"It Took the Stress out of Getting Help": The STAR-C-Telemedicine Mixed Methods Pilot.

BACKGROUND: Caring for a family member with Alzheimer's disease and related dementias can be mentally and physically taxing. Support programs are available to mitigate the strain of care, but caregivers report access challenges (e.g., distance). STAR-C is an evidence-based, effective, one-on-one caregiver educational intervention. However, family caregivers who do not live near a STAR-C consultant (e.g., rural caregivers) cannot participate in the program. The earth-bound mode presents a critical barrier to widely-available caregiver support. OBJECTIVES: We assessed the feasibility, preliminary efficacy, and cost of implementing a caregiver support intervention (STAR-C-Telemedicine), using Internet-based videoconferencing. DESIGN: Using a mixed-methods approach, we examined feasibility and pre- and post-intervention changes in caregiver burden. Focus groups provided feedback on program acceptability. SETTING: Participants, in their own homes, connected the university-based study staff using videoconferencing technology. PARTICIPANTS: Twenty family caregivers for those with dementia consented to the study. INTERVENTION: The STAR-C-TM intervention included 8 weekly sessions in which the universitybased consultant met (via videoconferencing) with caregivers in their homes. The intervention focused on identifying upsetting behaviors and identifying triggers to the behaviors. MEASUREMENTS: We assessed caregiver burden, depression and desire to institutionalize prior to and after the intervention. RESULTS: Fourteen caregivers (82% of those who started the intervention) completed all study components. We found statistically significant reductions in caregiver burden. Caregivers liked the videoconferencing option. Almost two-thirds reported, given the choice, that they would prefer it over an in-person offering. STAR-C-TM saved, on average, $1150/per caregiver over the traditional program. Qualitative findings supported the quantitative data. CONCLUSIONS: Telemedicine-based support for family caregivers is a feasible and cost-effective option. As the prevalence of dementia grows, programs such as STAR-C-TM can fill an important gap in caregiver education and support.

Serum vitamin D concentrations are associated with falling and cognitive function in older adults.

OBJECTIVES: To elucidate the mechanism through which vitamin D is associated with decreased falls. DESIGN: This was a convenience sample from a larger observational study examining correlations between vitamin D and 1) falls, 2) motor function, and 3) cognition (n=159). SETTING: Falls data were collected via weekly on-line surveys completed in the participants' homes. Yearly evaluations of motor and cognitive function were conducted in an out-patient setting of a large tertiary medical center. PARTICIPANTS: Participants from the Intelligent Systems for Assessment of Aging Changes Study (ISAAC), a community-based cohort study of independently living older adults over age 70, who had vitamin D concentration within 6 months of clinical evaluations were included in the analysis. RESULTS: Participants mean age was 85 years and 74% were women. Fallers (n=37) had significantly lower vitamin D concentration (32.9ng/ml) compared to non-fallers (39.2ng/ml) (p<0.01). The relationship between vitamin D and falls remained significant after adjusting for age, health status (via CIRS), and supplement use (p=0.004). Vitamin D concentration were significantly associated with cognitive impairment (Clinical Dementia Rating = 0.5) (p=0.02) and MMSE (p<0.01) after adjusting for age, gender, and education. Vitamin D concentrations did not correlate with any motor measures. CONCLUSION: Vitamin D concentrations correlated with cognition and falls, but not with motor measures. Further research is needed to demonstrate a causal relationship between vitamin D and cognitive function and determine if cognition plays a role in falls reduction.

In-home walking speeds and variability trajectories associated with mild cognitive impairment.

OBJECTIVE: To determine whether unobtrusive long-term in-home assessment of walking speed and its variability can distinguish those with mild cognitive impairment (MCI) from those with intact cognition. METHODS: Walking speed was assessed using passive infrared sensors fixed in series on the ceiling of the homes of elderly individuals participating in the Intelligent Systems for Assessing Aging Change (ISAAC) cohort study. Latent trajectory models were used to analyze weekly mean speed and walking speed variability (coefficient of variation [COV]). RESULTS: ISAAC participants living alone included 54 participants with intact cognition, 31 participants with nonamnestic MCI (naMCI), and 8 participants with amnestic MCI at baseline, with a mean follow-up of 2.6 ± 1.0 years. Trajectory models identified 3 distinct trajectories (fast, moderate, and slow) of mean weekly walking speed. Participants with naMCI were more likely to be in the slow speed group than in the fast (p = 0.01) or moderate (p = 0.04) speed groups. For COV, 4 distinct trajectories were identified: group 1, the highest baseline and increasing COV followed by a sharply declining COV; groups 2 and 3, relatively stable COV; and group 4, the lowest baseline and decreasing COV. Participants with naMCI were more likely to be members of either highest or lowest baseline COV groups (groups 1 or 4), possibly representing the trajectory of walking speed variability for early- and late-stage MCI, respectively. CONCLUSION: Walking speed and its daily variability may be an early marker of the development of MCI. These and other real-time measures of function may offer novel ways of detecting transition phases leading to dementia.

Variation in practice of ileal intubation among diverse endoscopy settings: results from a national endoscopic database.

BACKGROUND: Terminal ileum intubation rates at colonoscopy are variable. One of the major indications for terminal ileum intubation is to identify Crohn's disease. Signs and symptoms which raise a suspicion of Crohn's include abdominal pain/bloating, anaemia and diarrhoea. AIM: To determine the proportion of terminal ileal intubation in patients undergoing evaluation of abdominal pain/bloating, anaemia or diarrhoea with normal endoscopic findings at colonoscopy. METHODS: The Clinical Outcomes Research Initiative national endoscopic database was analysed to determine the proportion of terminal ileum intubation in patients undergoing evaluation of either abdominal pain/bloating, anaemia or diarrhoea with normal endoscopic findings at colonoscopy and to characterize this population of patients. Patients with known or suspected inflammatory bowel disease were excluded from the analysis. RESULTS: Between January 2000 and December 2003, 21 638 patients underwent complete colonoscopy for evaluation of either abdominal pain/bloating, anaemia or diarrhoea with normal colon findings. Overall, 3858 patients (18%) underwent terminal ileum evaluation. Intubation rates differed according to procedure indication: abdominal pain (13%), anaemia (13%), diarrhoea (28%). Terminal ileum assessment declined with advancing patient age and was least frequent in Black patients (12% vs. 18% in non-Blacks, P < 0.0001). Ileal intubation rates also varied among endoscopy site types: community (17%), academic (21%), Veterans Affairs Medical Centres (17%), P < 0.0001. Multiple logistic regression identified patients with the indication of diarrhoea (OR: 2.58) as more likely to undergo terminal ileum intubation when compared with those with abdominal pain/bloating. Patients in Veterans Affairs (OR: 1.26) and academic (OR: 1.29) sites were more likely to undergo terminal ileum intubation compared with community sites. CONCLUSION: Less than one-fifth of patients with either abdominal pain/bloating, anaemia or diarrhoea underwent ileal intubation in the setting of a normal colonoscopy. Significant practice variation was observed in rates of terminal ileum evaluation. Further study is required to determine whether terminal ileum examination impacts patient management or outcome.