Intermediate care and Dementia: Predicting the local burden

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Intermediate care and Dementia Predicting the
local burden

• Emma Reynish

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Format

• Numbers of people affected and characteristics of
  the population with dementia Dementia
  Prevalence in Europe EUROCODE
• Levels of dependency and behavioural
  disturbancePatient characteristics in
  Alzheimer's Disease ICTUS
• Patient characteristics acute general hospital
  admissionsFront door Comprehensive Geriatric
  Assessment Fife CGA

Reynish et al. Alzheimer's and Dementia 2009
Reynish et al. Neuroepidemiology 2007
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EUROCODE European Collaboration on
DementiaFunded by EUCoordinated by Alzheimer
Europe

• European Dementia Prevalence rates
• Systematic review with collaborative analysis

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Age and Sex specific prevalence
Male 60-64 0.2
65-69 1.8
70-74 3.2
75-79 7.0
80-84 14.5
85-89 20.9
90-94 29.2
gt95 32.4
Female 60-64 0.9
65-69 1.4
70-74 3.8
75-79 7.6
80-84 16.4
85-89 28.5
90-94 44.4
gt95 48.8
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Fife totalpopulation 361,890
3rd largest council population in Scotland (after
city of Glasgow and city of Edinburgh)
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Number of people with dementia in Fife

• Predicted from EUROCODE 5748
• Currently on GP databases 2211 (approx 40)
• Difference probably represents undiagnosed
  dementia

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Predicted Age distribution of patients in Fife
with Dementia
Using figures from EUROCODE ( EURODEM)
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Key findings

• With the advent of studies reporting prevalence
  in the oldest old it appears that this figure may
  have previously been under-estimated.
• Up to 2/3 of the population with dementia are
  over the age of 80 yrs.
• A large number of patients with dementia do not
  have a formal diagnosis

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Alzheimers disease treatment and management
across EuropeICTUS study A longitudinal
observational study of 1380 AD patients
Reynish et al. Neuroepidemiology 20072929-38
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Description of Baseline Cohort Demographics
Characteristic Total cohort Clinical Dementia Rating CDR Clinical Dementia Rating CDR Clinical Dementia Rating CDR p (?2)
Characteristic 0.5 1 2-3
Number 1377 587 (42.6) 608 (44.2) 182 13.2)
MMSE (mean ? SD) 20.5?3.9 22.5 ?3.1 19.7?3.7 16.5?3.5 lt0.0001
Age, years (mean ? SD) 76.3 ?7.7 74.7 ? 7.2 77.2 ? 7.8 78.1 ? 8.0 lt0.0001
Female () 891 (64.71) 356 (60.65) 412 (67.76) 123 (67.58) 0.0250
Education years (mean ? SD) 8 ?4.6 8.3 ? 4.8 7.8 ? 4.5 7.4 ? 4.3 0.0376
Yrs since diagnosis (mean ? SD) 0.4 ?0.8 0.3 ? 0.6 0.4 ? 0.8 0.5 ? 01.1 0.0108
Living arrangements
Lives with caregiver Lives alone Lives with other. 953 (69.21) 269 (19.54) 155 (11.26) 423 (72.06) 115 (19.59) 49 (8.35) 403 (66.28) 126 (20.72) 79 (12.99) 127 (69.78) 28 (15.38) 27 (14.84) 0.0205
Patients with AD are able to live independantly
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Description of Baseline CohortMedical
Characteristics
Characteristic Total cohort Clinical Dementia Rating CDR () Clinical Dementia Rating CDR () Clinical Dementia Rating CDR () p (?2)
Characteristic 0.5 1 2-3
Co-morbidity
hypertension (N1376) 538 (39.10) 216 (36.80) 236 (38.88) 86 (47.25) 0.0408
Diabetes (N1377) 162 (11.76) 62 (10.56) 67 (11.02) 33 (18.13) 0.0162
? Cholest (N1376) 350 (25.44) 164 (27.94) 145 (23.85) 41 (22.65) 0.1750
IHD (N1377) 184 (13.36) 78 (13.29) 84 (13.82) 22 (12.09) 0.8327
Depression (N1376) 327 (23.76) 149 (25.38) 133 (21.88) 45 (24.86) 0.3383
Epilepsy (N1375) 17 (1.24) 8 (1.37) 7 (1.15) 2 (1.10) 0.9428(1)
Stroke (N1376) 109 (7.92) 43 (7.34) 49 (8.06) 17 (9.34) 0.6730
Falls (N1375) 247 (17.96) 78 (13.31) 108 (17.79) 61 (33.52) lt0.0001
Patients with AD have significant comorbidity
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Description of Baseline CohortPatient assesment
Dependancy
Characteristic Total cohort Clinical Dementia Rating CDR Clinical Dementia Rating CDR Clinical Dementia Rating CDR
Characteristic 0.5 1 2-3
MMSE (mean ? SD) 20.5?3.9 22.5 ?3.1 19.7?3.7 16.5?3.5 lt0.0001
ADL Total Score (mean ? SD) 5.4 (0.9) 5.8 (0.4) 5.4 (0.8) 4.3 (1.3) lt0.0001
ADL scale (Katz S et al. JAMA 1963 185 914919.)

1. Personal hygiene
2. Dressing
3. toileting
4. transfers
5. Continence
6. feeding

Patients with AD need minimal assistance with
basic ADL
Score 1 independent 0.5needs assistance 0fully
dependant
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Neuropsychiatric inventory (NPI)

• assesses behavioural symptoms in dementia
• evaluates 12 disturbances/ domains
• examines whether symptoms have occurred over the
  past month
• informant asked about frequency of symptoms on a
  4-point scale1 (occasionally lt1/ week) to 4
  (very frequently gt1/ day).
• informant asked to rate the severity
  (disruptiveness, burden) of the behaviour on a
  three-point scale (mild, moderate, or severe).
• Domain rating severity X frequency (range of
  112).
• total NPI score sum of the scores of all the
  items.
• Range 0 (no disturbance) to 144 (severe
  impairment all domains).
• For symptom to be considered clinically relevant
  it is felt that the score for that domain must be
  greater than 3
• Schneider LS, et al. Am J Geriatr Psychiatry 2001

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Prevalence (NPI domain score 4) of clinically
relevant neuropsychiatric symptom in each NPI
domain
NPI Domain Clinical Dementia Rating CDR Clinical Dementia Rating CDR Clinical Dementia Rating CDR
NPI Domain Total cohort 0.5 Very mild N571 1 Mild N595 2-3 Moderate N179
Delusions 117 (8.7) 22 (3.85) 60(10.1) 35 (19.6)
Hallucinations 47 (3.5) 5 (0.9) 19 (3.2) 23 (12.8)
Agitation/Aggression 201 (14.9) 53 (9.3) 99 (16.6) 49 (27.4)
Depression 307 (22.8) 105 (18.4) 142 (23.9) 60 (33.5)
Anxiety 275 (20.5) 91 (15.9) 131 (22) 53 (29.6)
Euphoria 42 (3.1) 15 (2.6) 16 (2.6) 11 (6.5)
Apathy 423 (31.5) 105 (18.4) 232 (39) 86 (48)
Dis-inhibition 66 (4.9) 20 (3.5) 33 (5.6) 13 7.3)
Irritability 237 (17.6) 82 (14.4) 113 (19) 42 (23.5)
Aberrant Motor behaviour 146 (10.9) 28 (4.9) 79 (13.3) 39 (21.8)
Sleep 178 (13.2) 55 (9.6) 82 (13.8) 41 (22.9)
Eating 170 (12.6) 42 (7.36) 88 (14.8) 40 (22.4)
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Prevalence of clinically relevant symptom /
syndrome
Majority of patients with AD do not have symptoms
associated with challenging behaviour
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Findings

• A large proportion of Patients with AD do live
  independent lives
• In those with AD living at home impairment of
  basic activities of daily living (ADL) is minimal
  even in the moderate stages of dementia
• Neuropsychiatric symptoms associated with
  challenging behaviour are not common in the
  majority of patients with mild to moderate AD

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Intermediate Care Definition

• Intermediate care is the care provided following
  a crisis to help a patient maintain and regain as
  much of previous independence as possible. This
  care can include both health and social care
  prevention of avoidable admissions and supported
  discharge)
• Front door comprehensive geriatric assessment
  (CGA) recently introduced in Fife (Joint health
  and social care project)
• CGA provides an snap shot of the needs of those
  patients being admitted acutely to hospital

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Comprehensive geriatric assessment (CGA)

• A multidimensional interdisciplinary diagnostic
  process focused on determining a frail elderly
  persons medical, psychological and functional
  capability in order to develop a coordinated and
  integrated plan for treatment and long term
  follow-up
• LZ Rubenstein, JAGS, 1991398-16

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CGA the principal domains

• Physical health geriatric-specific. vision,
  hearing, continence, gait, and balance plus
  medical evaluation.
• Functional ability Review of ADLs and their
  change over time
• Cognitive and mental health Screening for
  cognitive impairment and delirium, plus liaison
  with psychiatric services.
• Socio-environmental situation Liaison with
  social services.

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Recording of Data-OASIS (PAS) Clinical Page

• EPR Electronic Patient Record

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CGA in the first 6 weeks preliminary data

• 793 emergency admissions to VHK over age 65
• 8 admissions to acute older persons mental health
  wards throughout Fife
• CGA performed and data entry complete on 159
  patients (20 of all acute admissions over 65
  years)

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CGA in the first 6 weeks preliminary data

• Of those who have had CGA performed (n159)
• 42 (26.4) had an AMT score of 7 or less (most
  likely to have dementia)
• 13 (8) were too ill to have AMT performed
• 104 (65) had AMT score gt7 (less likely to have
  dementia)

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CGA in the first month Patients with cognitive
impairment (n42)

• Mean age 81.86 (range 66-96)
• MF ratio 11.8
• 7 patients from nursing home (17)
• 7 patients had a diagnosis of dementia (17)
• 13 patients prone to falls (31)
• 8 patients carers reported problems coping at
  home (23 of those admitted from home)
• Ongoing analyses
• Current ADL and change in ADL over preceding 3
  months
• Prevalence of delirium
• Assessment of mobility (TUAG)

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Findings from CGA

• In crisis the majority of older people are
  admitted to general hospitals
• A significant proportion have cognitive
  impairment but no dementia diagnosis
• Of those patients with cognitive impairment there
  may have been opportunities for intermediate care
  team involvement to prevent admission

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Key messages

• Majority of people with dementia aged over 80
• Dementia is frequently undiagnosed
• A significant proportion of patients with
  dementia are able to live independently
• The prevalence of challenging behaviour is low
• General hospital admission has become the
  default for elderly patients in crisis despite
  the potential for prevention of admission by IC
  team

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A role for intermediate care?

• Expertise in caring for the over 80s with
  co-morbidity
• Capacity to assess for dementia diagnosis
• Aspiration to maintain independence at home
• Patient focused service guided by comprehensive
  assessment
• Supported by specialist mental health personnel
  when needs exist

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Collaborators

• E Reynish, H Bickel, M Lambert ,L Fratiglioni, E
  Von Strauss, D Frydecka, A Kiejna, M Prince, J
  Georges and the EUROCODE study group.
• E Reynish, PJ Ousset, S Andrieu, B Vellas and the
  ICTUS study group.

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EUROCODE Prevalence study group.

• Manubens JM, Martinez-Lage JM, Lacruz F,
  Muruzabal J, Larumbe R, Guarch C et al.
• Ott A, Breteler MM, van HF, Claus JJ, van der
  Cammen TJ, Grobbee DE et
• Prencipe M, Casini AR, Ferretti C, Lattanzio MT,
  Fiorelli M, Culasso F.
• Andersen K, Lolk A, Nielsen H, Andersen J, Olsen
  C, Kragh-Sorensen P.
• Ferini-Strambi L, Marcone A, Garancini P, Danelon
  F, Zamboni M, Massussi P et al.
• Azzimondi G, D'Alessandro R, Pandolfo G, Feruglio
  FS.
• von SE, Viitanen M, De RD, Winblad B, Fratiglioni
  L.
• Gabryelewicz T.
• Vilalta-Franch J, Lopez-Pousa S, Llinas-Regla J.
• Riedel-Heller SG, Busse A, Aurich C, Matschinger
  H, Angermeyer MC.
• Ravaglia G, Forti P, Maioli F, Sacchetti L,
  Mariani E, Nativio V et al.
• Gostynski M, jdacic-Gross V, Gutzwiller F, Michel
  JP, Herrmann F.
• Borjesson-Hanson A, Edin E, Gislason T, Skoog I.
• Tognoni G, Ceravolo R, Nucciarone B, Bianchi F,
  Dell'Agnello G, Ghicopulos I et al.
• De RD, Berardi D, Menchetti M, Ferrari G,
  Serretti A, Dalmonte E et al.
• Helmer C, Peres K, Letenneur L, Guttierez-Robledo
  LM, Ramaroson H, Barberger-Gateau P et al.
• Bdzan LB, Turczynski J, Szabert K.
• Gascon-Bayarri J, Rene R, Del Barrio JL, De
  Pedro-Cuesta J, Ramon JM, Manubens JM et al.

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ICTUS STUDY Group
B.Vellas (Toulouse), R.W.Jones (Bath), A.Burns
(Manchester), R.Bullock (Swindon), A Malick
(Warwick), E.Salmon (Liege), G.Waldemar /P
Johannsen (Copenhagen), J.F.Dartigues (Bordeaux),
F.Pasquier (Lille), J.Touchon (Montpellier),
P.Robert (Nice), A.S.Rigaud (Paris), V.Camus
(Tours), G. Stiens (Goettingen), L.Frölich
(Mannheim), M.Tsolaki (Thessalonica), G.Frisoni
(Brescia), G.Rodriguez (Genoa), A.Cherubini
(Perugia), L.Spiru (Bucharest), M.Boada
(Barcelona), A.Salva (Girona), E.Agüera-Morales
(Cordoba), J.M.Ribera-Casado (Madrid),P.M.Lage
(Pamplona), B.Winblad / (Stockholm), D Zekry
(Geneva), P.Scheltens (Amsterdam), M.Olde-Rikkert
(Nijmegen).