Archive for the ‘dementia’ Category

Lost and Found: Understanding Technologies Used to Locate Missing Persons with Alzheimer’s or Dementia

April 14, 2014 Comments off

Lost and Found: Understanding Technologies Used to Locate Missing Persons with Alzheimer’s or Dementia (PDF)
Source: Bureau of Justice Assistance

Alzheimer’s disease and other forms of dementia affect not only those who are living with the disease; these afflictions also impact the caregivers, law enforcement, and even neighbors. As the disease progresses, physical and mental capabilities are negatively impacted, short-term memory loss increases, and a person with Alzheimer’s might begin living in the past. As the person attempts to return to former places of employment or residences, they often get lost and need assistance returning to where they are currently residing. It is never possible to predict if or when a person with Alzheimer’s will wander or be unable to navigate familiar routes. Initiating a search for a person with Alzheimer’s can never be delayed, and conducting such searches can prove to be costly and consume extreme amounts of agency resources. It is crucial for law enforcement officers and other first responders to be familiar with and understand the signs of dementia and be aware of passive identification products used to identify persons with Alzheimer’s. In addition to passive identification techniques, there are technologies and products available that can be used to actively locate an individual who is lost.

Cellular location techniques and Global Positioning System devices are examples of proven methods for aiding law enforcement in a search for a missing person with dementia. This document will provide a technical description of these technologies and outline some of the advantages and disadvantages when employing these products. It will also provide comprehensive lists of locating devices that are currently available. Provided in each section is a short technical description of the technology and its advantages and the disadvantages. Appendix I and Appendix II provide a list of passive and active locating devices currently available.

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Dementia Special Care Units in Residential Care Communities: United States, 2010

December 2, 2013 Comments off

Dementia Special Care Units in Residential Care Communities: United States, 2010
Source: National Center for Health Statistics

Key findings

  • In 2010, 17% of residential care communities had dementia special care units.
  • Beds in dementia special care units accounted for 13% of all residential care beds.
  • Residential care communities with dementia special care units were more likely than those without to have more beds, be chain-affiliated, and be purposely built as a residential care community, and less likely to be certified or registered to participate in Medicaid.
  • Residential care communities with dementia special care units were more likely than those without to be located in the Northeast and in a metropolitan statistical area, and less likely to be in the West.

UK — Independent report: Peer support networks and dementia advisers: evaluation

October 10, 2013 Comments off

Independent report: Peer support networks and dementia advisers: evaluation
Source: Department of Health

This report, commissioned by the Department of Health, provides evidence on the importance of post diagnostic support for people with dementia and their carers, and the role that dementia advisers and peer support networks can provide in this.

Important messages from the report are:

  • people with dementia and carers saw dementia advisers and peer support networks as having a positive impact on their wellbeing and quality of life
  • demonstrator sites provided evidence of both dementia advisers and peer support networks filling a gap in service provision that often occurs after diagnosis but before
  • there is a need for more intensive support
  • both initiatives were seen as having resource saving implications for the local health and social care economy

Hygiene and the world distribution of Alzheimer’s disease; Epidemiological evidence for a relationship between microbial environment and age-adjusted disease burden

September 25, 2013 Comments off

Hygiene and the world distribution of Alzheimer’s disease; Epidemiological evidence for a relationship between microbial environment and age-adjusted disease burden
Source: Evolution, Medicine, and Public Health

Background and objectives:
Alzheimer’s disease (AD) shares certain etiological features with autoimmunity. Prevalence of autoimmunity varies between populations in accordance with variation in environmental microbial diversity. Exposure to microorganisms may improve individuals’ immunoregulation in ways that protect against autoimmunity, and we suggest that this may also be the case for AD. Here, we investigate whether differences in microbial diversity can explain patterns of age-adjusted AD rates between countries.

We use regression models to test whether pathogen prevalence, as a proxy for microbial diversity, across 192 countries can explain a significant amount of the variation in age-standardized AD disability-adjusted life-year (DALY) rates. We also review and assess the relationship between pathogen prevalence and AD rates in different world populations.

Based on our analyses, it appears that hygiene is positively associated with AD risk. Countries with greater degree of sanitation and lower degree of pathogen prevalence have higher age-adjusted AD DALY rates. Countries with greater degree of urbanization and wealth exhibit higher age-adjusted AD DALY rates.

Conclusions and implications:
Variation in hygiene may partly explain global patterns in AD rates. Microorganism exposure may be inversely related to AD risk. These results may help predict AD burden in developing countries where microbial diversity is rapidly diminishing. Epidemiological forecasting is important for preparing for future healthcare needs and research prioritization.

Political drive to screen for pre-dementia: not evidence based and ignores the harms of diagnosis

September 11, 2013 Comments off

Political drive to screen for pre-dementia: not evidence based and ignores the harms of diagnosis
Source: British Medical Journal

Clinical context
Dementia is age related and with an ageing global population is predicted to become an overwhelming and costly problem.

Diagnostic change
Introduction of broader diagnostic criteria for mild cognitive impairment and pre-dementia based on new cognitive screening tests coupled with cerebrospinal fluid biomarkers and neuroimaging.

Rationale for change
Past neglect of services and research in dementia has fuelled international calls for action and earlier treatment.

Leap of faith
People with mild symptoms will eventually develop dementia and interventions are more likely to be effective at an early stage.

Impact on prevalence
The current prevalence of dementia is thought to be 10-30% in people over the age of 80, but the adoption of new diagnostic criteria will result in up to 65% of this age group having Alzheimer’s disease diagnosed and up to 23% of non-demented older people being diagnosed with dementia.

Evidence of overdiagnosis
Screening for cognitive impairment and measurement of biomarkers and neuroimaging are increasing the diagnosis of mild cognitive impairment, which in many people will improve spontaneously.

Harms from overdiagnosis
Unnecessary investigation and treatments with side effects; adverse psychological and social outcomes; and distraction of resources and support from those with manifest dementia in whom need is greatest.

Current case identification and screening policy relies mostly on anecdotal and observational data from potentially biased sources, including those with vested commercial interests, rather than evidence from clinical trials. There is a lack of research focused on older people, in whom dementia is most prevalent.

Current policy is rolling out untested and uncontrolled experiments in the frailest people in society without a rigorous evaluation of its benefits and harms to individuals, families, service settings, and professionals.

A state-by-state guide to: Missing Senior/Adult Public Alert Systems

July 24, 2013 Comments off

A state-by-state guide to: Missing Senior/Adult Public Alert Systems
Source: International Association of Chiefs of Police

With more than 5 million Americans currently living with Alzheimer’s disease and approximately 500,000 new cases of this disease emerging each year, projections pronounce that there could be as many as 16 million Americans that will have Alzheimer’s by 2050. To help law enforcement protect this special population, IACP’s Alzheimer’s Initiatives program is committed to helping first responders improve their knowledge and skills to safeguard this special population.

This interactive map displays a state-by-state guide to the systems used to alert the public regarding missing persons with Alzheimer’s disease or other form of dementia. programs available throughout the 50 states. Also, once you click on a state, you will be able to see more in-depth state specific statistics and resources.

Evaluation of Excess Significance Bias in Animal Studies of Neurological Diseases

July 19, 2013 Comments off

Evaluation of Excess Significance Bias in Animal Studies of Neurological Diseases
Source: PLoS Biology

Animal studies generate valuable hypotheses that lead to the conduct of preventive or therapeutic clinical trials. We assessed whether there is evidence for excess statistical significance in results of animal studies on neurological disorders, suggesting biases. We used data from meta-analyses of interventions deposited in Collaborative Approach to Meta-Analysis and Review of Animal Data in Experimental Studies (CAMARADES). The number of observed studies with statistically significant results (O) was compared with the expected number (E), based on the statistical power of each study under different assumptions for the plausible effect size. We assessed 4,445 datasets synthesized in 160 meta-analyses on Alzheimer disease (n = 2), experimental autoimmune encephalomyelitis (n = 34), focal ischemia (n = 16), intracerebral hemorrhage (n = 61), Parkinson disease (n = 45), and spinal cord injury (n = 2). 112 meta-analyses (70%) found nominally (p≤0.05) statistically significant summary fixed effects. Assuming the effect size in the most precise study to be a plausible effect, 919 out of 4,445 nominally significant results were expected versus 1,719 observed (p<10−9). Excess significance was present across all neurological disorders, in all subgroups defined by methodological characteristics, and also according to alternative plausible effects. Asymmetry tests also showed evidence of small-study effects in 74 (46%) meta-analyses. Significantly effective interventions with more than 500 animals, and no hints of bias were seen in eight (5%) meta-analyses. Overall, there are too many animal studies with statistically significant results in the literature of neurological disorders. This observation suggests strong biases, with selective analysis and outcome reporting biases being plausible explanations, and provides novel evidence on how these biases might influence the whole research domain of neurological animal literature.

Self-Reported Increased Confusion or Memory Loss and Associated Functional Difficulties Among Adults Aged ≥60 Years — 21 States, 2011

May 14, 2013 Comments off

Self-Reported Increased Confusion or Memory Loss and Associated Functional Difficulties Among Adults Aged ≥60 Years — 21 States, 2011

Source: Morbidity and Mortality Weekly Report (CDC)

Declines in cognitive function vary among persons and can include changes in attention, memory, learning, executive function, and language capabilities that negatively affect quality of life, personal relationships, and the capacity for making informed decisions about health care and other matters (1). Memory problems typically are one of the first warning signs of cognitive decline, and mild cognitive impairment might be present when memory problems are greater than normal for a person’s age but not as severe as problems experienced with Alzheimer’s disease (2,3). Some, but not all, persons with mild cognitive impairment develop Alzheimer’s disease; others can recover from mild cognitive impairment if certain causes (e.g., medication side effects or depression) are detected and treated (3). In 2012, the U.S. Department of Health and Human Services published the National Plan to Address Alzheimer’s Disease, calling for expanding data collection and surveillance efforts to track the prevalence and impact of Alzheimer’s and other types of dementia (4). To estimate the prevalence of self-reported increased confusion or memory loss and associated functional difficulties among adults aged ≥60 years, CDC analyzed data from 21 states that administered an optional module in the 2011 Behavioral Risk Factor Surveillance System (BRFSS) survey. The results indicated that 12.7% of respondents reported increased confusion or memory loss in the preceding 12 months. Among those reporting increased confusion or memory loss, 35.2% reported experiencing functional difficulties. These results provide baseline information about the number of noninstitutionalized older adults with increased confusion or memory loss that is causing functional difficulties and might require services and supports now or in the future.

Monetary Costs of Dementia in the United States

April 5, 2013 Comments off

Monetary Costs of Dementia in the United States
Source: New England Journal of Medicine

We used nationally representative data to document comprehensively the incremental increase in costs attributable to dementia that arise from market transactions for goods and services as well as the costs of unpaid caregiving. We found that dementia leads to total annual societal costs of $41,000 to $56,000 per case, with a total cost of $159 billion to $215 billion nationwide in 2010. Our calculations suggest that the aging of the U.S. population will result in an increase of nearly 80% in total societal costs per adult by 2040.

The main component of the costs attributable to dementia is the cost for institutional and home-based long-term care rather than the costs of medical services — the sum of the costs for nursing home care and formal and informal home care represent 75 to 84% of attributable costs. Our estimate places dementia among the diseases that are the most costly to society. The cost for dementia care purchased in the marketplace ($109 billion) was similar to estimates of the direct health care expenditures for heart disease ($96 billion in 2008, or $102 billion in 2010 dollars) and significantly higher than the direct health care expenditures for cancer ($72 billion in 2008, or $77 billion in 2010 dollars). These costs do not include the costs of informal care, which are likely to be larger for dementia than for heart disease or cancer.

Although the costs attributable to dementia reported here are large, they are considerably smaller than those reported by the Alzheimer’s Association, which has estimated that in 2010 the monetary costs alone were $172 billion (2010 dollars) as compared with our estimate of $109 billion. There are several reasons for this higher estimate. It is likely that the cost per case reported by the Alzheimer’s Association is higher because it was estimated on the basis of a sample from a more severely impaired population (persons identified in the Medicare Current Beneficiary Survey as having dementia). The higher cost is also based on a significantly larger estimate of the prevalence of dementia. The national prevalence of dementia used by the Alzheimer’s Association is derived from a study of three Chicago neighborhoods. The diagnostic criteria for dementia used in that study did not require the presence of a limitation in ADLs or IADLs (a criterion that was used in ADAMS), a factor that probably led to the substantially higher estimate of the prevalence of dementia in the Chicago study. Finally, the cost estimate from the Alzheimer’s Association was not adjusted for the costs of coexisting conditions.

Proxy Consent to Research: The Legal Landscape

March 12, 2013 Comments off

Proxy Consent to Research: The Legal Landscape (PDF)

Source: Yale Journal of Health Policy, Law, and Ethics

When an adult suffers from a disorder that impairs his or her capacity to consent, may another person enroll that individual in research? The answer, it appears, is not a simple "yes" or "no," but rather "it depends."

The conduct of important research on disorders that affect many individuals. A growing population in our country suffers from illnesses that may affect decision-making, such as dementia, mental retardation, or, in certain instances, severe neuropsychiatric disorders. To illustrate this point, consider Alzheimer’s disease ("AD"). As the most common cause of dementia, the current and projected impact of AD is immense. An estimated four to fifteen million people are expected to suffer from Alzheimer’s disease by the year 2047. Beyond the quantitative impact of AD, the personal and relational costs of the disease are staggering. Patients in later stages may not recognize family members and often lose many of their core human traits and abilities. Many patients face institutionalization because of the common, yet extremely challenging, behavioral and psychiatric expressions of the disease. The financial costs are also significant. Current annual costs, both direct and indirect, approach $100 billion in the United States alone. It is urgent that research on this disease be strongly encouraged and facilitated.

Galactic Cosmic Radiation Leads to Cognitive Impairment and Increased Aβ Plaque Accumulation in a Mouse Model o f Alzheimer’s Disease

January 2, 2013 Comments off

Galactic Cosmic Radiation Leads to Cognitive Impairment and Increased Aβ Plaque Accumulation in a Mouse Model of Alzheimer’s Disease

Source: PLoS ONE

Galactic Cosmic Radiation consisting of high-energy, high-charged (HZE) particles poses a significant threat to future astronauts in deep space. Aside from cancer, concerns have been raised about late degenerative risks, including effects on the brain. In this study we examined the effects of 56Fe particle irradiation in an APP/PS1 mouse model of Alzheimer’s disease (AD). We demonstrated 6 months after exposure to 10 and 100 cGy 56Fe radiation at 1 GeV/µ, that APP/PS1 mice show decreased cognitive abilities measured by contextual fear conditioning and novel object recognition tests. Furthermore, in male mice we saw acceleration of Aβ plaque pathology using Congo red and 6E10 staining, which was further confirmed by ELISA measures of Aβ isoforms. Increases were not due to higher levels of amyloid precursor protein (APP) or increased cleavage as measured by levels of the β C-terminal fragment of APP. Additionally, we saw no change in microglial activation levels judging by CD68 and Iba-1 immunoreactivities in and around Aβ plaques or insulin degrading enzyme, which has been shown to degrade Aβ. However, immunohistochemical analysis of ICAM-1 showed evidence of endothelial activation after 100 cGy irradiation in male mice, suggesting possible alterations in Aβ trafficking through the blood brain barrier as a possible cause of plaque increase. Overall, our results show for the first time that HZE particle radiation can increase Aβ plaque pathology in an APP/PS1 mouse model of AD.

See: Space Travel May Be Harmful to the Brain, Study Suggests; Prolonged Cosmic Radiation Exposure Could Hasten Alzheimer’s (Science Daily)

Categories: dementia, PLoS ONE, science

Design and dementia: A case of garments designed to prevent undressing

August 14, 2012 Comments off

Design and dementia: A case of garments designed to prevent undressing

Source: Dementia

This article focuses on garments used in care environments. We investigate a patient overall, developed for the care of people with severe memory problems, severe learning difficulties and brain injuries. The aim of the use of a patient overall is to prevent undressing in socially inappropriate situations and/or to stop the user from removing an incontinence pad. This article is based on interviews of designers of medical textiles and patients and family carers in Finland. Both designers and patients found patient overalls to be infantilizing and stigmatizing for the user but accepted the basic functions of the product. We report results of a design project aimed at designing a new type of garment that takes into account the technical requirements but provides a more dignified look and opportunities for activity. We discuss the ethical issues concerning the use of this kind of product in the care of people with dementia.

Informant-reported cognitive symptoms that predict amnestic mild cognitive impairment

February 8, 2012 Comments off
Source:  BMC Geriatrics
Differentiating amnestic mild cognitive impairment (aMCI) from normal cognition is difficult in clinical settings. Self-reported and informant-reported memory complaints occur often in both clinical groups, which then necessitates the use of a comprehensive neuropsychological examination to make a differential diagnosis. However, the ability to identify cognitive symptoms that are predictive of aMCI through informant-based information may provide some clinical utility in accurately identifying individuals who are at risk for developing Alzheimer’s disease (AD).
The current study utilized a case-control design using data from an ongoing validation study of the Alzheimer’s Questionnaire (AQ), an informant-based dementia assessment. Data from 51 cognitively normal (CN) individuals participating in a brain donation program and 47 aMCI individuals seen in a neurology practice at the same institute were analyzed to determine which AQ items differentiated aMCI from CN individuals.
Forward stepwise multiple logistic regression analysis which controlled for age and education showed that 4 AQ items were strong indicators of aMCI which included: repetition of statements and/or questions [OR 13.20 (3.02, 57.66)]; trouble knowing the day, date, month, year, and time [OR 17.97 (2.63, 122.77)]; difficulty managing finances [OR 11.60 (2.10, 63.99)]; and decreased sense of direction [OR 5.84 (1.09, 31.30)].
Overall, these data indicate that certain informant-reported cognitive symptoms may help clinicians differentiate individuals with aMCI from those with normal cognition. Items pertaining to repetition of statements, orientation, ability to manage finances, and visuospatial disorientation had high discriminatory power.

Full Paper (PDF)

2011 Alzheimer’s Disease Facts and Figures

November 2, 2011 Comments off

2011 Alzheimer’s Disease Facts and Figures (PDF)
Source: Alzheimer’s Association

2011 Alzheimer’s Disease Facts and Figures provides a statistical resource for U.S. data related to Alzheimer’s disease, the most common type of dementia, as well as other dementias. Background and context for interpretation of the data are contained in the Overview. This information includes definitions of the types of dementia and a summary of current knowledge about Alzheimer’s disease. Additional sections address prevalence, mortality, caregiving and use and costs of care and services. The Special Report focuses on the benefits and challenges of early detection and diagnosis of Alzheimer’s disease.

Moderate alcohol consumption and cognitive risk

August 18, 2011 Comments off

Moderate alcohol consumption and cognitive risk (PDF)
Source: Neuropsychiatric Disease and Treatment

We reviewed 143 papers that described the relationship between moderate drinking of alcohol and some aspect of cognition. Two types of papers were found: (1) those that provided ratios of risk between drinkers and nondrinkers (74 papers in total) and (2) those that, although they did not provide such ratios, allowed cognition in drinkers to be rated as “better,” “no different,” or “worse” than cognition in nondrinkers (69 papers in total). The history of research on moderate drinking and cognition can be divided into two eras: 1977–1997 and 1998–present. Phase I (1977–1997) was the era of neuropsychological evaluation involving mostly young to middle-aged (18–50 years old) subjects. Although initial studies indicated moderate drinking impaired cognition, many later studies failed to confirm this, instead finding no difference in cognition between drinkers and nondrinkers. Phase II (1998–present) was and is the era of mental status exam evaluation involving mostly older (≥55 years old) subjects. These studies overwhelmingly found that moderate drinking either reduced or had no effect on the risk of dementia or cognitive impairment. When all the ratios of risk from all the studies in phase II providing such ratios are entered into a comprehensive meta-analysis, the average ratio of risk for cognitive risk (dementia or cognitive impairment/decline) associated with moderate “social” (not alcoholic) drinking of alcohol is 0.77, with nondrinkers as the reference group. The benefit of moderate drinking applied to all forms of dementia (dementia unspecified, Alzheimer’s disease, and vascular dementia) and to cognitive impairment (low test scores), but no significant benefit against cognitive decline (rate of decline in test scores) was found. Both light and moderate drinking provided a similar benefit, but heavy drinking was associated with nonsignificantly higher cognitive risk for dementia and cognitive impairment. Although the meta-analysis also indicated that wine was better than beer or spirits, this was based on a relatively small number of studies because most studies did not distinguish among these different types of alcohol. Furthermore, a number of the studies that did make the distinction reported no difference among the effects of these different types of alcohol. Therefore, at present this question remains unanswered. Analysis also showed that the presence of the apolipoprotein E epsilon 4 allele eliminated the benefit of moderate drinking. However, this was based on a relatively small number of studies and several other studies have found a beneficial effect of the epsilon e4 allele. Further studies are necessary to settle this question. The benefit of moderate alcohol for cognition was seen in both men and women, although the amount and pattern of drinking is very different between the two sexes. Lastly, the finding of unaffected or significantly reduced cognitive risk in light to moderate drinkers was seen in 14/19 countries for which country-specific ratio data were available, with three of the five remaining countries showing nonsignificant reductions as well. Overall, light to moderate drinking does not appear to impair cognition in younger subjects and actually seems to reduce the risk of dementia and cognitive decline in older subjects.

People with Dementia as Witnesses to Emotional Events

July 18, 2011 Comments off

People with Dementia as Witnesses to Emotional Events (PDF)
Source: National Institute of Justice

Demented elders are often the only witnesses to crimes against them, such as physical or financial elder abuse, yet they are disparaged and discounted as unreliable. Clinical experience with this population indicates that significant emotional experiences may be salient to people with dementia, and that certain behaviors and characteristics enhance their credibility as historians. For example, someone in an early stage of the disease may be able to reliably report on an event with strong emotional content. This is the first systematic research to identify people with dementia with reliable emotional memory and their characteristics.

A significant subset of older adults with dementing illnesses can reliably report emotional events in their lives. Compared to people with dementia with less reliable emotional memory, these individuals are able to report details of the event accurately and to recall the same event again after a short time delay. They are also likely to be an earlier stage of the disease, more aware of their own cognitive impairment, more likely to report negative events in their lives and to be able to recall an event without cues.

Older adults with dementia who are victims of crime should be evaluated for their ability to remember emotional events in their lives, and based on the results, allowed to provide testimony about the criminal events.

UK — Optimising treatment and care for people for people with behavioural and psychological symptoms of dementia

June 13, 2011 Comments off

Optimising treatment and care for people for people with behavioural and psychological symptoms of dementia (PDF)
Source: Department of Health

This best practice guide has been designed to support health and social care professionals to determine the best treatment and care for people experiencing behavioural and psychological symptoms of dementia (BPSD).

Theoretical Model Development in Elder Mistreatment

June 2, 2011 Comments off

Theoretical Model Development in Elder Mistreatment (PDF)
Source: National Institute of Justice

Elder mistreatment inquiry is a relative newcomer to the family violence arena and its empirically-based knowledge lacks a theoretical framework within which to understand its multiple manifestations. Effective intervention and prevention strategies depend upon theory-driven hypotheses testing in order to understand how risk factors at various social-ecological levels interact in the etiology of elder mistreatment. To foster theoretical model development, this article: (1) takes inventory of the empirically derived knowledge on elder mistreatment; (2) reviews the major theoretical approaches to the etiology of elder mistreatment; (3) proposes a new model of elder mistreatment of older adults with cognitive impairment. Each component of the NIJ-funded work was heavily informed by the methods and models from the adjacent areas of inquiry, child maltreatment and intimate partner violence. Information was obtained through an extensive literature review of the criminal justice, psychology, sociology, gerontology, forensics, and public health literature as well as from interviews with experts from elder mistreatment, child maltreatment, and intimate partner violence.

Medicare Atypical Antipsychotic Drug Claims for Elderly Nursing Home Residents

May 11, 2011 Comments off

Medicare Atypical Antipsychotic Drug Claims for Elderly Nursing Home Residents
Source: U.S. Department of Health and Human Services, Office of Inspector General

For the period January 1 through June 30, 2007, we determined using medical record review that 51 percent of Medicare claims for atypical antipsychotic drugs were erroneous, amounting to $116 million.

A member of Congress requested that OIG evaluate the extent to which elderly nursing home residents receive atypical antipsychotic drugs and the associated cost to Medicare. Specifically, this member expressed concern with atypical antipsychotic drugs prescribed to elderly nursing home residents for off-label conditions (i.e., conditions other than schizophrenia and/or bipolar disorder) and/or in the presence of the condition specified in the Food and Drug Administration’s (FDA) boxed warning (i.e., dementia). Medicare requires that drugs be prescribed for “medically accepted indications” for reimbursement. Further, CMS sets standards to ensure that nursing home residents’ drug therapy regimens are free from unnecessary drugs.

We also found that 14 percent of the 2.1 million elderly (i.e., age 65 and older) nursing home residents had at least 1 claim for these drugs. We determined using medical record review that 83 percent of Medicare claims for atypical antipsychotic drugs for elderly nursing home residents were associated with off-label conditions and that 88 percent were associated with the condition specified in the FDA boxed warning. We further determined through medical record review that 22 percent of the atypical antipsychotic drugs associated with the claims were not administered in compliance with CMS standards regarding unnecessary drugs in nursing homes, amounting to $63 million. Nursing homes’ failure to comply with these standards may affect their participation in Medicare. However, nursing homes’ noncompliance with these standards does not cause Medicare payments for these drugs to be erroneous.

To ensure that Medicare correctly pays for atypical antipsychotic drugs and that elderly nursing home residents are free from unnecessary drugs, we recommend that CMS (1) facilitate access to information necessary to ensure accurate coverage and reimbursement determinations, (2) assess whether survey and certification processes offer adequate safeguards against unnecessary antipsychotic drug use in nursing homes, (3) explore alternative methods beyond survey and certification processes to promote compliance with Federal standards regarding unnecessary drug use in nursing homes, and (4) take appropriate action regarding the claims associated with erroneous payments identified in our sample.

In its written comments on the report, CMS shared our concern and that of Congress over whether atypical antipsychotics and other drugs are being appropriately prescribed for elderly nursing home residents. CMS concurred with the second, third, and fourth recommendations; however, CMS did not concur with the first recommendation and expressed several general concerns with the report.

CMS did not concur with the first recommendation, stating that diagnosis information is not a required data element of pharmacy billing transactions nor is it generally included on prescriptions. OIG recognizes that the industry has not developed a standardized way of collecting diagnosis information for prescription drugs. However, without access to diagnosis information, CMS cannot determine the indications for which drugs were used. For this reason, CMS is unable, absent a medical review, to determine whether claims meet payment requirements.

Although CMS concurred with the second recommendation, we further recommend that CMS use its authority through the survey and certification processes to hold nursing homes accountable when unnecessary drug use is detected.

Although CMS concurred with the third recommendation, it did not believe some of the examples of alternative methods to promote compliance provided in the report to be practicable. We suggest that CMS either use its existing authority or seek new statutory authority to prevent payment and hold nursing homes responsible for submitting claims for drugs that are not administered according to CMS’s standards regarding unnecessary drug use in nursing homes.

+ Full Report (PDF)

Prediction of Dementia in Primary Care Patients

March 16, 2011 Comments off

Prediction of Dementia in Primary Care Patients
Source: PLoS ONE

Current approaches for AD prediction are based on biomarkers, which are however of restricted availability in primary care. AD prediction tools for primary care are therefore needed. We present a prediction score based on information that can be obtained in the primary care setting.

Methodology/Principal Findings
We performed a longitudinal cohort study in 3.055 non-demented individuals above 75 years recruited via primary care chart registries (Study on Aging, Cognition and Dementia, AgeCoDe). After the baseline investigation we performed three follow-up investigations at 18 months intervals with incident dementia as the primary outcome.

The best set of predictors was extracted from the baseline variables in one randomly selected half of the sample. This set included age, subjective memory impairment, performance on delayed verbal recall and verbal fluency, on the Mini-Mental-State-Examination, and on an instrumental activities of daily living scale. These variables were aggregated to a prediction score, which achieved a prediction accuracy of 0.84 for AD. The score was applied to the second half of the sample (test cohort). Here, the prediction accuracy was 0.79. With a cut-off of at least 80% sensitivity in the first cohort, 79.6% sensitivity, 66.4% specificity, 14.7% positive predictive value (PPV) and 97.8% negative predictive value of (NPV) for AD were achieved in the test cohort. At a cut-off for a high risk population (5% of individuals with the highest risk score in the first cohort) the PPV for AD was 39.1% (52% for any dementia) in the test cohort.

The prediction score has useful prediction accuracy. It can define individuals (1) sensitively for low cost-low risk interventions, or (2) more specific and with increased PPV for measures of prevention with greater costs or risks. As it is independent of technical aids, it may be used within large scale prevention programs.

Categories: dementia, PLoS ONE

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