimbursement. Further, over the next few years, most programs will switch from bonus incentives for participation to penalties for nonparticipation. This article aims to clarify current and rising quality measurement programs relevant to neurologists.

If you build (and moderate) it, they will come: the Smokefree Women Facebook page.

This analysis explores the impact of modifying the Smokefree Women Facebook social media strategy, from primarily promoting resources to encouraging participation in communications about smoking cessation by posting user-generated content. Analyses were performed using data from the Smokefree Women Facebook page to assess the impact of the revised strategy on reach and engagement. Fan engagement increased 430%, and a strong and statistically significant correlation (P < .05) between the frequency of moderator posts and community engagement was observed. The reach of the page also increased by 420%. Our findings indicate that the strategy shift had a statistically significant and positive effect on the frequency of interactions on the Facebook page, providing an example of an approach that may prove useful for reaching and engaging users in online communities. Additional research is needed to assess the association between engagement in virtual communities and health behavior outcomes.

Non-native language use and risk of incident dementia in the elderly.

Cognitive reserve is invoked to explain the protective effects of education and cognitively-stimulating activities against all-cause dementia and Alzheimer's disease (AD). For non-native English speakers (n-NES), speaking English may be a cognitive activity associated with lower dementia risk. We hypothesized that n-NES have lower risk of incident dementia/AD and that educational level might modify this relationship. Participants took part in the Einstein Aging Study (Bronx, NY), a longitudinal study of aging and dementia. All (n = 1779) spoke fluent English and self-reported birthplace and whether English was their first language. n-NES additionally reported mother tongue, age of English acquisition, and current percentile-use of a non-English language. Nested Cox proportional hazards models progressively adjusted for gender, race, education, and immigrant and marital status estimated hazard ratios (HR) for incident dementia/AD as a function of n-NES status. 390 (22%) participants were n-NES. 126 incident dementia cases occurred during 4174 person-years of follow-up (median 1.44; range 0-16); 101 individuals met criteria for probable/possible AD. There was no statistically-significant association between n-NES status and incident dementia in the fully-adjusted model (HR 1.26; 95% CI 0.76-2.09; p = 0.36). Results were similar for AD. Stratification of education into three groups revealed increased risk of dementia for n-NES with ≥ 16 years of education (HR 3.97; 95% CI 1.62-9.75; p = 0.003). We conclude that n-NES status does not appear to have an independent protective effect against incident dementia/AD, and that n-NES status may contribute to risk of dementia in an education-dependent manner.

Age-specific and sex-specific prevalence and incidence of mild cognitive impairment, dementia, and Alzheimer dementia in blacks and whites: a report from the Einstein Aging Study.

As the population ages, the need to characterize rates of cognitive impairment and dementia within demographic groups defined by age, sex, and race becomes increasingly important. There are limited data available on the prevalence and incidence of amnestic mild cognitive impairment (aMCI) and nonamnestic mild cognitive impairment (naMCI) from population-based studies. The Einstein Aging Study, a systematically recruited community-based cohort of 1944 adults aged 70 or older (1168 dementia free at baseline; mean age, 78.8 y; average follow-up, 3.9 y), provides the opportunity to examine the prevalence and incidence rates for dementia, Alzheimer dementia (AD), aMCI, and naMCI by demographic characteristics. Dementia prevalence was 6.5% (4.9% AD). Overall dementia incidence was 2.9/100 person-years (2.3/100 person-years for AD). Dementia and AD rates increased with age but did not differ by sex. Prevalence of aMCI was 11.6%, and naMCI prevalence was 9.9%. aMCI incidence was 3.8 and naMCI incidence was 3.9/100 person-years. Rates of aMCI increased significantly with age in men and in blacks; sex, education, and race were not significant risk factors. In contrast, naMCI incidence did not increase with age; however, blacks were at higher risk compared with whites, even when controlling for sex and education. Results highlight the public health significance of preclinical cognitive disease.

Differential impacts of age of acquisition on letter and semantic fluency in Alzheimer's disease patients and healthy older adults.

The degree to which the typical age of acquisition (AoA) of words and word frequency have separable influences on verbal production tasks has been strongly debated. To examine the overlap between these factors in verbal fluency tasks, the performance of Alzheimer's disease (AD) patients (N = 34) and normal elderly controls (N = 36) was compared on semantic (e.g., vegetables) and letter (e.g., words that begin with F) fluency tasks. These comparisons revealed that words generated for the semantic fluency task had an earlier AoA while words generated for the letter fluency task had a higher word frequency. Differences in AoA between AD patients and controls were larger for semantic than letter fluency. These results suggest that AoA has an effect on verbal production that is independent of word frequency and that AoA has a semantic locus.