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Background: Clinical features of dementia (cognition, function, and behavioral/psychological symptoms [BPSD]) may differentially affect Medicare expenditures/health care utilization.Methods: We linked cross-sectional data from the Aging, Demographics, and Memory Study to Medicare data to evaluate the association between dementia clinical features among those with dementia and Medicare expenditures/health care utilization (n = 234). Cognition was evaluated using the Mini-Mental State Examination (MMSE). Function was evaluated as the number of functional limitations (0-10). BPSD was evaluated as the number of symptoms (0-12). Expenditures were estimated with a generalized linear model (log-link and gamma distribution). Number of hospitalizations, institutional outpatient visits, and physician visits were estimated with a negative binomial regression. Medicare covered skilled nursing days were estimated with a zero-inflated negative binomial model.Results: Cognition and BPSD were not associated with expenditures. Among individuals with less than seven functional limitations, one additional limitation was associated with $123 (95% confidence interval: $19-$227) additional monthly Medicare spending. Better cognition and poorer function were associated with more hospitalizations among those with an MMSE less than three and less than six functional limitations, respectively. BPSD had no effect on hospitalizations. Poorer function and fewer BPSD were associated with more skilled nursing among individuals with one to seven functional limitations and more than four symptoms, respectively. Cognition had no effect on skilled nursing care. No clinical feature was associated with institutional outpatient care. Of individuals with an MMSE less than 15, poorer cognition was associated with fewer physician visits. Among those with more than six functional limitations, poorer function was associated with fewer physician visits.Conclusions: Poorer function, not cognition or BPSD, was associated with higher Medicare expenditures. [ABSTRACT FROM AUTHOR]

Background: Dementia results in changes in cognition, function, and behavior. We examine the effect of sociodemographic and clinical risk factors on cognitive, functional, and behavioral declines in incident dementia patients.Methods: We used longitudinal data from the National Alzheimer's Coordinating Center to evaluate cognitive (Mini-Mental State Exam [MMSE]), functional (Functional Activities Questionnaire [FAQ]), and behavioral (Neuropsychiatric Inventory Questionnaire [NPI-Q] severity score) trajectories for incident dementia patients over an 8-year period. We evaluated trajectories of 457 patients with mixed effects linear regression models.Results: In the first year, cognition worsened by -1.518 (95% confidence interval [CI] -1.745, -1.291) MMSE points (0-30 scale). Education, race, and region of residence predicted cognition at diagnosis. Age of onset, geographic region of residence, and history of hypertension and congestive heart failure predicted cognitive changes. Function worsened by 3.464 (95% CI 3.131, 3.798) FAQ points in the first year (0-30 scale). Cognition, gender, race, region of residence and place of residence, and a history of stroke and hypercholesterolemia predicted function at diagnosis. Place of residence and a history of diabetes predicted functional changes. Behavioral symptoms worsened by 0.354 (95% CI 0.123, 0.585) NPI-Q points in the first year (0-36 scale). Age of onset, region of residence, and history of hypertension and psychiatric problems predicted behaviors at diagnosis. Cognition explained changes in behavior.Conclusions: Sociodemographic characteristics and clinical comorbidities predict cognitive and functional changes. Only cognitive status explains behavioral decline. Results provide an understanding of the characteristics that impact cognitive, functional, and behavioral decline. [ABSTRACT FROM AUTHOR]

Background. Existing studies on the relationships between impairments and activities of daily living (ADLs) in nursing home residents have serious limitations. This study examines the relationships among admission impairments, including pain, depression, incontinence, balance, and falls, and follow-up ADLs, as well as the effect of the nursing home on follow-up ADLs of extended-stay nursing home residents. Methods. This longitudinal cohort study consisted of 4,942 extended-stay residents who were admitted into 377 Minnesota nursing homes during 2004. General linear mixed models were used for all analyses. with 14 resident-level and 8 facility-level control variables. Results, Incontinence and balance function at admission were significantly associated with increases in ADL dependence at follow-up. Individual nursing homes had independent effects on all three ADL models. Similar findings were found after facility-level control variables were added. conclusions. Incontinence predicts subsequent ADL functional levels. The relationship between balance dysfunction and subsequent ADL dependence could be causal. Future studies of the causal relationships between impairments and ADL should examine the effectiveness of impairment interventions on ADL as well as these relationships in different subgroups of nursing home residents. [ABSTRACT FROM AUTHOR]

Background. The Program for All-inclusive Care of the Elderly (PACE) has been hailed as successful but of limited appeal This study contrasts the effects on hospital utilization of PACE and a more liberal variant, the Wisconsin Partnership Program (WPP). Methods. Hospital and emergency room (ER) utilization data from two sites that used both PACE and WPP to serve elderly clients were compared. The analysis of utilization was conducted using a cross-sectional longitudinal approach. The statistical significance of the difference between WPP and PACE groups was calculated by using regressions that adjusted for gender, race (white/nonwhite), age, original reason for entitlement in Medicare (elderly/disabled), dual eligibility, diagnoses during the previous 6 months, and county of residence. Results. The PACE enrollees had fewer hospital admissions, preventable hospital admissions, hospital days, ER visits, and preventable ER visits than the WPP enrollees had. There was no difference in the length of hospital stays. Conclusions. PACE is more effective in controlling hospital and ER utilization than is the more flexible variant (WPP). [ABSTRACT FROM AUTHOR]

Background: Although the Minimum Data Set (MDS) presents a wide range of opportunities for policy makers and practitioners interested in outcomes of nursing home care for frail elderly persons, researchers have debated the validity and reliability of measurements in the MDS from the outset. To investigate this issue, the authors studied the accuracy of functional assessments by comparing the MDS and interview data collected in two evaluation studies.Methods: Activities of daily living (ADL) assessment data from 3385 nursing home residents were collected from interviews with nursing home residents (n = 1200), family members (n = 1070), and nursing home staff (n = 1115). The MDS data for these nursing home residents were obtained and matched with the interview data. The agreement in ADL assessments between interview data and the MDS was assessed using Kappa statistics and multinomial logit regression for each of the three data sources.Results: The agreement on ADL assessments between MDS and interview data was low to moderate (Kappa = 0.25 to 0.52), regardless of the sources of data. Interview data from staff and family proxies agreed to a greater degree with the MDS than did data collected from nursing home residents. The MDS reported fewer ADL difficulties than did staff proxies and more ADL difficulties than did nursing home residents. These findings held even after adjustment for other confounding factors using multinomial logit regression.Conclusions: The substantial discrepancy between MDS and interview data can be attributed to both bias and error. The ADL assessments based on residents' and family or staff reports differ, but the size of these differences depends on the proxy type and the method of data collection. [ABSTRACT FROM AUTHOR]

Background. Although the Minimum Data Set (MDS) presents a wide range of opportunities for policy makers and practitioners interested in outcomes of nursing home care for frail elderly persons, researchers have debated the validity and reliability of measurements in the MDS from the outset. To investigate this issue, the authors studied the accuracy of functional assessments by comparing the MDS and interview data collected in two evaluations studies. Methods. Activities of daily living (ADL) assessment data from 3385 nursing home residents were collected from interviews with nursing home residents (n = 1200), family members (n = 1070), and nursing home staff (n = 1115). The MDS data for these nursing home residents were obtained and matched with the interview data. The agreement in ADL assessments between interview data and the MDS was assessed using Kappa statistics and multinomial logit regression for each of the three data sources. Results. The agreement on ADL assessments between MDS and interview data was low to moderate (Kappa = 0.25 to 0.52), regardless of the sources of data. Interview data from staff and family proxies agreed to a greater degree with the MDS than did data collected from nursing home residents. The MDS reported fewer ADL difficulties than did staff proxies and more ADL difficulties than did nursing home residents. These findings held even after adjustment for other confounding factors using multinomial logit regression. Conclusions. The substantial discrepancy between MDS and interview data can be attributed to both bias and error. The ADL assessments based on residents' and family or staff reports differ, but the size of these differences depends on the proxy type and the method of data collection. [ABSTRACT FROM AUTHOR]

Background: Quality of life (QOL) is a goal for nursing home residents, but measures are needed to tap this phenomenon.Methods: In-person QOL interviews were attempted for 1988 residents, stratified by cognitive functioning, from 40 nursing homes in five states. Likert-type response options were used with reversion to dichotomous responses when necessary; z-score transformations were used to combine the formats. Tests of internal consistency and confirmatory factor analysis were performed; cluster analysis was used to shorten the scales. Correlations between domain scores were examined, and tests of convergent validity performed. Analyses were repeated for subgroups based on cognitive functioning levels.Results: Long QOL scales were constructed for 1316 of the 1988 residents, including many with substantial cognitive impairment. Confirmatory factor analysis confirmed 10 QOL domains. Cronbach alphas ranged from.76 to.52. The majority (93%) of the 45 possible interscale correlations among domains were below.l4 and the rest were between.4 and.5. QOL scales were correlated with, but distinct from, residents' emotions ratings and overall satisfaction, and each was correlated with a corresponding summary rating for the domain.Conclusions: QOL can be feasibly measured from resident self-report for much of the nursing home population, including cognitively impaired residents. Additional research is suggested on the measures, but the approach has promise for regulation, continuous quality improvement, and public information. [ABSTRACT FROM AUTHOR]

Background: The Wisconsin Partnership Program (WPP) is a variation on the Program for All-inclusive Care of the Elderly (PACE) model that is designed to be more flexible by allowing frail elderly dual-eligible (for both Medicare and Medicaid) clients to use their regular primary care physicians instead of relying on the physician hired by PACE. Case management is provided by a team of nurse, social worker, and nurse practitioner. The latter is charged with communicating with the client's primary physician.Methods: We compared the functional status and satisfaction of WPP elderly enrollees with those of two sets of dually eligible controls drawn from the Medicaid waiver rosters. One set of controls came from persons in the same county who opted not to enroll in WPP. The second came from matched counties that did not have access to the WPP. Enrollees were interviewed in person. Family members were interviewed by telephone.Results: The prevalence of activities of daily living (ADLs) and instrumental activities of daily living (IADLs) dependency was lower for the WPP sample than that for the controls. The pattern of unmet needs was generally comparable. About half of each sample had a written advance directive. Overall, there were few areas of significant difference in beneficiaries' satisfaction. The WPP families were more satisfied than either control group that services were provided when needed and were better coordinated. There were no significant differences in the prevalence of any aspect of care burden.Conclusions: The impact of WPP seems limited. There is some evidence that families perceive better coordinated care. A more complete evaluation will await the analysis of the differences in utilization patterns between WPP and the controls. [ABSTRACT FROM AUTHOR]

Background: Duplication of funding and resultant inefficiencies have prompted active consideration of pooling the funding for persons covered by both Medicare and Medicaid into a single managed care program. This study reports the initial results of the first such program.Methods: A sample of enrollees in Minnesota Senior Health Options (MSHO) and two sets of controls (within the same catchment area and outside it) as well as their families were interviewed to assess their functional status and satisfaction with their medical care. Respondents included those living in the community and those living in nursing homes.Results: The MSHO and control samples were generally alike in terms of demographics and illness patterns. The differences that were found reflected those attributable to geographic location more than program. The groups were also similar with regard to functional status. There were few satisfaction differences among the community-dwelling samples, but the MSHO nursing residents and especially their families expressed more satisfaction with several aspects of care.Conclusions: Whereas no causal conclusions about outcomes can be drawn from a cross-sectional sample, there is no indication that managed care for the dually eligible population has profound impacts on care. However, the system of care provided to nursing home residents is appreciated over traditional care. [ABSTRACT FROM AUTHOR]

Focuses on geriatrics in the U.S. Definition of geriatrics; Basic principles of chronic illness care; Features of geriatric policy; Possible solutions to the issue of chronic diseases.

The author comments on a study on bathing disability and the risk of long-term admission to a nursing home. He notes that any geriatrician knows that bathing is an early-loss activity of daily living and bathing may be the predictor of greater disability now or in the future. The author also mentions that the risk factors for the Program of All-Inclusive Care for the Elderly enrollees include age, IADL and bowel incontinence.

Presents a critique of an article published in the September 2001 issue of the 'Journal of Gerontology' concerning the Minnesota Senior Health Options (MSHO) Program. Mandate of the health plans under MSHO; Comparison between the services given by Medicaid and the MSHO; Explanation for the greater extent of advance directives among MSHO enrollees.

A response by Robert L. Kane to a letter to the editor about his article "Ptolemaic Bathing" is presented.

The article focuses on the impact of morbidity and disability projections in old age on health care policy. The theory on population aging can largely affect health care policy. For instance, it can have substantial impact on the size of cost estimates for long-term care. It can also create social havoc with the even-more-aged population seeing themselves as disabled.

Presents a letter to the editor in response to a letter by Robert Kane on the need to formally establish a group of professionals with personal experience in chronic care in the U.S.

Presents a letter to the editor about professionals with personal experience in chronic care.