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Biomedical subjects

Malaz Boustani

Publications and source records attributed to Malaz Boustani.

17 recordsLinked to original sources
PubMed2006

Who refuses the diagnostic assessment for dementia in primary care?

OBJECTIVE: Early screening and detection of dementia in primary care remains controversial. At least half of the patients identified as cognitively impaired by screening instruments do not meet criteria for dementia and some patients refuse further evaluation following a positive screen. The aim of this study was to identify the characteristics of patients who refuse a clinical diagnostic assessment for dementia after screening. DESIGN: Cross sectional study. SETTING: Seven primary care practice centers in Indianapolis. PARTICIPANTS: Four hundred and thirty-four individuals aged 65 and older who screened positive for dementia with a mean age of 74.6, 67% women, and 68% African-American. MAIN OUTCOME MEASURE: Patients' acceptance of undergoing a dementia diagnostic assessment that included neuropsychological testing, caregiver interview, and medical chart review. RESULTS: Among patients with positive screening results for dementia, approximately half (47.7%) refused further assessment to confirm their screening results. In a bivariate analysis, possible factors associated with a higher probability of refusing dementia assessment were older age and better screening score. In a multiple logistic regression model, performing well on the temporal orientation of the screening instrument was associated with a higher probability of refusing diagnostic assessment for dementia (OR = 1.37; p = 0.001). Also, African-American patients aged 80 and older were more likely to refuse the diagnostic assessment than African-Americans less than 80 years of age (OR = 3.1, p < 0.001), while there was no significant age association for white patients (OR = 0.9, p = 0.728). CONCLUSIONS: Older primary care patients who perceived themselves as having no cognitive symptoms refused dementia diagnostic assessment despite their positive screening results. We must improve our understanding of the decision-making process driving patients' beliefs and behaviors about the benefits and risks of dementia screening and diagnosis before implementing any broad-based screening initiatives for dementia.

Black or African American↗
PubMed2006

Comorbidity profile of dementia patients in primary care: are they sicker?

OBJECTIVES: To compare the medical comorbidity of older patients with and without dementia in primary care. DESIGN: Cross-sectional study. SETTING: Wishard Health Services, which includes a university-affiliated, urban public hospital and seven community-based primary care practice centers in Indianapolis. PARTICIPANTS: Three thousand thirteen patients aged 65 and older attending seven primary care centers in Indianapolis, Indiana. MEASUREMENTS: An expert panel diagnosed dementia using International Classification of Diseases, 10th Revision, criteria. Comorbidity was assessed using 10 physician-diagnosed chronic comorbid conditions and the Chronic Disease Score (CDS). RESULTS: Patients with dementia attending primary care have on average 2.4 chronic conditions and receive 5.1 medications. Approximately 50% of dementia patients in this setting are exposed to at least one anticholinergic medication, and 20% are prescribed at least one psychotropic medication. After adjusting for patients' age, race, and sex, patients with and without dementia have a similar level of comorbidity (mean number of chronic medical conditions, 2.4 vs 2.3, P=.66; average CDS, 5.8 vs 6.2, P=.83). CONCLUSION: Multiple medical comorbid conditions are common in older adults with and without dementia in primary care. Despite their cholinergic deficit, a substantial proportion of patients with dementia are exposed to anticholinergic medications. Models of care that incorporate this medical complexity are needed to improve the treatment of dementia in primary care.

Aged↗
PubMed2005

Dementia care and quality of life in assisted living and nursing homes.

PURPOSE: There are few empirical studies relating components of long-term care to quality of life for residents with dementia. This study relates elements of dementia care in residential care/assisted living (RC/AL) facilities and nursing homes to resident quality of life and considers the guidance this information provides for practice and policy. DESIGN AND METHODS: We used a variety of report and observational measures of the structure and process of care and 11 standardized measures of quality of life to evaluate the care for and quality of life of 421 residents with dementia in 35 RC/AL facilities and 10 nursing homes in four states. Data were collected cross sectionally on-site, and we conducted a 6-month follow-up by telephone. RESULTS: Change in quality of life was better in facilities that used a specialized worker approach, trained more staff in more domains central to dementia care, and encouraged activity participation. Residents perceived their quality of life as better when staff was more involved in care planning and when staff attitudes were more favorable. Better resident-staff communication was related to higher quality of life as observed and reported by care providers. Also, more stable resident-staff assignment was related to care providers' lower quality-of-life ratings. IMPLICATIONS: Improvement in resident quality of life may be achieved by improved training and deployment of staff.

Aged, 80 and over↗
PubMed2005

Characteristics associated with depression in long-term care residents with dementia.

We describe the prevalence, assessment, and treatment of, as well as characteristics associated with, depression in residential care/assisted living and nursing home residents with dementia. Overall, 25% of the participants were depressed. Depression was related to severe cognitive impairment, behavioral symptoms, pain, and for-profit nursing home residence.

Aged, 80 and over↗
PubMed2005

Characteristics associated with behavioral symptoms related to dementia in long-term care residents.

This article describes care for behavioral symptoms related to dementia (BSRD) and identifies their potential correlates among 347 residents with dementia living in 45 assisted living facilities and nursing homes from four states. The prevalence of BSRD was associated with staff training and resident cognition, mood, mobility, and psychotropic use. Attention to staff training and depression management might improve BSRD.

Aged, 80 and over↗
PubMed2005

Characteristics associated with mobility limitation in long-term care residents with dementia.

This article describes the prevalence, assessment, and treatment of, as well as characteristics associated with, mobility limitation in 343 residents with dementia in 45 assisted living facilities and nursing homes. Overall, 89% of residents had some degree of mobility limitation. Mobility limitation was associated with fewer behavioral symptoms, low fluid intake, professional assessment, and professional and informal treatment.

Assisted Living Facilities↗
PubMed2005

Characteristics associated with low food and fluid intake in long-term care residents with dementia.

This article describes the prevalence, assessment, and treatment of, as well as characteristics associated with, the food and fluid intake of 407 residents with dementia in 45 assisted living facilities and nursing homes. Overall, 54% of observed residents had low food intake, and 51% had low fluid intake. Staff monitoring of residents, having meals in a public dining area, and the presence of noninstitutional features were each associated with higher food and fluid intake.

Aged↗
PubMed2005

Attitudes, stress, and satisfaction of staff who care for residents with dementia.

PURPOSE: Considering the increasing proportion of residents in long-term care who have dementia, and the important influence that direct care providers have on resident quality of life, this study explores the dementia-related attitudes of residential care/assisted living (RC/AL) and nursing home staff, as well as their work stress and satisfaction. DESIGN AND METHODS: Data were derived from interviews with 154 direct care providers from 31 RC/AL facilities and 10 nursing homes who participated in the Collaborative Studies of Long-Term Care. RESULTS: Stress was more often reported by care providers who had been working for 1 to 2 years (compared with longer); in addition, those who had been working for 1 to 2 years were more likely to espouse hopeful or person-centered attitudes than those who had been working for a longer period of time. Also, a person-centered attitude related to satisfaction, and perceived competence in providing dementia care was consistently associated with dementia-sensitive attitudes and job satisfaction. IMPLICATIONS: Attending to the welfare and ongoing training of workers who have demonstrated job commitment may lessen their tendency to become jaded over time or seek job opportunities elsewhere. Further, the attitudes the staff hold related to dementia and the training they receive to provide dementia care are important for their own well-being.

Adult↗
PubMed2005

Implementing a screening and diagnosis program for dementia in primary care.

BACKGROUND: Primary care physicians are positioned to provide early recognition and treatment of dementia. We evaluated the feasibility and utility of a comprehensive screening and diagnosis program for dementia in primary care. METHODS: We screened individuals aged 65 and older attending 7 urban and racially diverse primary care practices in Indianapolis. Dementia was diagnosed according to International Classification of Diseases (ICD)-10 criteria by an expert panel using the results of neuropsychologic testing and information collected from patients, caregivers, and medical records. RESULTS: Among 3,340 patients screened, 434 scored positive but only 227 would agree to a formal diagnostic assessment. Among those who completed the diagnostic assessment, 47% were diagnosed with dementia, 33% had cognitive impairment-no dementia (CIND), and 20% were considered to have no cognitive deficit. The overall estimated prevalence of dementia was 6.0% (95% confidence interval (CI) 5.5% to 6.6%) and the overall estimate of the program cost was $128 per patient screened for dementia and $3,983 per patient diagnosed with dementia. Only 19% of patients with confirmed dementia diagnosis had documentation of dementia in their medical record. CONCLUSIONS: Dementia is common and undiagnosed in primary care. Screening instruments alone have insufficient specificity to establish a valid diagnosis of dementia when used in a comprehensive screening program; these results may not be generalized to older adults presenting with cognitive complaints. Multiple health system and patient-level factors present barriers to this formal assessment and thus render the current standard of care for dementia diagnosis impractical in primary care settings.

Aged↗
PubMed2004

Medication undertreatment in assisted living settings.

BACKGROUND: Residential care/assisted living (RC/AL) is a rapidly growing, long-term care setting, where medication use has not been carefully examined. We sought to determine the prevalence and predictors of nonprescribing of selected medications whose value in decreasing morbidity has been established in clinical trials. METHODS: As part of a survey of a stratified random sample of 193 RC/AL facilities in Florida, Maryland, New Jersey, and North Carolina, data were gathered on 2014 residents 65 years and older. Patient characteristics and diagnoses were recorded based on medical record reviews and in-person patient assessments; all medications administered at least 4 of the previous 7 days were recorded. Data on facility characteristics were obtained by interviewing facility administrators. Bivariate and multivariate logistic regression was performed to identify associations between medication nonprescribing and facility characteristics, physician visitation, and patient age, sex, race, comorbidity, functional dependency, and cognition. RESULTS: Of 328 subjects with congestive heart failure, 204 (62.2%) were not receiving an angiotensin-converting enzyme inhibitor; of 172 subjects with prior myocardial infarction, 60.5% were not receiving aspirin and 76.2% were not receiving beta-blockers; of 435 patients with history of stroke, 37.5% were not receiving an anticoagulant or antiplatelet agent; and of 315 patients with osteoporosis, 61.0% were not receiving calcium supplementation and 51.1% were not receiving any treatment for the condition. Resident age, race, sex, comorbidity, cognitive status, and dependency in activities of daily living were rarely associated with nonprescribing; in contrast, facility factors-particularly facility type and the frequency of physician visits-were somewhat more frequently associated with nonprescribing. CONCLUSIONS: Undertreatment appears to be prevalent in RC/AL facilities. Since preserving independence is often a primary goal of care in these settings, more attention may need to be paid to the use of treatments that have been shown to reduce long-term morbidity.

Aged↗
PubMed2004

Can we trust depression screening instruments in healthy 'old-old' adults?

OBJECTIVE: Despite a growing understanding of late-life depression, few studies focus on the old-old, those 75 years and over. We wished to characterize depressive symptoms and determine the accuracy of two common screening instruments for major and minor depression in a population of old-old retirees. METHODS: Participants lived independently in one of two Continuing Care Retirement Communities and volunteered for an in-home interview about cancer screening attitudes. As part of this baseline interview, they were screened with the Geriatric Depression Scale (GDS) and the Center for Epidemiologic Studies-Depression (CES-D) scale. Those agreeing to a second interview received an evaluation using the Structured Clinical Interview for DSM-IV (SCID-IV), performed by a geriatric psychiatrist within two weeks of the initial interview. RESULTS: In an educated and cognitively intact group of retirees averaging 80 years of age, the GDS and CES-D performed poorly using standard cutpoints in detecting both major (sensitivity 60% for both) and minor (sensitivity 33% and 50%, respectively) depression. One in five participants had significant depression as confirmed by SCID-IV evaluation. Twelve percent had major depression and 7% had minor depression. Most participants had their first episode of either after age 60. CONCLUSIONS: Contrary to most studies evaluating the GDS and CES-D for accuracy in detecting late-life depression, these instruments at standard cutpoints performed poorly in this group of healthy older adults. The healthy old-old may require novel screening interventions to detect clinically significant depression.

Aged↗
PubMed2004

Development and implementation of nonpharmacologic protocols for the management of patients with Alzheimer's disease and their families in a multiracial primary care setting.

PURPOSE: Most patients and families with dementia are cared for in primary care clinics. These clinics are seldom designed to provide the necessary comprehensive care. The purpose of this article is to describe nonpharmacologic protocols for the management of patients with Alzheimer's disease and their families that are administered as part of a multifaceted care-management intervention program in a multiracial primary care clinic. DESIGN & METHODS: The nonpharmacologic component for the integrated program of collaborative care was developed based on a literature review and previous clinical experience. The care is coordinated by a geriatric nurse practitioner who meets with patients, families, and the primary care physicians. The nonpharmacologic protocols included general educational guidelines about Alzheimer's disease. Specific protocols to treat the common behavioral disturbances associated with Alzheimer's disease also were developed. A major component of the intervention is a monthly psychoeducational support group for caregivers. RESULTS: The intervention has been well accepted by patients, families, and physicians. Approximately one-half of the treatment group has participated in the support group regularly. IMPLICATIONS: The integration of behavioral interventions and team care within the primary care environment has been successful.

Aged↗
PubMed2004

Behavioral symptoms in residential care/assisted living facilities: prevalence, risk factors, and medication management.

OBJECTIVES: To examine the prevalence, correlates, and medication management of behavioral symptoms in elderly people living in residential care/assisted living (RC/AL) facilities. DESIGN: Cross-sectional study. SETTINGS: A stratified random sample of 193 RC/AL facilities in four states (Florida, Maryland, New Jersey, North Carolina). PARTICIPANTS: A total of 2,078 RC/AL residents aged 65 and older. MEASUREMENT: Behavioral symptoms were classified using a modified version of the Cohen-Mansfield Agitation Inventory. Additional items on resistance to care were also examined. RESULTS: Approximately one-third (34%) of RC/AL residents exhibited one or more behavioral symptoms at least once a week. Thirteen percent exhibited aggressive behavioral symptoms, 20% demonstrated physically nonaggressive behavioral symptoms, 22% expressed verbal behavioral symptoms, and 13% resisted taking medications or activities of daily living care. Behavioral symptoms were associated with the presence of depression, psychosis, dementia, cognitive impairment, and functional dependency, and these relationships persisted across subtypes of behavioral symptoms. Overall, behavioral symptoms were more prevalent in smaller facilities. More than 50% of RC/AL residents were taking a psychotropic medication, and two-thirds had some mental health problem indicator (dementia, depression, psychosis, or other psychiatric illness). CONCLUSION: Integrating mental health services within the process of care in RC/AL is needed to manage and accommodate the high prevalence of behavioral symptoms in this evolving long-term setting.

Activities of Daily Living↗
PubMed2003

Screening for dementia in primary care: a summary of the evidence for the U.S. Preventive Services Task Force.

BACKGROUND: Dementia is a large and growing problem but is often not diagnosed in its earlier stages. Screening and earlier treatment could reduce the burden of suffering of this syndrome. PURPOSE: To review the evidence of benefits and harms of screening for and earlier treatment of dementia. DATA SOURCES: MEDLINE, PsycINFO, EMBASE, the Cochrane Library, experts, and bibliographies of reviews. STUDY SELECTION: The authors developed eight key questions representing a logical chain between screening and improved health outcomes, along with eligibility criteria for admissible evidence for each question. Admissible evidence was obtained by searching the data sources. DATA EXTRACTION: Two reviewers abstracted relevant information using standardized abstraction forms and graded article quality according to U.S. Preventive Services Task Force criteria. DATA SYNTHESIS: No randomized, controlled trial of screening for dementia has been completed. Brief screening tools can detect some persons with early dementia (positive predictive value < or =50%). Six to 12 months of treatment with cholinesterase inhibitors modestly slows the decline of cognitive and global clinical change scores in some patients with mild to moderate Alzheimer disease. Function is minimally affected, and fewer than 20% of patients stop taking cholinesterase inhibitors because of side effects. Only limited evidence indicates that any other pharmacologic or nonpharmacologic intervention slows decline in persons with early dementia. Although intensive multicomponent caregiver interventions may delay nursing home placement of patients who have caregivers, the relevance of this finding for persons who do not yet have caregivers is uncertain. Other potential benefits and harms of screening have not been studied. CONCLUSIONS: Screening tests can detect undiagnosed dementia. In persons with mild to moderate clinically detected Alzheimer disease, cholinesterase inhibitors are somewhat effective in slowing cognitive decline. The effect of cholinesterase inhibitors or other treatments on persons with dementia detected by screening is uncertain.

Aged↗
PubMed2003

Acceptance of dementia screening in continuous care retirement communities: a mailed survey.

BACKGROUND: In a recent systematic review of the evidence for dementia screening to support recommendations from the US Preventive Services Task Force, we found no evidence regarding the interest or willingness of older adults to be screened, and insufficient evidence to provide an estimate of the potential harms of dementia screening. OBJECTIVE: In an attempt to address the acceptability of dementia screening, we asked older adults living in two Continuous Care Retirement Communities (CCRC) if they would agree to routine screening for memory problems. DESIGN: Cross-sectional study using self-administered mailed survey questionnaires. SETTING: Two CCRCs in Orange County, North Carolina. PARTICIPANTS: 500 residents of the independent living section of CCRCs. RESULTS: There was a 64% survey response rate. Of these, 49% of participants stated they would agree to routine screening for memory problems. In comparison to people who would not agree to routine memory screening, those who accepted memory screening were more likely to accept depression screening, be male, use drug-administration assisted devices, and take more medications. CONCLUSION: Approximately half of the residents in this affluent residential community setting were not willing to be screened routinely for memory problems. This high refusal rate indicates that dementia screening may be associated with perceived harms. We must improve our understanding of the decision-making process driving individual's beliefs and behaviors about dementia screening before implementing any broad-based screening initiatives for dementia or cognitive impairment.

Aged↗
PubMed2001

The public health impact of Alzheimer's disease, 2000-2050: potential implication of treatment advances.

Recent developments in basic research suggest that therapeutic breakthroughs may occur in Alzheimer's disease treatment over the coming decades. To model the potential magnitude and nature of the effect of these advances, historical data from congestive heart failure and Parkinson's disease were used. Projections indicate that therapies which delay disease onset will markedly reduce overall disease prevalence, whereas therapies to treat existing disease will alter the proportion of cases that are mild as opposed to moderate/severe. The public health impact of such changes would likely involve both the amount and type of health services needed. Particularly likely to arise are new forms of outpatient services, such as disease-specific clinics and centers. None of our models predicts less than a threefold rise in the total number of persons with Alzheimer's disease between 2000 and 2050. Therefore, Alzheimer's care is likely to remain a major public health problem during the coming decades.

Alzheimer Disease↗