To describe the clinical performance of the cognition battery on Step 1 (CogStep1) as a screening tool to detect (1) individuals with objective cognitive impairment regardless of their Mini-Mental State Exam (MMSE) score, and specifically (2) to identify patients who could potentially benefit from anti-amyloid treatments. It was hypothesized that CogStep1 was sensitive enough to identify individuals with mild stages of cognitive deterioration compared with a comprehensive neuropsychological and clinical evaluation.
Design
Cross-sectional study.
Setting and Participants
Patients aged 60 and older referred to the Toulouse Memory Clinic.
Methods
Participants underwent a comprehensive neuropsychological and clinical evaluation and were also screened with the integrated care in older people (ICOPE)-monitor Step 1 by trained health professionals a maximum of 6 months before their memory consultation. Objective cognitive impairment was defined as mild cognitive impairment (MCI) or dementia, according to National Institute on Aging and the Alzheimer's Association criteria. A positive CogStep1 screening was considered if people had at least 1 mistake in the 3-word recall or the time orientation (weekday, month, year). Sensitivity, specificity, area under the receiver operating characteristic curve (AUROC), positive predictive value (PPV), and negative predictive value (NPV) were estimated.
Results
Among the 352 participants [54.8% women, mean age 76.5 (SD 6.7)], 78.1% had a positive screening for CogStep1, and 75.6% had objective cognitive impairment. The clinimetric properties of CogStep1 to detect objective cognitive impairment (vs those without) were sensitivity = 87.0 (95% CI, 82.3–90.8), specificity = 48.8 (95% CI, 37.9–59.9), AUROC = 0.68 (95% CI, 0.62–0.74), PPV = 83.8 (95% CI, 78.8–87.9), and NPV = 55.3 (95% CI, 43.4–66.7). We found similar values among individuals with MCI or mild dementia who could be potential users of new anti-amyloid drugs (MMSE score ≥ 20 or 22).
Conclusion and Implications
CogStep1 demonstrated good sensitivity and PPV to identify objective cognitive impairment among older people referred to a memory clinic. Achieving excellent sensitivity and specificity values is challenging for a very short test. However, CogStep1 proved useful for risk-stratifying patients who can benefit from further cognitive assessment, biomarker measurements, and therapeutic management, especially in the context of new anti-amyloid therapies.
{"title":"Cognition Assessment with ICOPE-Monitor: Identifying Candidates for Novel Therapies","authors":"Emmanuel Gonzalez-Bautista PhD, MBBS , Maria Soto PhD, MD , Marie Fourteau MSc , Caroline Berbon MSc , Bruno Vellas PhD, MD , Julien Delrieu PhD, MD , Davide Angioni MD","doi":"10.1016/j.jamda.2024.105483","DOIUrl":"10.1016/j.jamda.2024.105483","url":null,"abstract":"<div><h3>Objective</h3><div>To describe the clinical performance of the cognition battery on Step 1 (CogStep1) as a screening tool to detect (1) individuals with objective cognitive impairment regardless of their Mini-Mental State Exam (MMSE) score, and specifically (2) to identify patients who could potentially benefit from anti-amyloid treatments. It was hypothesized that CogStep1 was sensitive enough to identify individuals with mild stages of cognitive deterioration compared with a comprehensive neuropsychological and clinical evaluation.</div></div><div><h3>Design</h3><div>Cross-sectional study.</div></div><div><h3>Setting and Participants</h3><div>Patients aged 60 and older referred to the Toulouse Memory Clinic.</div></div><div><h3>Methods</h3><div>Participants underwent a comprehensive neuropsychological and clinical evaluation and were also screened with the integrated care in older people (ICOPE)-monitor Step 1 by trained health professionals a maximum of 6 months before their memory consultation. Objective cognitive impairment was defined as mild cognitive impairment (MCI) or dementia, according to National Institute on Aging and the Alzheimer's Association criteria. A positive CogStep1 screening was considered if people had at least 1 mistake in the 3-word recall or the time orientation (weekday, month, year). Sensitivity, specificity, area under the receiver operating characteristic curve (AUROC), positive predictive value (PPV), and negative predictive value (NPV) were estimated.</div></div><div><h3>Results</h3><div>Among the 352 participants [54.8% women, mean age 76.5 (SD 6.7)], 78.1% had a positive screening for CogStep1, and 75.6% had objective cognitive impairment. The clinimetric properties of CogStep1 to detect objective cognitive impairment (vs those without) were sensitivity = 87.0 (95% CI, 82.3–90.8), specificity = 48.8 (95% CI, 37.9–59.9), AUROC = 0.68 (95% CI, 0.62–0.74), PPV = 83.8 (95% CI, 78.8–87.9), and NPV = 55.3 (95% CI, 43.4–66.7). We found similar values among individuals with MCI or mild dementia who could be potential users of new anti-amyloid drugs (MMSE score ≥ 20 or 22).</div></div><div><h3>Conclusion and Implications</h3><div>CogStep1 demonstrated good sensitivity and PPV to identify objective cognitive impairment among older people referred to a memory clinic. Achieving excellent sensitivity and specificity values is challenging for a very short test. However, CogStep1 proved useful for risk-stratifying patients who can benefit from further cognitive assessment, biomarker measurements, and therapeutic management, especially in the context of new anti-amyloid therapies.</div></div>","PeriodicalId":17180,"journal":{"name":"Journal of the American Medical Directors Association","volume":"26 4","pages":"Article 105483"},"PeriodicalIF":4.2,"publicationDate":"2025-02-10","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143074908","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2025-02-10DOI: 10.1016/j.jamda.2025.105489
Ricardo Aurélio Carvalho Sampaio, Yukiko Nishita, Chikako Tange, Shu Zhang, Mitsuru Shinohara, Mana Tateishi, Kanae Furuya, Sayaka Kubota, Priscila Yukari Sewo Sampaio, Naoyuki Sato, Hiroshi Shimokata, Hidenori Arai, Rei Otsuka
Objectives: This study investigated the interactive associations of age, apolipoprotein E ε4 (APOE4) genetic status, physical activity energy expenditure (PAEE), and physical functioning on processing speed over a 10-year period.
Design: In this longitudinal study, participants underwent biennial assessments from 2002 to 2012 as part of the National Institute for Longevity Sciences-Longitudinal Study of Aging (NILS-LSA).
Setting and participants: We used data from 2518 middle-aged and older community-dwelling adults in Japan.
Methods: Processing speed was assessed using the Digit Symbol Substitution Test, and additional data included APOE4 genotyping, objective PAEE measurement via accelerometry (in kcal/d), and physical functioning assessments (handgrip strength and walking speed, dichotomized according to specific cutoffs: <18 kg for women and <28 kg for men [weakness], and <1 m/s [slowness], respectively). Mixed-effects models were used to analyze the data, accounting for time-varying covariates, including living arrangement, hypertension, hyperlipidemia, diabetes, depressive symptoms, smoking, sleep duration, energy intake, and body mass index.
Results: Results revealed significant 3-way interactive associations among PAEE × age × APOE4 carrier (β = 0.000025, P = .021) and among slowness × age × APOE4 carrier (β = -0.014187, P = .013) on cognitive processing speed. Higher PAEE was associated with better processing speed, whereas slowness was associated with poorer processing speed, particularly in older APOE4 carriers. Although weakness showed significant interactions with age and APOE4 carrier, no 3-way interaction was observed.
Conclusions and implications: Our findings underscore the complex interplay among physical activity, physical functioning, age, and genetic risk on processing speed. The protective associations of higher PAEE levels and better physical functioning, especially in older APOE4 carriers, suggest that maintaining an active lifestyle and mobility may be crucial for individuals with a genetic predisposition to cognitive decline.
{"title":"Interactive Associations of Age, Apolipoprotein E ε4 Gene, Physical Activity, and Physical Functioning on Processing Speed.","authors":"Ricardo Aurélio Carvalho Sampaio, Yukiko Nishita, Chikako Tange, Shu Zhang, Mitsuru Shinohara, Mana Tateishi, Kanae Furuya, Sayaka Kubota, Priscila Yukari Sewo Sampaio, Naoyuki Sato, Hiroshi Shimokata, Hidenori Arai, Rei Otsuka","doi":"10.1016/j.jamda.2025.105489","DOIUrl":"https://doi.org/10.1016/j.jamda.2025.105489","url":null,"abstract":"<p><strong>Objectives: </strong>This study investigated the interactive associations of age, apolipoprotein E ε4 (APOE4) genetic status, physical activity energy expenditure (PAEE), and physical functioning on processing speed over a 10-year period.</p><p><strong>Design: </strong>In this longitudinal study, participants underwent biennial assessments from 2002 to 2012 as part of the National Institute for Longevity Sciences-Longitudinal Study of Aging (NILS-LSA).</p><p><strong>Setting and participants: </strong>We used data from 2518 middle-aged and older community-dwelling adults in Japan.</p><p><strong>Methods: </strong>Processing speed was assessed using the Digit Symbol Substitution Test, and additional data included APOE4 genotyping, objective PAEE measurement via accelerometry (in kcal/d), and physical functioning assessments (handgrip strength and walking speed, dichotomized according to specific cutoffs: <18 kg for women and <28 kg for men [weakness], and <1 m/s [slowness], respectively). Mixed-effects models were used to analyze the data, accounting for time-varying covariates, including living arrangement, hypertension, hyperlipidemia, diabetes, depressive symptoms, smoking, sleep duration, energy intake, and body mass index.</p><p><strong>Results: </strong>Results revealed significant 3-way interactive associations among PAEE × age × APOE4 carrier (β = 0.000025, P = .021) and among slowness × age × APOE4 carrier (β = -0.014187, P = .013) on cognitive processing speed. Higher PAEE was associated with better processing speed, whereas slowness was associated with poorer processing speed, particularly in older APOE4 carriers. Although weakness showed significant interactions with age and APOE4 carrier, no 3-way interaction was observed.</p><p><strong>Conclusions and implications: </strong>Our findings underscore the complex interplay among physical activity, physical functioning, age, and genetic risk on processing speed. The protective associations of higher PAEE levels and better physical functioning, especially in older APOE4 carriers, suggest that maintaining an active lifestyle and mobility may be crucial for individuals with a genetic predisposition to cognitive decline.</p>","PeriodicalId":17180,"journal":{"name":"Journal of the American Medical Directors Association","volume":" ","pages":"105489"},"PeriodicalIF":4.2,"publicationDate":"2025-02-10","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143414589","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2025-02-08DOI: 10.1016/j.jamda.2025.105486
Huai Cheng
{"title":"Evaluating ChatGPT's Outputs to 16 Alzheimer's Disease Myths: Can ChatGPT 4.o Generate Reliable Results?","authors":"Huai Cheng","doi":"10.1016/j.jamda.2025.105486","DOIUrl":"https://doi.org/10.1016/j.jamda.2025.105486","url":null,"abstract":"","PeriodicalId":17180,"journal":{"name":"Journal of the American Medical Directors Association","volume":" ","pages":"105486"},"PeriodicalIF":4.2,"publicationDate":"2025-02-08","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143399468","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2025-02-08DOI: 10.1016/j.jamda.2024.105476
Divya Ajay MD, MPH , Shubing Cai PhD , Wenhan Guo MS , Helena Temkin-Greener PhD
Objectives
Prior studies suggested that urinary incontinence (UI) may be a risk factor for nursing home (NH) placement among older community-dwelling individuals. Our objectives were to evaluate if UI is an independent risk factor in NH placement among assisted living (AL) residents and assess the impact of UI on NH placement by race/ethnicity.
Design
This retrospective cohort study is based on the 2019-2021 Medicare enrollment and claims data.
Setting and Participants
Medicare beneficiaries residing in AL communities, and those with a new UI diagnosis, between January 1, 2020, and June 30, 2020, were identified. All residents were followed through December 31, 2021, to identify permanent NH placement (length of stay ≥90 days).
Methods
Individual covariates (age, race/ethnicity, chronic conditions) and AL community factors (bed size, proportion of Medicare-Medicaid dually eligible residents) were included. We estimated logistic regression models with individual and AL random effects and robust SEs. Interaction effects were estimated to examine differences in NH placement by race/ethnicity.
Results
Of 247,010 AL residents, 20.45% had UI. Overall, 15.7% of residents were permanently placed in NHs during the study period; 14.2% had no UI, and 21.7% had UI. After controlling for confounders, UI significantly (P < .01) increased the probability of NH placement, a 14% increase relative to the mean. Compared with white residents without UI, white residents with UI had 1.93 percentage point (pp) higher probability of NH placement. Although Black and Hispanic residents overall had lower risk of placement, that risk increased significantly for residents with UI: 3.43 pp higher for Black residents and 3.68 pp higher for Hispanic residents.
Conclusions and Implications
This first and largest study of UI in AL communities demonstrated that UI is an independent risk factor for permanent NH placement. Education and identifying and treating UI early may allow AL residents to avoid or delay NH placement.
{"title":"Urinary Incontinence Is an Independent Risk Factor for Nursing Home Placement among Assisted Living Residents","authors":"Divya Ajay MD, MPH , Shubing Cai PhD , Wenhan Guo MS , Helena Temkin-Greener PhD","doi":"10.1016/j.jamda.2024.105476","DOIUrl":"10.1016/j.jamda.2024.105476","url":null,"abstract":"<div><h3>Objectives</h3><div>Prior studies suggested that urinary incontinence (UI) may be a risk factor for nursing home (NH) placement among older community-dwelling individuals. Our objectives were to evaluate if UI is an independent risk factor in NH placement among assisted living (AL) residents and assess the impact of UI on NH placement by race/ethnicity.</div></div><div><h3>Design</h3><div>This retrospective cohort study is based on the 2019-2021 Medicare enrollment and claims data.</div></div><div><h3>Setting and Participants</h3><div>Medicare beneficiaries residing in AL communities, and those with a new UI diagnosis, between January 1, 2020, and June 30, 2020, were identified. All residents were followed through December 31, 2021, to identify permanent NH placement (length of stay ≥90 days).</div></div><div><h3>Methods</h3><div>Individual covariates (age, race/ethnicity, chronic conditions) and AL community factors (bed size, proportion of Medicare-Medicaid dually eligible residents) were included. We estimated logistic regression models with individual and AL random effects and robust SEs. Interaction effects were estimated to examine differences in NH placement by race/ethnicity.</div></div><div><h3>Results</h3><div>Of 247,010 AL residents, 20.45% had UI. Overall, 15.7% of residents were permanently placed in NHs during the study period; 14.2% had no UI, and 21.7% had UI. After controlling for confounders, UI significantly (<em>P</em> < .01) increased the probability of NH placement, a 14% increase relative to the mean. Compared with white residents without UI, white residents with UI had 1.93 percentage point (pp) higher probability of NH placement. Although Black and Hispanic residents overall had lower risk of placement, that risk increased significantly for residents with UI: 3.43 pp higher for Black residents and 3.68 pp higher for Hispanic residents.</div></div><div><h3>Conclusions and Implications</h3><div>This first and largest study of UI in AL communities demonstrated that UI is an independent risk factor for permanent NH placement. Education and identifying and treating UI early may allow AL residents to avoid or delay NH placement.</div></div>","PeriodicalId":17180,"journal":{"name":"Journal of the American Medical Directors Association","volume":"26 4","pages":"Article 105476"},"PeriodicalIF":4.2,"publicationDate":"2025-02-08","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143066534","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2025-02-08DOI: 10.1016/j.jamda.2024.105479
Jessica Benfer PhD, MS, MPH , Gretchen G. Tucker MA , John G. Cagle PhD, MSW
Objectives
Nursing home dementia specialty care units are highly publicized as beneficial for residents with dementia, but we know little about these units and what makes them “special.” Leveraging primary data from a national survey of nursing home representatives and the LTCfocus data, this study aims to describe characteristics and features of dementia specialty care units and examine variations in nursing home quality ratings.
Design
National survey.
Setting and Participants
Nationally, 256 nursing homes were randomly selected. Surveys with questions about dementia specialty care units were mailed to nursing home representatives in September/November 2023.
Methods
A total of 166 surveys were returned from 126 nursing homes and compared with LTCfocus data. Descriptive statistics and qualitative analyses were used to analyze data.
Results
A total of 105 (83.3%) respondents corroborated with LTCfocus data (kappa = 0.67, P < .05) regarding presence of dementia specialty care units. Of 21 respondents (16.7%) not corroborating, inconsistencies were almost equal regarding directions of mismatching. Seventy-seven nursing homes had dementia specialty care units, 44% of which were rated 4 to 5 stars for quality. Nonprofit nursing homes had higher star ratings compared with for-profit nursing homes. Wander gardens, interactive technologies, and restraints were used less frequently than personalized music, communal dining, locked units, outdoor access, and visiting animals on the units.
Conclusions and Implications
Researchers using LTCfocus data to determine the presence of dementia specialty care units can be confident that designations are accurate. This study adds to our description of nursing home dementia specialty care units and provides insights into their presence in some nursing homes. Further research is needed to understand the relationship between profit status and quality ratings.
{"title":"Describing Dementia Specialty Care Units in US Nursing Homes: Leveraging National Survey Data From HARBORS and LTCfocus","authors":"Jessica Benfer PhD, MS, MPH , Gretchen G. Tucker MA , John G. Cagle PhD, MSW","doi":"10.1016/j.jamda.2024.105479","DOIUrl":"10.1016/j.jamda.2024.105479","url":null,"abstract":"<div><h3>Objectives</h3><div>Nursing home dementia specialty care units are highly publicized as beneficial for residents with dementia, but we know little about these units and what makes them “special.” Leveraging primary data from a national survey of nursing home representatives and the LTCfocus data, this study aims to describe characteristics and features of dementia specialty care units and examine variations in nursing home quality ratings.</div></div><div><h3>Design</h3><div>National survey.</div></div><div><h3>Setting and Participants</h3><div>Nationally, 256 nursing homes were randomly selected. Surveys with questions about dementia specialty care units were mailed to nursing home representatives in September/November 2023.</div></div><div><h3>Methods</h3><div>A total of 166 surveys were returned from 126 nursing homes and compared with LTCfocus data. Descriptive statistics and qualitative analyses were used to analyze data.</div></div><div><h3>Results</h3><div>A total of 105 (83.3%) respondents corroborated with LTCfocus data (kappa = 0.67, <em>P</em> < .05) regarding presence of dementia specialty care units. Of 21 respondents (16.7%) not corroborating, inconsistencies were almost equal regarding directions of mismatching. Seventy-seven nursing homes had dementia specialty care units, 44% of which were rated 4 to 5 stars for quality. Nonprofit nursing homes had higher star ratings compared with for-profit nursing homes. Wander gardens, interactive technologies, and restraints were used less frequently than personalized music, communal dining, locked units, outdoor access, and visiting animals on the units.</div></div><div><h3>Conclusions and Implications</h3><div>Researchers using LTCfocus data to determine the presence of dementia specialty care units can be confident that designations are accurate. This study adds to our description of nursing home dementia specialty care units and provides insights into their presence in some nursing homes. Further research is needed to understand the relationship between profit status and quality ratings.</div></div>","PeriodicalId":17180,"journal":{"name":"Journal of the American Medical Directors Association","volume":"26 3","pages":"Article 105479"},"PeriodicalIF":4.2,"publicationDate":"2025-02-08","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143074912","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2025-02-08DOI: 10.1016/j.jamda.2024.105427
Heeeun Jang PhD , Ariel Avgar PhD , Russell Weaver PhD , Daniel Spertus BA , Kiran Abraham-Aggarwal , Joanna Bryan Ringel MPH , Madeline Sterling MD, MPH, MS
Objectives
Our study investigates unionization trends among direct care workers (DCWs) in the United States and examines the association between unionization and their wealth outcomes.
Design
This is a cross-sectional study using data from the Current Population Survey and Annual Social and Economic Supplement from 2009 to 2023.
Setting and Participants
Our study is based on US representative household surveys. The sample includes 17,522 DCWs (eg, personal care aides, nursing assistants, home health workers).
Methods
The prevalence and trend in labor unionization among DCWs and the association between their union status and wealth outcomes (hourly wage, employer-sponsored health insurance, pension plans, and poverty status) were analyzed. Union status identified by formal union membership or coverage by a union without formal membership.
Results
The sample was composed of mostly women (87%); they had a mean age of 41.8 ± 14.5 years, 38.1% were non-Hispanic White, 30.4% were non-Hispanic Black, 21.6% were Hispanic, and 9.9% were Asian and other. Overall, 12% (n = 1850) of DCWs were unionized. The Cox trend test showed decreasing in unionization rates over the study years. In fully adjusted models, unionized DCWs earned more than nonunionized DCWs ($1.2; 95% CI, $0.8-$1.6; P < .001). They were also more likely to have employer-sponsored health care insurance (odds ratio, 2.0; 95% CI, 1.8-2.3; P < .001) and pension plan (odds ratio, 1.8; 95% CI, 1.6-2.0; P < .001), with higher employer's contribution to health insurance ($561.2; 95% CI, $303.1-$819.3; P < .001). Also, unionization was negatively associated with DCWs' poverty status (odds ratio, 0.7; 95% CI, 0.6-0.9; P < .001).
Conclusions and Implications
Unionization is an effective means of improving the financial well-being of DCWs, a workforce that is currently facing challenging working conditions and high levels of turnover.
{"title":"What Do Unions Do for Direct Care Workers? Assessing Employment and Economic Outcomes","authors":"Heeeun Jang PhD , Ariel Avgar PhD , Russell Weaver PhD , Daniel Spertus BA , Kiran Abraham-Aggarwal , Joanna Bryan Ringel MPH , Madeline Sterling MD, MPH, MS","doi":"10.1016/j.jamda.2024.105427","DOIUrl":"10.1016/j.jamda.2024.105427","url":null,"abstract":"<div><h3>Objectives</h3><div>Our study investigates unionization trends among direct care workers (DCWs) in the United States and examines the association between unionization and their wealth outcomes.</div></div><div><h3>Design</h3><div>This is a cross-sectional study using data from the Current Population Survey and Annual Social and Economic Supplement from 2009 to 2023.</div></div><div><h3>Setting and Participants</h3><div>Our study is based on US representative household surveys. The sample includes 17,522 DCWs (eg, personal care aides, nursing assistants, home health workers).</div></div><div><h3>Methods</h3><div>The prevalence and trend in labor unionization among DCWs and the association between their union status and wealth outcomes (hourly wage, employer-sponsored health insurance, pension plans, and poverty status) were analyzed. Union status identified by formal union membership or coverage by a union without formal membership.</div></div><div><h3>Results</h3><div>The sample was composed of mostly women (87%); they had a mean age of 41.8 ± 14.5 years, 38.1% were non-Hispanic White, 30.4% were non-Hispanic Black, 21.6% were Hispanic, and 9.9% were Asian and other. Overall, 12% (n = 1850) of DCWs were unionized. The Cox trend test showed decreasing in unionization rates over the study years. In fully adjusted models, unionized DCWs earned more than nonunionized DCWs ($1.2; 95% CI, $0.8-$1.6; <em>P</em> < .001). They were also more likely to have employer-sponsored health care insurance (odds ratio, 2.0; 95% CI, 1.8-2.3; <em>P</em> < .001) and pension plan (odds ratio, 1.8; 95% CI, 1.6-2.0; <em>P</em> < .001), with higher employer's contribution to health insurance ($561.2; 95% CI, $303.1-$819.3; <em>P</em> < .001). Also, unionization was negatively associated with DCWs' poverty status (odds ratio, 0.7; 95% CI, 0.6-0.9; <em>P</em> < .001).</div></div><div><h3>Conclusions and Implications</h3><div>Unionization is an effective means of improving the financial well-being of DCWs, a workforce that is currently facing challenging working conditions and high levels of turnover.</div></div>","PeriodicalId":17180,"journal":{"name":"Journal of the American Medical Directors Association","volume":"26 3","pages":"Article 105427"},"PeriodicalIF":4.2,"publicationDate":"2025-02-08","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142872427","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2025-02-08DOI: 10.1016/j.jamda.2025.105488
Geetha Mukerji, Leahora Rotteau, Joanne Goldman, Amol A Verma, Kaveh G Shojania, Fahad Razak, Sid Feldman, Patricia Rios, Laura Pus, Pauline Pariser, Tara O'Brien, Andrea L Moser, Brian M Wong
Objectives: Transfers to acute care hospitals expose long-term care residents to potential harm. We implemented Long-Term Care Plus (LTC+) at the outset of the COVID-19 pandemic to reduce emergency department (ED) transfers and improve access to urgent medical services by providing virtual specialist consultation, system navigation, and diagnostic and laboratory testing to 54 long-term care homes (LTCHs).
Design: This mixed-methods study aimed to determine if LTC+ led to a decrease in avoidable acute care transfers and to explore participants' perceptions and contextual factors influencing uptake.
Setting and participants: LTC+ was implemented across 54 LTCHs and 3 hospital hubs in Toronto, Canada.
Methods: Statistical process control charts were created to detect changes in ED transfer rates, stratifying data into high- and low-uptake LTCHs to evaluate the effect of LTC+ on ED transfer rates across 54 LTCHs. Semistructured interviews were conducted with health care providers, administrators, residents, and caregivers across 6 LTCHs and 3 hospital hubs and analyzed thematically.
Results: There were 9658 ED transfers during the study period (April 2020 to March 2022), of which 3860 (40.0%) did not require admission. LTC+ delivered 534 virtual consultations, with 5 LTCHs accounting for 59% of program use. Compared with baseline (January 2019 to February 2020), transfer rates decreased by 40%, with no difference seen between LTCHs with high vs low uptake. Factors influencing uptake include program awareness, motivation, alignment of LTCH resources and program services, and commitment to ED avoidance.
Conclusions and implications: The LTC+ program did not reduce ED transfers beyond secular trends attributable to the broader effects of the COVID-19 pandemic. Participants that used LTC+ identified important benefits that extended beyond ED avoidance including building self-efficacy and capacity in LTCHs to provide client-centered care with cross-sectoral collaboration. Refinements to the LTC+ program design and delivery and structural changes are needed to increase impact.
{"title":"A Program to Reduce Emergency Department Transfers and Build Long-Term Care Home Capacity: A Mixed-Methods Study.","authors":"Geetha Mukerji, Leahora Rotteau, Joanne Goldman, Amol A Verma, Kaveh G Shojania, Fahad Razak, Sid Feldman, Patricia Rios, Laura Pus, Pauline Pariser, Tara O'Brien, Andrea L Moser, Brian M Wong","doi":"10.1016/j.jamda.2025.105488","DOIUrl":"https://doi.org/10.1016/j.jamda.2025.105488","url":null,"abstract":"<p><strong>Objectives: </strong>Transfers to acute care hospitals expose long-term care residents to potential harm. We implemented Long-Term Care Plus (LTC+) at the outset of the COVID-19 pandemic to reduce emergency department (ED) transfers and improve access to urgent medical services by providing virtual specialist consultation, system navigation, and diagnostic and laboratory testing to 54 long-term care homes (LTCHs).</p><p><strong>Design: </strong>This mixed-methods study aimed to determine if LTC+ led to a decrease in avoidable acute care transfers and to explore participants' perceptions and contextual factors influencing uptake.</p><p><strong>Setting and participants: </strong>LTC+ was implemented across 54 LTCHs and 3 hospital hubs in Toronto, Canada.</p><p><strong>Methods: </strong>Statistical process control charts were created to detect changes in ED transfer rates, stratifying data into high- and low-uptake LTCHs to evaluate the effect of LTC+ on ED transfer rates across 54 LTCHs. Semistructured interviews were conducted with health care providers, administrators, residents, and caregivers across 6 LTCHs and 3 hospital hubs and analyzed thematically.</p><p><strong>Results: </strong>There were 9658 ED transfers during the study period (April 2020 to March 2022), of which 3860 (40.0%) did not require admission. LTC+ delivered 534 virtual consultations, with 5 LTCHs accounting for 59% of program use. Compared with baseline (January 2019 to February 2020), transfer rates decreased by 40%, with no difference seen between LTCHs with high vs low uptake. Factors influencing uptake include program awareness, motivation, alignment of LTCH resources and program services, and commitment to ED avoidance.</p><p><strong>Conclusions and implications: </strong>The LTC+ program did not reduce ED transfers beyond secular trends attributable to the broader effects of the COVID-19 pandemic. Participants that used LTC+ identified important benefits that extended beyond ED avoidance including building self-efficacy and capacity in LTCHs to provide client-centered care with cross-sectoral collaboration. Refinements to the LTC+ program design and delivery and structural changes are needed to increase impact.</p>","PeriodicalId":17180,"journal":{"name":"Journal of the American Medical Directors Association","volume":" ","pages":"105488"},"PeriodicalIF":4.2,"publicationDate":"2025-02-08","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143399466","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2025-02-07DOI: 10.1016/j.jamda.2024.105474
Joury van der Griend MD , Fenne Wouters PhD , Gary Y.C. Yeung MD , Ineke J. Gerridzen MD, PhD , Karlijn J. Joling PhD , Sytse U. Zuidema MD, PhD , Martin Smalbrugge MD, PhD , Eefje M. Sizoo MD, PhD
Objective
Psychotropic drugs are frequently prescribed for challenging behavior in residents with dementia in nursing homes. Recommendations on psychotropic drug use for challenging behavior are described in the Dutch multidisciplinary guideline “Problem behavior in dementia.” This study aimed to gain insight into the adherence to guideline recommendations on drug type and timing of evaluations of different types of psychotropic drugs for challenging behavior in a national sentinel network of Dutch nursing homes.
Design
Prospective observational study.
Setting and Participants
Data on psychotropic drug use of residents in a sentinel network of 22 nursing homes across the Netherlands were collected during a 3-month measurement period in 2021.
Methods
Physicians completed registration forms integrated into the electronic health record after reporting on psychotropic drug use in progress notes. Prescribed drug type(s), type of drug intervention (start/stop/change in dosage/evaluation), and drug indications were recorded. Adherence to guideline recommendations on drug type was achieved if prescribed psychotropic drugs were recommended for the specified indication. Adherence to guideline recommendations on timing of evaluations was achieved if evaluations were reported within 7 days after starting.
Results
A total of 1279 forms on psychotropic drug use for specified challenging behaviors in 599 residents were collected. Recommended psychotropic drugs were used in 57% of all forms. The highest rate of recommended psychotropic drugs was for psychotic behavior (80%), followed by agitation (48%). Adherence was lowest for nighttime restlessness (22%). Of all newly started prescriptions, 17% were evaluated within the recommended 7 days after starting.
Conclusions and Implications
Adherence to guideline recommendations on drug type was present in just over half of the cases. Frequently, evaluations were not reported or were performed after the recommended time frame. Further research is needed to determine the reasons for non-recommended psychotropic drug use, low evaluation reporting rates, and factors that influence adherence. The use of a sentinel network may increase awareness and adherence.
{"title":"Adherence to Guideline Recommendations on Psychotropic Drug Use for Challenging Behavior in Dementia","authors":"Joury van der Griend MD , Fenne Wouters PhD , Gary Y.C. Yeung MD , Ineke J. Gerridzen MD, PhD , Karlijn J. Joling PhD , Sytse U. Zuidema MD, PhD , Martin Smalbrugge MD, PhD , Eefje M. Sizoo MD, PhD","doi":"10.1016/j.jamda.2024.105474","DOIUrl":"10.1016/j.jamda.2024.105474","url":null,"abstract":"<div><h3>Objective</h3><div>Psychotropic drugs are frequently prescribed for challenging behavior in residents with dementia in nursing homes. Recommendations on psychotropic drug use for challenging behavior are described in the Dutch multidisciplinary guideline “Problem behavior in dementia.” This study aimed to gain insight into the adherence to guideline recommendations on drug type and timing of evaluations of different types of psychotropic drugs for challenging behavior in a national sentinel network of Dutch nursing homes.</div></div><div><h3>Design</h3><div>Prospective observational study.</div></div><div><h3>Setting and Participants</h3><div>Data on psychotropic drug use of residents in a sentinel network of 22 nursing homes across the Netherlands were collected during a 3-month measurement period in 2021.</div></div><div><h3>Methods</h3><div>Physicians completed registration forms integrated into the electronic health record after reporting on psychotropic drug use in progress notes. Prescribed drug type(s), type of drug intervention (start/stop/change in dosage/evaluation), and drug indications were recorded. Adherence to guideline recommendations on drug type was achieved if prescribed psychotropic drugs were recommended for the specified indication. Adherence to guideline recommendations on timing of evaluations was achieved if evaluations were reported within 7 days after starting.</div></div><div><h3>Results</h3><div>A total of 1279 forms on psychotropic drug use for specified challenging behaviors in 599 residents were collected. Recommended psychotropic drugs were used in 57% of all forms. The highest rate of recommended psychotropic drugs was for psychotic behavior (80%), followed by agitation (48%). Adherence was lowest for nighttime restlessness (22%). Of all newly started prescriptions, 17% were evaluated within the recommended 7 days after starting.</div></div><div><h3>Conclusions and Implications</h3><div>Adherence to guideline recommendations on drug type was present in just over half of the cases. Frequently, evaluations were not reported or were performed after the recommended time frame. Further research is needed to determine the reasons for non-recommended psychotropic drug use, low evaluation reporting rates, and factors that influence adherence. The use of a sentinel network may increase awareness and adherence.</div></div>","PeriodicalId":17180,"journal":{"name":"Journal of the American Medical Directors Association","volume":"26 4","pages":"Article 105474"},"PeriodicalIF":4.2,"publicationDate":"2025-02-07","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143059454","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2025-02-07DOI: 10.1016/j.jamda.2024.105481
Joshua D. Niznik PharmD, PhD , Florentia E. Sileanu MS , Xinhua Zhao PhD , Kelvin Tran PharmD, MPS , Laura C. Hanson MD, MPH , Alan Kinlaw PhD , Thomas R. Radomski MD, MS , Alexa Ehlert MS , Sydney Springer PharmD, MS , Binxin Cao PharmD, MPH , Loren J. Schleiden MS , Carolyn T. Thorpe PhD, MPH
Objectives
Identifying people with possible dementia in health care systems is important to study outcomes and target improvements in care. This study sought to compare the performance of diagnostic codes and Minimum Data Set (MDS)-based measures for identifying dementia and cognitive impairment in older veteran nursing home residents.
Design
Retrospective, cross-sectional analysis.
Setting and Participants
We used real-world health care data from the Veterans Affairs (VA) Residential History File, VA Corporate Data Warehouse (CDW), Medicare claims, and the MDS to assemble a cohort of VA Community Living Center (CLC) admissions over 2015 to 2021 for veterans aged ≥ 65 with dual VA and Medicare enrollment (n = 54,234).
Methods
We defined 3 measures of possible dementia: (1) claims/CDW diagnoses using Chronic Conditions Warehouse (CCW) algorithms for Alzheimer’s disease or non-Alzheimer’s dementia; (2) MDS active diagnosis items for Alzheimer’s disease and non-Alzheimer’s dementia; and (3) MDS Cognitive Function Scale (CFS) assessment indicating at least mild cognitive impairment. We calculated proportions identified with each definition, and sensitivity, specificity, and positive predictive value of claims/CDW diagnoses and MDS indicators for dementia for identifying CFS impairment.
Results
Among VA CLC residents, 61.4% met at least 1 criterion for possible dementia (38.6% claims/CDW, 23.3% MDS active diagnosis, 50.8% CFS). Diagnoses from claims/CDW had 56.5% sensitivity and 80.0% specificity for identifying veterans with CFS cognitive impairment. Active diagnoses from the MDS exhibited poorer sensitivity (38.1%), but higher specificity (92.0%) identifying veterans with cognitive impairment on the CFS.
Conclusions and Implications
Consistent with what has been reported in Medicare nursing home residents, we observed only partial overlap between indicators of possible dementia across diagnosis codes and other indicators vs cognitive assessments in MDS. Our findings support the utility of these measures for identifying individuals with possible dementia across different systems, but further work is needed to understand implications when using diagnosis codes or cognitive assessments.
{"title":"A Comparison of Measures for Identifying Possible Dementia in Veterans Affairs Nursing Home Residents","authors":"Joshua D. Niznik PharmD, PhD , Florentia E. Sileanu MS , Xinhua Zhao PhD , Kelvin Tran PharmD, MPS , Laura C. Hanson MD, MPH , Alan Kinlaw PhD , Thomas R. Radomski MD, MS , Alexa Ehlert MS , Sydney Springer PharmD, MS , Binxin Cao PharmD, MPH , Loren J. Schleiden MS , Carolyn T. Thorpe PhD, MPH","doi":"10.1016/j.jamda.2024.105481","DOIUrl":"10.1016/j.jamda.2024.105481","url":null,"abstract":"<div><h3>Objectives</h3><div>Identifying people with possible dementia in health care systems is important to study outcomes and target improvements in care. This study sought to compare the performance of diagnostic codes and Minimum Data Set (MDS)-based measures for identifying dementia and cognitive impairment in older veteran nursing home residents.</div></div><div><h3>Design</h3><div>Retrospective, cross-sectional analysis.</div></div><div><h3>Setting and Participants</h3><div>We used real-world health care data from the Veterans Affairs (VA) Residential History File, VA Corporate Data Warehouse (CDW), Medicare claims, and the MDS to assemble a cohort of VA Community Living Center (CLC) admissions over 2015 to 2021 for veterans aged ≥ 65 with dual VA and Medicare enrollment (n = 54,234).</div></div><div><h3>Methods</h3><div>We defined 3 measures of possible dementia: (1) claims/CDW diagnoses using Chronic Conditions Warehouse (CCW) algorithms for Alzheimer’s disease or non-Alzheimer’s dementia; (2) MDS active diagnosis items for Alzheimer’s disease and non-Alzheimer’s dementia; and (3) MDS Cognitive Function Scale (CFS) assessment indicating at least mild cognitive impairment. We calculated proportions identified with each definition, and sensitivity, specificity, and positive predictive value of claims/CDW diagnoses and MDS indicators for dementia for identifying CFS impairment.</div></div><div><h3>Results</h3><div>Among VA CLC residents, 61.4% met at least 1 criterion for possible dementia (38.6% claims/CDW, 23.3% MDS active diagnosis, 50.8% CFS). Diagnoses from claims/CDW had 56.5% sensitivity and 80.0% specificity for identifying veterans with CFS cognitive impairment. Active diagnoses from the MDS exhibited poorer sensitivity (38.1%), but higher specificity (92.0%) identifying veterans with cognitive impairment on the CFS.</div></div><div><h3>Conclusions and Implications</h3><div>Consistent with what has been reported in Medicare nursing home residents, we observed only partial overlap between indicators of possible dementia across diagnosis codes and other indicators vs cognitive assessments in MDS. Our findings support the utility of these measures for identifying individuals with possible dementia across different systems, but further work is needed to understand implications when using diagnosis codes or cognitive assessments.</div></div>","PeriodicalId":17180,"journal":{"name":"Journal of the American Medical Directors Association","volume":"26 4","pages":"Article 105481"},"PeriodicalIF":4.2,"publicationDate":"2025-02-07","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143074902","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2025-02-07DOI: 10.1016/j.jamda.2024.105480
Tingting Zhang MD, PhD , Christopher M. Santostefano MPH, RN , Daniel Harris MPH, PhD , Antoinette B. Coe PharmD, PhD , Andrew R. Zullo PharmD, PhD , Lauren B. Gerlach DO, MS , Richa Joshi MS , Julie P.W. Bynum MD, MPH , Theresa I. Shireman PhD
Objectives
To estimate the immediate and long-term effects of a visitor restriction policy on antipsychotic use in nursing home (NH) residents with Alzheimer's disease and related dementias (ADRD) during COVID-19.
Design
A repeated cross-sectional study time series analysis was conducted using NH electronic health records (EHRs) from January 1, 2020, to December 31, 2021.
Setting and Participants
A large, multistate sample of NH residents living with ADRD.
Methods
We calculated weekly changes in facility-level prevalence of antipsychotic use using interrupted time series (ITS) to compare level and slope changes in antipsychotic use before, during, and after NH visitation restrictions. Generalized linear models with generalized estimating equations, logit link, binomial distribution, and AR-1 correlation structure were used for all ITS analyses. Final models were stratified by long- and short-stay residents and adjusted for NH-level covariates including resident demographics, clinical diagnoses, and nurse staffing.
Results
We observed more than 8500 long-stay and 2700 short-stay NH residents with ADRD. Among long-stay residents, the weekly prevalence of antipsychotic use increased from 18.9% as of January 7, 2020, to 24.9% by December 31, 2021. For short-stay residents, antipsychotic use increased from 21.1% to 26.6% over this same window. The ITS analysis showed no meaningful changes in the relative rate of change in antipsychotic use during and after visitor restrictions, relative to pre-policy trends.
Conclusions and Implications
The Centers for Medicare and Medicaid Services visitation restriction policy had no meaningful impact on antipsychotic use among NH residents with ADRD. However, antipsychotic use increased over time for both long- and short-stay residents and remained above pre-pandemic levels by the end of 2021. Our findings emphasize the potential for increased reliance on pharmacotherapy to manage resident symptoms during public health emergencies. Future infection control efforts should prioritize safe interpersonal care delivery and consider policies that improve vigilance of medication utilization changes among high-risk populations.
{"title":"Effects of Visitation Restriction on Antipsychotic Drug Use among Nursing Home Residents with ADRD during the COVID-19 Pandemic","authors":"Tingting Zhang MD, PhD , Christopher M. Santostefano MPH, RN , Daniel Harris MPH, PhD , Antoinette B. Coe PharmD, PhD , Andrew R. Zullo PharmD, PhD , Lauren B. Gerlach DO, MS , Richa Joshi MS , Julie P.W. Bynum MD, MPH , Theresa I. Shireman PhD","doi":"10.1016/j.jamda.2024.105480","DOIUrl":"10.1016/j.jamda.2024.105480","url":null,"abstract":"<div><h3>Objectives</h3><div>To estimate the immediate and long-term effects of a visitor restriction policy on antipsychotic use in nursing home (NH) residents with Alzheimer's disease and related dementias (ADRD) during COVID-19.</div></div><div><h3>Design</h3><div>A repeated cross-sectional study time series analysis was conducted using NH electronic health records (EHRs) from January 1, 2020, to December 31, 2021.</div></div><div><h3>Setting and Participants</h3><div>A large, multistate sample of NH residents living with ADRD.</div></div><div><h3>Methods</h3><div>We calculated weekly changes in facility-level prevalence of antipsychotic use using interrupted time series (ITS) to compare level and slope changes in antipsychotic use before, during, and after NH visitation restrictions. Generalized linear models with generalized estimating equations, logit link, binomial distribution, and AR-1 correlation structure were used for all ITS analyses. Final models were stratified by long- and short-stay residents and adjusted for NH-level covariates including resident demographics, clinical diagnoses, and nurse staffing.</div></div><div><h3>Results</h3><div>We observed more than 8500 long-stay and 2700 short-stay NH residents with ADRD. Among long-stay residents, the weekly prevalence of antipsychotic use increased from 18.9% as of January 7, 2020, to 24.9% by December 31, 2021. For short-stay residents, antipsychotic use increased from 21.1% to 26.6% over this same window. The ITS analysis showed no meaningful changes in the relative rate of change in antipsychotic use during and after visitor restrictions, relative to pre-policy trends.</div></div><div><h3>Conclusions and Implications</h3><div>The Centers for Medicare and Medicaid Services visitation restriction policy had no meaningful impact on antipsychotic use among NH residents with ADRD. However, antipsychotic use increased over time for both long- and short-stay residents and remained above pre-pandemic levels by the end of 2021. Our findings emphasize the potential for increased reliance on pharmacotherapy to manage resident symptoms during public health emergencies. Future infection control efforts should prioritize safe interpersonal care delivery and consider policies that improve vigilance of medication utilization changes among high-risk populations.</div></div>","PeriodicalId":17180,"journal":{"name":"Journal of the American Medical Directors Association","volume":"26 4","pages":"Article 105480"},"PeriodicalIF":4.2,"publicationDate":"2025-02-07","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143074916","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
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