Rates of formal diagnosis in people screened positive for dementia in primary care: results of the DelpHi-Trial.

BACKGROUND: Primary data about rates of formal diagnosis of dementia in the German primary care sector are widely lacking. OBJECTIVES: Main objectives are to analyze the rate of syndrome diagnosis in primary care patients who screened positive for dementia, the distribution of differential diagnoses, and factors associated with undiagnosed dementia. METHODS: DelpHi-MV (Dementia: life- and person-centered help in Mecklenburg-Western Pomerania) is an ongoing general practitioner (GP)-based, randomized, controlled intervention trial. A total of 4,064 patients (≥70 years, living at home) recruited from 108 participating GP practices were screened for dementia (DemTect < 9). Of 692 eligible patients (17%), a total of 406 subjects (59%) provided informed consent. Present analyses are based on the data of 243 patients with complete baseline assessment on January 1, 2014 (preliminary data). Formal diagnoses were retrieved from the medical records of the treating GPs. A conditional fixed effect regression analysis was performed to analyze factors associated with undiagnosed dementia. RESULTS: A total of 40% of patients who screened positive for dementia had been formally diagnosed with dementia. Unspecified dementia was diagnosed in 53%, vascular dementia in 24%, and Alzheimer's disease in 19% of these patients. Undiagnosed dementia was significantly associated with a higher mean score in the Mini-Mental State Examination (odds ratio, 1.11; p < 0.01, 95% confidence interval 1.04-1.18). CONCLUSIONS: The diagnosis rate of dementia in German primary care (40%) is well within the range of the international data (20-50%). The results emphasize the need for action to enhance recognition and differential diagnosis of dementia.

Does an interdisciplinary network improve dementia care? Results from the IDemUck-study.

BACKGROUND: Most persons with dementia live at home and are treated in the primary care. However, the ambulatory health care system in Germany contains a lot of "interface problems" and is not optimized for the future challenges. Innovative concepts like regional networks in dementia care exist on a project level and need to be tested for efficacy to encourage implementation. The goal of the study is the scientific evaluation of an already existing regional dementia network. METHODS: Prospective randomized controlled trial of 235 community-living elderly with dementia and their family caregivers of network treatment (n=117) compared to usual care (n=118) in a predominantly rural region. The allocation to intervention or control group was based on network membership of their General Practitioner. Intervention patients received diagnostic evaluation and subsequent treatment according to network guidelines. Main outcome measures were the early contact with a neurologic or psychiatric specialist and dementia-specific medication as well as quality of life of the patients, and as secondary outcomes caregiver burden and caregiver health-related quality of life. RESULTS: Network patients were more likely to receive antidementive drugs (50.5 % vs. 35.8 %; p=0.035) and had more often contact to a neurologist (18.6 % vs. 2.8 %; p<0.001). No group differences were found on patient's quality of life nor overall effects or treatment by time effects. Intervention caregivers reported no significant improvements in health related quality of life measured by SF-36 and EQ-5D. CONCLUSION: The management of dementia patients in an interdisciplinary regional network solelyprovides measurable advantages with respect to the provision of dementia-specific medication and utilization of medical treatment i.e. referral rates to specialists. Further evaluation research is needed to identify relevant mechanismsof collaborative processes with respect to their impact on patient and caregiver related outcomes.

The benefits of implementing a computerized intervention-management-system (IMS) on delivering integrated dementia care in the primary care setting.

BACKGROUND: A computerized Intervention-Management-System (IMS) has been developed and implemented to facilitate dementia care management. IMS is a rule-based expert decision support system that matches individual patient characteristics to a computerized knowledge base. One of the most important functionalities of IMS is to support the compilation of the individual intervention plan by systematically identifying unmet needs and suggesting the corresponding specific interventions for recommendation to the general practitioner (GP). The present analysis aimed to determine if the implementation of IMS improves the identification of unmet needs and the recommendation of adequate specific interventions. In addition, the feasibility and acceptability of the IMS were evaluated. METHODS: Delphi-MV is an on-going GP-based, cluster-randomized, controlled intervention trial to implement and evaluate a collaborative dementia care management program for community-dwelling PWDs and their caregivers. IMS was developed and implemented over the course of the DelpHi-trial. The identified unmet needs and the interventions that were recommended to the GP before and after the implementation of IMS were compared. To evaluate the feasibility and acceptability of the IMS, a survey was conducted among the current users of IMS. RESULTS AND CONCLUSIONS: After the implementation of IMS, the number of specific interventions recommended to the GP increased by 85%. Our findings provide evidence that IMS improves the systematic identification of unmet needs and the subsequent recommendation of interventions to address these needs. The users evaluated IMS as very helpful and would like to use it for their future work. However, the usability could be further improved.

Dementia care management: going new ways in ambulant dementia care within a GP-based randomized controlled intervention trial.

BACKGROUND: Increasing prevalence of dementia is a major challenge for the German healthcare system. The study DelpHi-MV ("Dementia: life- and person-centered help in Mecklenburg-Western Pomerania") aims to implement and evaluate an innovative subsidiary support system for persons with dementia (PwDs) living at home and their caregivers. METHODS: DelpHi-MV is a GP-based cluster randomized controlled intervention trial. DelpHi-Intervention aims to provide "optimum care" by integrating multi-professional and multimodal strategies to individualize and optimize treatment of dementia within the framework of the established healthcare and social service system. The intervention is conducted by Dementia Care Managers (DCMs)--nurses with dementia-specific training--at the people's homes. Based on German guidelines for evidence-based diagnoses and treatment of dementia, a comprehensive set of 95 interventio--modules--the "DelpHi-Standard"--was defined. Each module consists of predefined trigger condition(s), a subsequent intervention task, as well as at least one criterion for its completion. The intervention begins with a comprehensive assessment of the care situation, needs, and resources. The DCM develops and implements an intervention plan tailored to the individual conditions in close cooperation with the GP. EXPECTED RESULTS AND CONCLUSIONS: We expect statistically significant differences between control and intervention group in primary outcomes (quality of life, behavioral and psychological symptoms of dementia, pharmacotherapy, caregiver burden). Results can provide evidence for the effectiveness and efficacy of dementia care management according to the "Delphi-Standard"--prerequisites for implementing this concept into routine healthcare.

[Prevalence of dementia and medical care in German nursing homes: a nationally representative survey]. / Prävalenz von Demenzen und ärztliche Versorgung in deutschen Pflegeheimen: eine bundesweite repräsentative Studie.

OBJECTIVE: The study aimed to determine the prevalence of dementia and the degree of medical care among residents of nursing homes based on a nationally representative sample of nursing homes in Germany for the first time. METHODS: Based on a probability sample of 609 long-term care institutions in Germany, we drew a sample of 86 facilities by applying a two-stage random procedure. All residents of the participating care facilities were comprehensively assessed by qualified nurses using a standardized Care and Behavior Assessment (CBA). RESULTS: Of the 4,481 residents assessed in 58 care facilities (mean age 82.6 years;78 % female) on average 68.6 % (95 % CI: 67.0 - 69.8) were affected by a dementia-syndrome, 56.6 % by a severe dementia-syndrome. There were frequent contacts between residents and general practitioners, but provision of specialized medical care seemed to be deficient in many aspects. CONCLUSION: People with dementia form the major group of residents in German nursing homes. The study provides important data on need for care and health care planning.

At-risk alcohol drinking in primary care patients aged 75 years and older.

BACKGROUND: Little is known about the prevalence and risk factors of alcohol problems among older people (especially those aged 75 years and more). The aims of this study were to report alcohol consumption patterns and to determine their association with socio-demographic variables and health characteristics. METHOD: 3224 non-demented subjects aged 75 and over and attending general practitioners (GPs) (n = 138) in an urban area of Germany were studied by structured clinical interviews including detailed assessment of alcohol consumption patterns distinguishing between abstainers, moderate drinkers and at-risk drinkers (>20 g of alcohol for women and >30 g of alcohol for men). RESULTS: A high proportion (50.1%) of the sample were abstainers, 43.4% were moderate drinkers. The prevalence of at-risk alcohol consumption was 6.5% (95% CI 5.6-7.4). Rates were significantly higher for men (12.1%; 95% CI 10.2-14.0) compared to women (3.6%; 95% CI 2.8-4.4). After full adjustment for confounding variables we found that compared to moderate drinking abstaining from alcohol was significantly associated with female gender, lower education, and mobility impairment. Compared to moderate drinking at-risk drinking was significantly higher among men, individuals with a liver disease, and current smokers. CONCLUSIONS: Multivariate analysis revealed that, apart from liver disease, at-risk drinking in a non-demented population aged 75 and over was associated with relatively good physical and mental health. Nevertheless, public prevention measures should focus on at-risk drinkers to make them aware of potential risks of high alcohol consumption in old age.

Prevalence and risk factors for depression in non-demented primary care attenders aged 75 years and older.

BACKGROUND: Depression among the elderly is an important public health issue. The aims of this study were to report the prevalence of depression and to determine the impact of socio-demographic variables, functional impairment and medical diagnoses, lifestyle factors, and mild cognitive impairment on depression as part of the German Study on Ageing, Cognition and Dementia in Primary Care Patients (AgeCoDe Study). METHODS: Included in the cross-sectional survey were 3327 non-demented subjects aged 75 and over attending general practitioners (GPs) (n=138) in an urban area of Germany. The GDS-15 Geriatric Depression Scale was used to measure depression with a threshold of <6/6+. Associations with social and clinical risk factors were assessed by means of multiple logistic regression models. RESULTS: The prevalence of depression was 9.7% (95% confidence interval 8.7-10.7). In a univariate analysis, the following variables were significantly associated with depression: female gender, increasing age, living alone, divorce, lower educational status, functional impairment, comorbid somatic disorder, mild cognitive impairment, smoking, and abstinence from alcohol. After full adjustment for confounding variables, odds ratios for depression were significantly higher only for functional impairment, smoking, and multi-domain mild cognitive impairment. LIMITATIONS: Recruitment procedures might have led to an underestimation of current prevalence. The cross-sectional data did not allow us to analyze the temporal relationship between risk factors and depression. CONCLUSIONS: The prevalence of depression in the elderly is high and remains high into old age. In designing prevention programs, it is important to call more attention to the impact of functional and cognitive impairment on depression.

Proxy screening tools improve the recognition of dementia in old-age homes: results of a validation study.

BACKGROUND: Despite the high true prevalence of dementia, demential disorders of residents of old age homes may often be not recognized. There is a need for a standardised tool which includes observations of nursing staff. OBJECTIVE: To describe and validate the Dementia Screening Scale (DSS) for use by nursing staff in old-age homes. METHODS: All residents of 20 randomly selected old age homes in the city of Mannheim, Germany (n = 1, 922) were rated by nurses using the seven-item proxy dementia rating scale. Based on a subset of residents (n = 598) the DSS was validated against independent diagnostic assessments made by trained psychologists including the Mini-Mental-State-Examination (MMSE), the Dementia Scale of the Brief Assessment Schedule (BAS DEM), and the Washington University Clinical Dementia Rating (CDR). RESULTS: Using the CDR as a gold standard, the DSS correctly classified at a cut-off of 2/3, 85.8% of the mildly, moderately, or severely demented residents. The accuracy of the DSS was only a little worse than that of the MMSE and the BAS DEM. CONCLUSION: The DSS is well-suited for the recognition of dementia in old age homes. It achieved a better validity than global diagnosis-related staff assessments and compared to performance-based instruments. It is easier to apply, more economic, and associated with a fewer rate of non-response.