Diagnosis and Disruption: Population-Level Analysis Identifying Points of Care at Which Transitions Are Highest for People with Dementia and Factors That Contribute to Them.

OBJECTIVES: To examine transitions that individuals with dementia experience longitudinally and to identify points of care when transitions are highest and the factors that contribute to those transitions. DESIGN: Population-based 10-year retrospective cohort study from 2000 to 2011. SETTING: General community. PARTICIPANTS: All individuals aged 65 and older newly diagnosed with dementia in British Columbia, Canada. MEASUREMENTS: The frequency and timing of transitions over 10 years, participant characteristics associated with greater number of transitions, and the influence of recommended dementia care and high-quality primary care on number of transitions. RESULTS: Individuals experience a spike in transitions during the year of diagnosis, driven primarily by hospitalizations, despite accounting for end of life or newly moving to a long-term care facility (LTCF). This occurs regardless of survival time or care location. Regardless of survival time, individuals not in LTCFs experience a marked increase in hospitalizations in the year before and the year of death, often exceeding hospitalizations in the year of diagnosis. Receipt of recommended dementia care and receipt of high-quality primary care were independently associated with fewer transitions across care settings. CONCLUSION: The spike in transitions in the year of diagnosis highlights a distressing period for individuals with dementia during which unwanted or unnecessary transitions might occur and suggests a useful target for interventions. There is an association between recommended dementia care and outcomes and evidence of the continued value of high-quality primary care in a complex population at a critical point when gaps in continuity are especially likely.

Caring for dementia: a population-based study examining variations in guideline-consistent medical care.

BACKGROUND: Evidence indicates that early detection and management of dementia care can improve outcomes. We assess variations in dementia care based on processes outlined in clinical guidelines by the BC Ministry of Health. METHOD: A population-based retrospective cohort study of community-dwelling seniors using patient-level administrative data in British Columbia, Canada. Guidelines measured: laboratory testing, imaging, prescriptions, complete examination, counseling, and specialist referral. RESULTS: Older patients were less likely to receive guideline-consistent medical care. Patients in higher income categories had higher odds of receiving counseling (confidence interval or CI 1.13-153) and referrals (15.1 CI 1.18-1.95) compared with those of lower income. Over a quarter of the cohort received an antipsychotic (28%) or nonrecommended benzodiazepine (26%). Individuals living within "rural" health authorities or of low income were more likely to receive antipsychotic treatment. CONCLUSION: Patterns of inequality by age and income may signal barriers to care, particularly for management of dementia care processes.

Exploring the ecology of Canada's publicly funded residential long-term care bed supply.

Despite Canada's increasing population of seniors and the varying long-term care (LTC) strategies that provinces have implemented, little research has focused on understanding the extent to which publicly funded residential LTC bed supply varies across provinces, or the factors influencing this variation. Our study involved an analysis in which we examined the association of three select jurisdictional characteristics with LTC bed supply: population age demographics, provincial wealth, and provincial investments in home care. No significant cross-jurisdictional "ecology" or inter-relatedness was found between the variation in LTC bed supply and any of the examined variables. Interprovincial variation in bed supply also did not statistically influence alternate level of care days specific to LTC waits, suggesting that these days were not influenced simply by differences in LTC bed supply and that other provincial-level factors were in play.

Variations in self-reported practice of physicians providing clinical care to individuals with dementia: a systematic review.

OBJECTIVES: To determine to what extent actual practice as reported in the literature is consistent with clinical guidelines for dementia care. DESIGN: A systematic review of empirical studies of clinical services provided by physicians to older adults with a diagnosis of dementia. SETTING: All settings involving primary care physicians in which a diagnosis of dementia is provided. PARTICIPANTS: Physicians providing care to individuals aged 60 and older with a primary or secondary diagnosis of dementia. INTERVENTION: Seven dementia care processes recommended by guidelines: formal memory testing, imaging, laboratory testing, interventions, counseling, community service, and specialist referrals. MEASUREMENTS: Web of Knowledge, PubMed, Science Direct, MedLine, PsychINFO, EMBASE, and Google Scholar databases were searched for articles in English published before March 1, 2012. RESULTS: Twelve studies met the final inclusion criteria, all of which were self-reported cross-sectional surveys. There was broad variation in the proportion of physicians who reported conducting each dementia care process, with the widest variation in formal memory testing (4-96%). Recently published studies reflected a shift in scope of care, reporting that high proportions of physicians provided interventions, counseling, and referrals to specialist. CONCLUSION: Despite the availability and dissemination of established best practice guidelines, there is still wide variation in physician practice patterns in dementia care. The quality of currently available studies limits the ability to draw strong conclusions. Better information on practice patterns and their relationship to outcomes for individuals with dementia and their caregivers using more-robust study designs is needed to address the needs of the increasing number of individuals who will require dementia care.

A method for identifying research priorities for health systems research on health and aging.

A rapid and feasible priority-setting method conducted within a limited budget was used to identify research topics that would have an influence on health services for older adults. Health and aging researchers, policy makers, and caregivers were recruited to complete Delphi surveys that generated and ranked topics and identified other potential researchers. An interdisciplinary team of researchers was selected to produce and submit a proposal to a peer-review-granting agency. This method can be adapted by organizations to determine the focus of their research agenda and to engage individuals for collaboration on future research projects.

Designation, diligence and drift: understanding laboratory expenditure increases in British Columbia, 1996/97 to 2005/06.

BACKGROUND: Laboratory testing is one of the fastest growing areas of health services spending in Canada. We examine the extent to which increases in laboratory expenditures might be explained by testing that is consistent with guidelines for the management of chronic conditions, by analyzing fee-for-service physician payment data in British Columbia from 1996/97 and 2005/06. METHOD: We used direct standardization to quantify the effect on laboratory expenditures from changes in: fee levels; population growth; population aging; treatment prevalence; expenditure on recommended tests for those conditions; and expenditure on other tests. The chronic conditions selected were those with guidelines containing laboratory recommendations developed by the BC Guidelines and Protocol Advisory Committee: diabetes, hypertension, congestive heart failure, renal failure, liver disease, rheumatoid arthritis, osteoarthritis and dementia. RESULT: Laboratory service expenditures increased by $98 million in 2005/06 compared to 1996/97, or 3.6% per year after controlling for population growth and aging. Testing consistent with guideline-recommended care for chronic conditions explained one-third (1.2% per year) of this growth. Changes in treatment prevalence were just as important, contributing 1.5% per year. Hypertension was the most common condition, but renal failure and dementia showed the largest changes in prevalence over time. Changes in other laboratory expenditure including for those without chronic conditions accounted for the remaining 0.9% growth per year. CONCLUSION: Increases in treatment prevalence were the largest driver of laboratory cost increases between 1996/97 and 2005/06. There are several possible contributors to increasing treatment prevalence, all of which can be expected to continue to put pressure on health care expenditures.

Cystamine and ethyl-eicosapentaenoic acid treatment fail to prevent malonate-induced striatal toxicity in mice.

Cystamine has demonstrated neuroprotective activity in a variety of studies, and is currently being evaluated in a human clinical trial in Huntington's disease (HD). Cystamine treatment of various genetic models of HD demonstrated protection against neurodegeneration and/or improvement in behavior. Given the need for a rapid screening tool for HD therapeutics, we assessed the potential therapeutic benefits of cystamine in a short-term acute toxicity murine model of striatal cell death. Cystamine did not provide neuroprotection against bilateral intrastriatal malonate injections in mice as measured by lesion size, loss of striatal volume, or decreased striatal neuronal counts. Similar results were obtained for treatment with another potential therapeutic agent that was protective in genetic mouse models of HD, the essential fatty acid ethyl-eicosapentaenoic acid. Our findings suggest that this toxic model is not reflective or predictive of findings in genetic mouse models, and may not be useful as a preclinical screen for HD therapeutics.