Maintenance of occupational therapy (OT) for dementia: protocol of a multi-center, randomized controlled and pragmatic trial.

BACKGROUND: There is a growing interest in developing tailored non-pharmacological strategies to face patients' needs in dementia. Occupational therapy (OT) may contribute to promote self-empowerment of both patients and caregivers. France has implemented nationwide OT over a short-term period of 3/4 months. The main objective of the MathéoAlz study is to measure the impact of maintaining OT over 4 supplementary months on patients' neuropsychiatric symptoms. METHODS/DESIGN: The MatheoAlz trial (Maintenance of Occupational Therapy in Alzheimer's disease) is a multi-center, pragmatic randomized controlled trial testing maintenance of OT over 4 supplementary months compared to routine OT delivered as recommended. This paper describes the study protocol. MatheoAlz plans to enroll 240 dyads, i.e. dementia patients and caregivers, whose main inclusion criteria are: prescription for routine OT, patients with mild or moderate dementia, living at home, receiving support from an informal caregiver. The study will compare a control group of patients benefiting from 12 to 15 initial sessions of OT over 3/4 months and an intervention group of patients benefiting from these initial sessions plus 8 extra home sessions over 4 supplementary months. The main outcome is the patient's neuropsychiatric symptoms assessed by the Neuropsychiatric Inventory at 8 months. Several clinical outcomes and economic consequences are measured at 4, 8 and 12 months. DISCUSSION: This is the first trial designed to assess the specific impact of the maintaining OT on the patients' neuropsychiatric symptoms burden. The results will inform policymakers on strategies to implement in the near future. TRIAL REGISTRATION: This trial was registered at ClinicalTrials.gov on February 16, 2018, identifier: NCT03435705 .

A comprehensive approach of the determinants of use of care in dementia: the Recaredem (recourse to care in dementia) cross-sectional study.

BACKGROUND: Given the rate of the undiagnosed cases of dementia and the consequences of inappropriate care, understanding the factors that explain the use of medical and health care in dementia is a critical concern. Our objective was to identify the psychosocial and medical determinants of use of care in dementia. METHODS: The study sample consisted of 308 participants: the persons with dementia (n = 99) selected from three French population-based cohorts (i.e. PAQUID, 3C, AMI), their family caregivers (primary, n = 96, and secondary, n = 51), and their general practitioners (n = 62). Use of care in dementia was considered according to two indicators: (1) recourse to secondary care, (2) number of community and health services used. RESULTS: Multiple logistic models including sociodemographics and psychosocial variables revealed that the determinants of nonuse of care are similar both for the recourse to secondary care and for the number of community and health services used: lack of education and the contribution of the people with dementia to the decisions regarding their own care and dementia care services in the community area. In addition, satisfaction of the primary caregiver with the services used by his/her relative is associated with non-recourse to secondary care. CONCLUSIONS: Taken together, these results highlight the predominant role of psychosocial factors in the use of care in dementia and the importance of addressing this issue through an integrative approach including psychological, social, medical, and family dimensions.

Description of general practitioners' practices when suspecting cognitive impairment. Recourse to care in dementia (Recaredem) study.

OBJECTIVE: General practitioners (GPs) play a major role in the assessment of dementia but it is still unrecognized in primary care and its management is heterogeneous. Our objective is to describe the usual practices, and their determinants, of French GPs in this field. METHODS: GPs' characteristics and practices when facing cognitive decline were collected through a telephone interview and a postal questionnaire. A descriptive analysis of all study variables was conducted. The study of quantitative explanatory variables was done by testing the equality of means and the choice of qualitative variables was based on the chi-square independence test or Fischer test. RESULTS: Hundred two GPs completed the study. GPs were in majority men, working in urban areas. Mean age was 54.4 years old. GPs' feeling of confidence and self-perception of follow-up of national recommendations is linked with their practices. Performing a clinical interview to assess cognitive impairment is linked with good communication skills. GPs feel less confident to give information about resources for dementia. The main reason alleged for underdiagnosis is the limited effectiveness of drug therapy. CONCLUSIONS: This study underlines the importance of GPs' feeling of confidence when managing cognitively impaired patients with dementia, and the need of increasing training in the field of dementia, which could improve the awareness of GPs about diagnosis and available resources.

Living alone and unplanned hospitalizations among older adults: a population-based longitudinal study.

Background: The association of living alone with hospitalization among the general elderly population has been rarely investigated, and the influence of common disorders on this association remains unknown. Methods: We used data on participants in the Swedish National study on Aging and Care in Kungsholmen ( n = 3130). Risk and number of unplanned hospitalizations and length of hospital stays were studied over a period of 2 years. We used Cox proportional hazard models to estimate hazard ratios (HRs) of incident hospitalization and zero-inflated negative binomial regression models adjusted for potential confounders to estimate incident rate ratios (IRR) of the number of hospitalizations and total length of stay associated with living alone. Results: A total of 1768 participants (56.5%) lived alone. Five hundred and sixty-one (31.7%) of those who lived alone had at least one unplanned hospitalization. In the multivariate analyses, living alone was significantly associated with the risk of unplanned hospitalization (HR = 1.21, 95% confidence interval [CI] 1.01-1.45) and the number of hospitalizations (IRR = 1.35, 95% CI 1.04-1.76) but not with the length of hospital stays. In stratified analyses, the association between living alone and unplanned hospitalizations remained statistically significant only among men (HR = 1.52, 95% CI 1.17-1.99). Conclusions: Living alone is associated with higher risks of unplanned hospitalization in elderly, especially for men.

Benefits of Occupational Therapy in Dementia Patients: Findings from a Real-World Observational Study.

BACKGROUND: There is a growing interest in developing non-pharmacological approaches in dementia. Clinical efficacy of occupational therapy (OT) under routine care conditions has not been investigated yet. OBJECTIVE: To analyze the short-term effects of OT in patients with dementia; and to identify factors related to greater benefit. METHODS: Patients referred to OT were evaluated before starting a 3-month intervention and at 3 and 6 months later. Measures included: Mini-Mental State Examination (MMSE), Disability Assessment in Dementia (DAD), Neuropsychiatric Inventory (NPI) Questionnaire, patients' quality of life (EQ 5D-VAS), caregivers' burden (Zarit scale), and amount of informal care. Linear mixed models were used to analyze trajectories of outcomes. Logistic regressions with stepwise descending selection were used to study factors associated with benefits. RESULTS: 421 dementia patients benefited from OT (mean MMSE = 17.3). Patients remained cognitively stable over time. Functional performances also remained stable at 3 months and significantly decreased at 6 months (crude reduction of 2.8 points, p < 0.01). Behavioral troubles were significantly reduced over the intervention period and remained stable after (p < 0.01). Patients' quality of life increased over the 3-month intervention (p = 0.16) and significantly decreased thereafter. Caregivers' burden and informal care significantly decreased over the 3-month intervention and remained stable thereafter. Patients who benefited from OT with regard to function were less educated and had higher cognitive level. CONCLUSION: OT may be an effective intervention to maintain cognition and functionality and to reduce psychiatric symptoms in dementia patients. Mild stages of dementia could gain more benefits from OT with regard to functional decline.

Influence of Incipient Dementia on Hospitalization for Primary Care Sensitive Conditions: A Population-Based Cohort Study.

BACKGROUND: Studies have reported that moderate/severe stages of dementia are linked to increased hospitalization rates, but little is known about the influence of incipient dementia on hospitalizations for primary care sensitive conditions (PCSCs). OBJECTIVE: To examine the associations between incipient dementia and hospitalization outcomes, including all-cause and PCSC hospitalization. METHODS: A total of 2,268 dementia-free participants in the Swedish National study on Aging and Care-Kungsholmen were interviewed and clinically examined at baseline. Participants aged ≥78 years were followed for 3 years, and those aged 60-72 years, for 6 years. Number of hospitalizations was retrieved from the National Patient Register. Dementia was diagnosed in accordance with Diagnostic and Statistical Manual of Mental Disorders-IV criteria. Hospitalization outcomes were compared in participants who did and did not develop dementia. Zero-inflated Poisson regressions and logistic regressions were used in data analysis. RESULTS: During the follow-up, 175 participants developed dementia. The unadjusted PCSC admission rate was 88.2 per 1000 person-years in those who developed dementia and 25.6 per 1000 person-years in those who did not. In the fully adjusted logistic regression model, incipient dementia was associated with an increased risk of hospitalization for PCSCs (OR = 2.3, 95% CI 1.3-3.9) but not with the number of hospitalizations or with all-cause hospitalization. Risks for hospitalization for diabetes, congestive heart failure, and pyelonephritis were higher in those who developed dementia than in those who did not. About 10% participants had a PCSC hospitalization attributable to incipient dementia. CONCLUSION: People with incipient dementia are more prone to hospitalization for PCSCs but not to all-cause hospitalization.

Effect of Early Referral to Specialist in Dementia on Institutionalization and Functional Decline: Findings from a Population-Based Study.

BACKGROUND: Although early diagnosis has been hypothesized to benefit both patients and caregivers, until now studies evaluating the effect of early dementia diagnosis are lacking. OBJECTIVE: To investigate the influence of early specialist referral for dementia on the risk of institutionalization and functional decline in Activity of Daily Living (ADL). METHODS: Incident dementia cases were screened in a prospective population-based cohort, the Three-City Study, and initial specialist consultation for cognitive complaint was assessed at dementia diagnosis. Proportional hazard regression and illness-death models were used to test the association between specialist referral and, respectively, institutionalization and functional decline. RESULTS: Only one third of the incident individuals with dementia had consulted a specialist for cognitive problems early (36%). After adjustment on potential confounders (including cognitive and functional decline) and competing risk of death, participants who had consulted a specialist early in the disease course presented a higher rate of being institutionalized than those who did not (Hazard Ratio = 2.00, 95% Confidence Interval (CI): 1.09- 3.64). But early specialist referral was not associated with further functional decline (HR = 1.09, 95% CI: 0.71- 1.67). CONCLUSIONS: Early specialist referral in dementia is associated with increased risk of institutionalization but not with functional decline in ADL. These findings suggest that early care referral in dementia may be a marker of concern for patients and/or caregivers; subsequent medical and social care could be suboptimal or inappropriate to allow patients to stay longer at home.

Impact of living alone on institutionalization and mortality: a population-based longitudinal study.

BACKGROUND: Living alone is common among elderly people in Western countries, and studies on its relationship with institutionalization and all-cause mortality have shown inconsistent results. We investigated that the impact of living alone on institutionalization and mortality in a population-based cohort of elderly people. METHODS: Data originate from the Swedish National study on Aging and Care-Kungsholmen. Participants aged ≥66 years and living at home (n = 2404) at baseline underwent interviews and clinical examination. Data on living arrangements were collected in interviews. All participants were followed for 6 years; survival status and admission into institutions were tracked continuously through administrative registers from 2001 to 2007. Data were analysed using Cox proportional hazard models, competing risk regressions and Laplace regressions with adjustment for potential confounders. RESULTS: Of the 2404 participants, 1464 (60.9%) lived alone at baseline. During the follow-up, 711 (29.6%) participants died, and 185 (15.0%) were institutionalized. In the multi-adjusted Cox model, the hazard ratio (HR) of mortality in those living alone was 1.35 (95% confidence interval [CI] 1.18 to 1.54), especially among men (HR = 1.44, 95% CI 1.18 to 1.76). Living alone shortened survival by 0.6 years and was associated with the risk of institutionalization (HR = 1.74, 95% CI 1.10 to 2.77) after taking death into account as a competing risk. CONCLUSIONS: Living alone is associated with elevated mortality, especially among men and an increased risk of institutionalization. Over a 6-year period, living alone was related to a half year reduction in survival among elderly people in Sweden.

[New professional field in France: Analysis of the training needs of case managers]. / Nouveau champ professionnel en France. Les besoins de formation des gestionnaires de cas.

Case management is a relatively new career field in France. It was first introduced on an experimental basis in 2007-2008, and was then developedfollowing the National Alzheimer Plan and finally enshrined in legislation in 2012. This careerfield is based on a set of tasks widely described internationally: identifying the right level of intervention, standardized multidimensional assessment, planning all aid (care and social services), implementation of the plan, monitoring and reassessment and periodic reassessment of all needs in a continuous and long-term process. The specific, systematic and dedicated nature of these tasks to these tasks makes training essential. Regulations also stipulate that the professional must acquire additional training by a dedicated inter-university degree. This requirement is a French specificity The authors present the history of case management and training in France and analyze the various international training frameworks identified by an Internet search. Moreover, based on the opinions expressed by case managers at different times of the scientific assessment and a review ofseveral studies conducted by inter-university case management program students, this article highlights the specific training needs of case managers and how the proposed training can meet these needs.

Survival and early recourse to care for dementia: A population based study.

BACKGROUND: A large proportion of dementia cases are still undiagnosed. Although early dementia care has been hypothesized to benefit both patients and families, evidence-based benefits are lacking. Thus, investigating the benefits for newly demented persons according to their recourse to care in the "real life" appears critical. METHODS: We examined the relation between initial care recourse care and demented individuals' survival in a large cohort of incident dementia cases screened in a prospective population-based cohort, the Three-City Study. We assessed recourse to care for cognitive complaint at the early beginning of dementia when incident cases were screened. We classified patients in three categories: no care recourse, general practitioner consultation or specialist consultation. We used proportional hazard regression models to test the association between recourse to care and mortality, adjusting on socio-demographical and clinical characteristics. RESULTS: Two hundred and fifty-three incident dementia participants were screened at the 2 year or 4 year follow-up. One third of the incident demented individuals had not consulted a physician for cognitive problems. Eighty-six (34.0%) individuals had reported a cognitive problem only to their general practitioner (GP) and 80 (31.6%) had consulted a specialist. Mean duration of follow-up after incident dementia was 5.1 years, during which 146 participants died. After adjustment on potential confounders, participants who had consulted a specialist early in the disease course presented a poorer survival than those who did not consult any physician (hazard ratio = 1.64, 95% confidence interval 1.03-2.62). There was a trend but no significant differential survival profile between participants who complained to their GP and those without any care recourse. CONCLUSION: Neither recourse to a specialist nor recourse to GP improve survival of new dementia cases. Those who had consulted a specialist early in the disease course even reported a worse life expectancy than those who did not.

[Determinants of support for dementia patients in general practice: a qualitative approach based on an epidemiological cohort]. / Déterminants de la prise en charge des patients déments dépistés dans une cohorte populationnelle : approche qualitative auprès de leurs médecins généralistes.

BACKGROUND: the analysis of access to diagnosis and care pathway for dementia patients shows that the disease is not considered as a priority for the general practitioner (GP). Different studies have point out under diagnosis of dementia. PURPOSE: the purpose of this qualitative study was to document the determinants of the diagnosis and management of dementia by GP. METHODS: recruitment of GPs (n = 12) was made from incident cases of dementia who were identified during the follow-up of subject enrolled in the 3 Cities cohort study. A semi-structured interview was conducted with an interview guide focused on the experience of the doctors. A phenomenological and pragmatic analysis, taking into account all the linguistic and extra linguistic evidence contained in the transcript was conducted. RESULTS: several emerging categories have been described: the doctors believe that the management of Alzheimer's disease is a public health problem and not an individual, the positioning of the GP in the care system is central. Determinants that influence the management are the identity of the physician, the impression of a fuzzy nosology, the finding of a therapeutic ineffectiveness, the priority given to severe co-morbidities and the workload of the general practitioner. However, the ordering of these categories according to the pragmatic phenomenological approach showed that the identity of the doctor, professional and personal, is at the origin of behavioral variability in their medical care. CONCLUSION: in a context of increased workload, the GP favors the assumption of comorbidities in the elderly given fuzzy nosology of dementia and uncertainty about the therapeutic efficacy. The phenomenological approach allows understanding that the human identity of the doctor, personal and professional identity, is the major factor that influence its care attitude for demented patients.

The 2008-2012 French Alzheimer plan: a unique opportunity for improving integrated care for dementia.

The 2008-2012 French Alzheimer plan has proposed measures to improve care for dementia patients in a more personalized and graduate approach owing to patients and caregivers needs. A key measure of the plan is the nationwide implementation of the MAIA (French acronym for Maison pour l'Autonomie et l'Intégration des malades d'Alzheimer). The main goal is to implement a process of integration through a network of partners involved in elderly care, assistance, or support. The MAIA model comprises tools and mechanisms necessary to improve the integrated care process; in particular, case management for elderly in complex situations. The purpose of this paper is to describe the main measures from the national plan that aim to improve care for dementia patients with an emphasis on the MAIA measure. We summarize initial results of case management activity in one MAIA in the South West of France and we present two vignettes of cases benefiting from case management in order to demonstrate the nature of intervention. The French Alzheimer plan has promoted several non-pharmacological strategies for dementia patients. Implementation of both integrated care and case management represent a challenging perspective for the elderly and health professionals.

Effectiveness of disease-management programs for improving diabetes care: a meta-analysis.

BACKGROUND: We conducted a meta-analysis of randomized controlled trials to assess the effectiveness of disease-management programs for improving glycemic control in adults with diabetes mellitus and to study which components of programs are associated with their effectiveness. METHODS: We searched several databases for studies published up to December 2009. We included randomized controlled trials involving adults with type 1 or 2 diabetes that evaluated the effect of disease-management programs on glycated hemoglobin (hemoglobin A1(C)) concentrations. We performed a meta-regression analysis to determine the effective components of the programs. RESULTS: We included 41 randomized controlled trials in our review. Across these trials, disease-management programs resulted in a significant reduction in hemoglobin A1(C) levels (pooled standardized mean difference between intervention and control groups -0.38 [95% confidence interval -0.47 to -0.29], which corresponds to an absolute mean difference of 0.51%). The finding was robust in the sensitivity analyses based on quality assessment. Programs in which the disease manager was able to start or modify treatment with or without prior approval from the primary care physician resulted in a greater improvement in hemoglobin A1(C) levels (standardized mean difference -0.60 v. -0.28 in trials with no approval to do so; p < 0.001). Programs with a moderate or high frequency of contact reported a significant reduction in hemoglobin A1(C) levels compared with usual care; nevertheless, only programs with a high frequency of contact led to a significantly greater reduction compared with low-frequency contact programs (standardized mean difference -0.56 v. -0.30, p = 0.03). INTERPRETATION: Disease-management programs had a clinically moderate but significant impact on hemoglobin A1(C) levels among adults with diabetes. Effective components of programs were a high frequency of patient contact and the ability for disease managers to adjust treatment with or without prior physician approval.