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The growing number of people living with dementia (PLWD) requires a coordinated clinical response to deliver pragmatic, evidence‐based interventions in frontline care settings. However, infrastructure to support such a response is lacking. Moreover, there are too few researchers conducting rigorous embedded pragmatic clinical trials (ePCTs) to make the vision of high quality, widely accessible dementia care a reality. National Institute on Aging (NIA) Imbedded Pragmatic Alzheimer's disease and Related Dementias Clinical Trials (IMPACT) Collaboratory seeks to improve the pipeline of early career researchers qualified to lead ePCTs by funding career development awards. Even with support from the Collaboratory, awardees face practical and methodological challenges to success, recently exacerbated by the COVID‐19 pandemic. We first describe the training opportunities and support network for the IMPACT CDA recipients. This report then describes the unique career development challenges faced by early‐career researchers involved in ePCTs for dementia care. Topics addressed include challenges in establishing a laboratory, academic promotion, mentoring and professional development, and work‐life balance. Concrete suggestions to address these challenges are offered for early‐career investigators, their mentors, and their supporting institutions. While some of these challenges are faced by researchers in other fields, this report seeks to provide a roadmap for expanding the work of the IMPACT Collaboratory and initiating future efforts to recruit, train, and retain talented early‐career researchers involved in ePCTs for dementia care. [ABSTRACT FROM AUTHOR]

Background: Patients who undergo the complex series of transitions from the hospital to a skilled nursing facility (SNF) back to home represent a unique patient population with multiple comorbidities and impaired functional abilities. The needs and outcomes of patients who are discharged from the hospital to SNF before returning home are understudied in care transitions scholarship.Objective: To study the patient and caregiver challenges and perspectives on transitions from the hospital to the SNF and back to home.Design: Between 48 h and 1 week after discharge from the SNF, semi-structured interviews were performed with a convenience sample of patients and caregivers in their homes. Within 1 to 2 weeks after the baseline interview, follow-up interviews were performed over the phone.Participants: A total of 39 interviewees comprised older adults undergoing the series of transitions from hospital to skilled nursing facility to home and their informal caregivers.Main Measures: A constructionist, grounded-theory approach was used to code the interviews, identify major themes and subthemes, and develop a theoretical model explaining the outcomes of the SNF to home transition.Key Results: The mean age of the patients was 76.6 years and 64.8 years for the caregivers. Four major themes were identified: comforts of home, information needs, post-SNF care, and independence. Patients noted an extended time away from home and were motivated to return to and remain in the home. Information needs were variably met and affected post-SNF care, including medication management, appointments, and therapy gains and setbacks. Interviewees identified independent function at home as the most important outcome of the transition home.Conclusions: Post-SNF in home support is needed rapidly after discharge from the SNF to prevent adverse outcomes. In-home support needs to be highly individualized based on a patient's and caregiver's unique situation and needs. [ABSTRACT FROM AUTHOR]

Background: Aberrant angiogenesis may play a role in the development of Alzheimer's disease and related dementia.Objective: To explore the relationship between angiogenesis activity and evidence of neurodegeneration among older adults.Methods: Cross-sectional study of 49 older adults clinically characterized as cognitively normal, mild cognitive impairment, or early Alzheimer's disease. In addition to neuroimaging, we completed assays on peripheral blood, including: vascular endothelial growth factor, tumor necrosis factor, fibroblast growth factor, and amyloid-β peptide 40. We used advanced polychromatic flow cytometry to phenotype circulating mononuclear cells to assess angiogenesis activity.Results: Although we documented differences in cognitive performance, structural changes on neuroimaging, and burden of amyloid and tau on positron emission tomography, angiogenesis activity did not vary by group. Interestingly, VEGF levels were shown to be increased among subjects with mild cognitive impairment. In ANCOVA models controlling for age, sex, intracranial volume, and monocyte subpopulations, angiogenesis activity was correlated with increased white matter hyperintensities.Conclusion: We demonstrate a significant association between angiogenesis activity and cerebrovascular disease. To better understand the potential of angiogenesis as an intervention target, longitudinal studies are needed. [ABSTRACT FROM AUTHOR]

Background: When working with surrogate decision-makers, physicians often encounter ethical challenges that may cause moral distress which can have negative consequences for physicians.Objective: To determine frequency of and factors associated with physicians' moral distress caring for patients requiring a surrogate.Design: Prospective survey.Participants: Physicians (n = 154) caring for patients aged 65 years and older and their surrogate decision-makers (n = 362 patient/surrogate dyads). Patients were admitted to medicine or medical intensive care services, lacked decisional capacity and had an identified surrogate.Main Measures: Moral distress thermometer.Key Results: Physicians experienced moral distress in the care of 152 of 362 patients (42.0%). In analyses adjusted for physician, patient, and surrogate characteristics, physician/surrogate discordance in preferences for the plan of care was not significantly associated with moral distress. Physicians were more likely to experience moral distress when caring for older patients (1.06, 1.02-1.10), and facing a decision about life-sustaining treatment (3.58, 1.54-8.32). Physicians were less likely to experience moral distress when caring for patients residing in a nursing home (0.40, 0.23-0.69), patients who previously discussed care preferences (0.56, 0.35-0.90), and higher surrogate ratings of emotional support from clinicians (0.94, 0.89-0.99). Physicians' internal discordance when they prefer a more comfort-focused plan than the patient is receiving was associated with significantly higher moral distress (2.22, 1.33-3.70) after adjusting for patient, surrogate, and physician characteristics.Conclusions: Physician moral distress occurs more frequently when the physician is male, the patient is older or requires decisions about life-sustaining treatments. These findings may help target interventions to support physicians. Prior discussions about patient wishes is associated with lower distress and may be a target for patient-centered interventions. [ABSTRACT FROM AUTHOR]

Background: Alzheimer disease results in progressive functional decline, leading to loss of independence.Objective: To determine whether collaborative care plus 2 years of home-based occupational therapy delays functional decline.Design: Randomized, controlled clinical trial. (ClinicalTrials.gov: NCT01314950).Setting: Urban public health system.Patients: 180 community-dwelling participants with Alzheimer disease and their informal caregivers.Intervention: All participants received collaborative care for dementia. Patients in the intervention group also received in-home occupational therapy delivered in 24 sessions over 2 years.Measurements: The primary outcome measure was the Alzheimer's Disease Cooperative Study Group Activities of Daily Living Scale (ADCS ADL); performance-based measures included the Short Physical Performance Battery (SPPB) and Short Portable Sarcopenia Measure (SPSM).Results: At baseline, clinical characteristics did not differ significantly between groups; the mean Mini-Mental State Examination score for both groups was 19 (SD, 7). The intervention group received a median of 18 home visits from the study occupational therapists. In both groups, ADCS ADL scores declined over 24 months. At the primary end point of 24 months, ADCS ADL scores did not differ between groups (mean difference, 2.34 [95% CI, -5.27 to 9.96]). We also could not definitively demonstrate between-group differences in mean SPPB or SPSM values.Limitation: The results of this trial are indeterminate and do not rule out potential clinically important effects of the intervention.Conclusion: The authors could not definitively demonstrate whether the addition of 2 years of in-home occupational therapy to a collaborative care management model slowed the rate of functional decline among persons with Alzheimer disease. This trial underscores the burden undertaken by caregivers as they provide care for family members with Alzheimer disease and the difficulty in slowing functional decline.Primary Funding Source: National Institute on Aging. [ABSTRACT FROM AUTHOR]

Background Communication problems between family surrogates and intensive care unit (ICU) clinicians have been documented, but few interventions are effective. Nurses have the potential to play an expanded role in ICU communication and decision making. Objectives To conduct a pilot randomized controlled trial of the family navigator (FN), a distinct nursing role to address family members' unmet communication needs early in an ICU stay. Methods An interprofessional team developed the FN protocol. A randomized controlled pilot intervention trial of the FN was performed in a tertiary referral hospital's ICU to test the feasibility and acceptability of the intervention.The intervention addressed informational and emotional communication needs through daily contact by using structured clinical updates, emotional and informational support modules, family meeting support, and follow-up phone calls. Results Twenty-six surrogate/patient pairs (13 per study arm) were enrolled. Surrogates randomized to the intervention had contact with the FN on 90% or more of eligible patient days. All surrogates agreed that they would recommend the FN to other families. Open-ended comments from both surrogates and clinicians were uniformly positive. Conclusions Having a fully integrated nurse empowered to facilitate decision making is a feasible intervention in an ICU and is well-received by ICU families and staff. A larger randomized controlled trial is needed to demonstrate impact on important outcomes, such as surrogates' well-being and decision quality. [ABSTRACT FROM AUTHOR]

Objectives To analyze the costs for long-stay (>90 days) nursing home ( NH) decedents with and without hospice care. Design Retrospective cohort study using a 1999-2009 data set of linked Medicare and Medicaid claims and minimum data set (MDS) assessments. Setting Indiana NHs. Participants Long-stay NH decedents (N = 2,510). Measurements Medicare costs were calculated for 2, 7, 14, 30, 90, and 180 days before death; Medicaid costs were calculated for dual-eligible beneficiaries. Total costs and costs for hospice, NH, and inpatient care are reported. Results Of 2,510 long-stay NH decedents, 35% received hospice. Mean length of hospice was 103 days (median 34 days). Hospice users were more likely to have cancer ( P < .001), a do-not-resuscitate order in place ( P < .001), greater cognitive impairment ( P < .001), and worse activity of daily living (ADL) function ( P < .001) and less likely to have had a hospitalization in the year before death ( P < .001). In propensity score analyses, hospice users had lower total Medicare costs for all time periods up to and including 90 days before death. For dually eligible beneficiaries, overall costs and Medicare costs were significantly lower for hospice users up to 30 days before death. Medicaid costs were not different between the groups except for the 2-day time period. Conclusion In this analysis of costs to Medicare and Medicaid for long-stay NH decedents, use of hospice did not increase costs in the last 6 months of life. Evidence supporting cost savings is sensitive to analyses that vary the time period before death. [ABSTRACT FROM AUTHOR]

Objectives To explore differences in treatment and survival outcome between poor, older black and white women with breast cancer. Design Retrospective cohort study. Setting Public safety net hospital. Participants Women aged 65 and older diagnosed with breast cancer from 1999 to 2008 (n = 1,000). Measurements Breast cancer treatments that black and white women sought were compared using the Pearson chi-square test. All-cause mortality of black and white women was compared using hazard ratios derived from a multivariate Cox proportional hazards model. Results There was no significant difference between older black and white women in surgical treatment, radiation therapy, chemotherapy, or hormone therapy over the study period. Race was not a significant predictor of survival in the Cox proportional hazards model that controlled for stage of cancer, age at diagnosis, dual-eligibility status, comorbid conditions, body mass index, smoking history, mammogram screening, and treatment for breast cancer. Conclusion Race did not appear to affect treatment or mortality in a cohort of older women with low socioeconomic status. This may be associated with similar healthcare delivery and equivalent access to health care for the older black and white women in this study. [ABSTRACT FROM AUTHOR]

The Aging Brain Care ( ABC) Medical Home aims to improve the care, health outcomes, and medical costs of Medicare beneficiaries with dementia or depression across central Indiana. This population health management program, funded by the Centers for Medicare and Medicaid Services Innovation Center, expanded an existing collaborative dementia and depression care program to serve 1,650 older adults in a local safety-net hospital system. During the first year, 20 full-time clinical staff were hired, trained, and deployed to deliver a collaborative care intervention. In the first 18 months, an average of 13 visits was provided per person. Thirty percent of the sample had a diagnosis of dementia, and 77% had a diagnosis of depression. Sixty-six percent of participants with high depression scores (Patient Health Questionnaire-9 score ≥14) had at least a 50% reduction in their depressive symptoms. Fifty-one percent of caregivers of individuals with dementia had at least a 50% reduction in caregiver stress symptoms (measured by the Healthy Aging Brain Care Monitor-Caregiver Version). After 18 months, the ABC Medical Home has demonstrated progress toward improving the health of older adults with dementia and depression. Scalable and practical models like this show initial promise for answering the challenges posed by the nation's rapidly aging population. [ABSTRACT FROM AUTHOR]

Objectives To report the results from a prospective cohort study on the association between blood pressure ( BP) and cognitive function in elderly African Americans. Design Prospective cohort study conducted from 1997 to 2009. Setting Community-based study in Indianapolis. Participants African Americans aged 65 years or older (N = 3,145). Measurements At each assessment, participant cognitive function was measured using the Community Screening Interview for Dementia. Other measurements included BP, height, weight, education level, antihypertensive medication use, alcohol use, smoking, and history of chronic medical conditions. Results Longitudinal assessments (n = 5,995) contributed by 2,721 participants with complete independent variables were analyzed using a semiparametric mixed-effects model. Systolic BP ( SBP) of approximately 135 mmHg and diastolic BP ( DBP) of approximately 80 mmHg were associated with optimal cognitive function after adjusting for other variables ( P = .02). Weight loss with body mass index < 30.0 kg/m2 was significantly related to poorer cognitive performance ( P < .001). Older age at first assessment, lower education level; smoking; and history of depression, stroke, and diabetes mellitus were related to worse cognitive function; taking antihypertensive medication and drinking alcohol were associated with better cognitive function. Conclusion High and low BP were associated with poorer cognitive performance. A joint optimal region of SBP and DBP for cognitive function has been identified, which may provide useful clinical information on optimal BP control in cognitive health and lead to better quality of life for elderly adults. [ABSTRACT FROM AUTHOR]

Objectives To describe transitions in care of persons with dementia with attention to nursing facility transitions. Design Prospective cohort. Setting Public health system. Participants Four thousand one hundred ninety-seven community-dwelling older adults. Measurements Participants' electronic medical records were merged with Medicare claims, Medicaid claims, the Minimum Data Set ( MDS), and the Outcome and Assessment Information Set ( OASIS) from 2001 to 2008 with a mean follow-up of 5.2 years from the time of enrollment. Results Older adults with prevalent (n = 524) or incident (n = 999) dementia had greater Medicare (44.7% vs 44.8% vs 11.4%, P < .001) and Medicaid (21.0% vs 16.8% vs 1.4%, P < .001) nursing facility use, greater hospital (76.2% vs 86.0% vs 51.2%, P < .001) and home health (55.7% vs 65.2% vs 27.3%, P < .001) use, more transitions in care per person-year of follow-up (2.6 vs 2.7 vs 1.4, P < .001), and more mean total transitions (11.2 vs 9.2 vs 3.8, P < .001) than those who were never diagnosed (n = 2,674). For the 1,523 participants with dementia, 74.5% of transitions to nursing facilities were transfers from hospitals. For transitions from nursing facilities, the conditional probability was 41.0% for a return home without home health care, 10.7% for home health care, and 39.8% for a hospital transfer. Of participants with dementia with a rehospitalization within 30 days, 45% had been discharged to nursing facilities from the index hospitalization. At time of death, 46% of participants with dementia were at home, 35% were in the hospital, and 19% were in a nursing facility. Conclusion Individuals with dementia live and frequently die in community settings. Nursing facilities are part of a dynamic network of care characterized by frequent transitions. [ABSTRACT FROM AUTHOR]

OBJECTIVES: To examine the frequency of surrogate decisions for in-hospital do-not-resuscitate (DNR) orders and the timing of DNR order entry for surrogate decisions. DESIGN: Retrospective cohort study. SETTING: Large, urban, public hospital. PARTICIPANTS: Hospitalized adults aged 65 and older over a 3-year period (1/1/2004–12/31/2006) with a DNR order during their hospital stay. MEASUREMENTS: Electronic chart review provided data on frequency of surrogate decisions, patient demographic and clinical characteristics, and timing of DNR orders. RESULTS: Of 668 patients, the ordering physician indicated that the DNR decision was made with the patient in 191 cases (28.9%), the surrogate in 389 (58.2%), and both in 88 (13.2%). Patients who required a surrogate were more likely to be in the intensive care unit (62.2% vs 39.8%, P<.001) but did not differ according to demographic characteristics. By hospital Day 3, 77.6% of patient decisions, 61.9% of surrogate decisions, and 58.0% of shared decisions had been made. In multivariable models, the number of days from admission to DNR order was higher for surrogate (odds ratio (OR)=1.97, P<.001) and shared decisions (OR=1.48, P=.009) than for patient decisions. The adjusted hazard ratio for hospital death was higher for patients with surrogate than patient decisions (2.61, 95% confidence interval (CI)=1.56–4.36). Patients whose DNR orders were written on Day 6 or later were twice as likely to die in the hospital (OR=2.20, 95% CI=1.45–3.36) than patients with earlier DNR orders. CONCLUSION: For patients who have a DNR order entered during their hospital stay, order entry occurs later when a surrogate is involved. Surrogate decision-making may take longer because of the greater ethical, emotional, or communication complexity of making decisions with surrogates than with patients. [ABSTRACT FROM AUTHOR]

Background: Caring for an individual with Alzheimer's dementia (AD) is stressful, and studies show that this stress has an impact on both the physical and mental health of the caregiver. However, many questions remain about the characteristics of AD patients and their caregivers that contribute to this stress and how it impacts caregivers' use of healthcare resources.Objective: To study the impact of stress on the physical and mental health of the caregiver.Design: Patients underwent extensive testing to allow description of their degree of cognitive impairment, behavioral and psychological symptoms, medical comorbidities, and functional abilities. Caregivers were assessed for depressive symptoms and also for emergency department (ED) use and hospitalizations in the previous six months. Multivariate logistic regression was used to evaluate impact of patients' dementia symptoms on caregivers' acute care utilization.Participants: One hundred and fifty-three AD patients and their caregivers attending two large, urban, university-affiliated primary care practices were enrolled in a cross-sectional study to examine the facets of dementia caregiving that impact caregiver acute health care utilization.Results: Twenty-four percent of the caregivers had at least one ED visit or hospitalization in the six months prior to enrollment. After adjusting for caregiver age, gender, and education, our logistic regression model found that the caregivers' acute care utilization was associated with their depression as measured by the PHQ-9 (OR 1.09, 95% CI 1.00-1.18), the patients' behavioral and psychological symptoms as measured by the NPI (OR 1.04, 95% CI 1.01-1.08), and the patients' functional status as measured by the ADCS-ADL (OR 1.05, 95% CI 1.01-1.09).Conclusion: To improve the health of AD caregivers, a primary care system needs to reallocate resources to manage the functional, behavioral, and psychological symptoms related to the care-recipients suffering from AD. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

Purpose: To evaluate the effectiveness of oral corticosteroid therapy in patients with stable chronic obstructive pulmonary disease.Data Identification: An English-language literature search using MEDLINE (1966 to 1989) and a bibliographic review of all retrieved articles identified 33 original studies of oral corticosteroid use in chronic obstructive pulmonary disease published since 1951.Study Selection: We submitted a photocopy of each study's "methods" section to three nonstudy physician-investigators who used nine explicit criteria to independently assess study quality. Ten studies met all criteria and five studies met some of the criteria.Data Extraction: To compare outcomes across all qualifying studies, we defined response to therapy as a 20% or greater increase in the baseline forced expiratory volume in 1 second (FEV1); we defined the treatment effect size for each study as the proportion of patients who responded to corticosteroid therapy minus the proportion of patients who responded to placebo. Potential confounding variables as related to eligibility criteria and treatment protocols were also assessed for each study.Results Of Data Synthesis: Among ten studies that met all nine criteria, we found no significant differences in eligibility criteria, treatment protocol, or study design. No association was found between treatment effect size and publication date, study size, mean patient age, or FEV1. These studies had reported effect sizes ranging from 0% to 56%; we calculated a weighted mean effect size of 10% (95% CI, 2% to 18%). When studies meeting only some of the criteria were included in the calculation, the weighted mean effect size was 11% (95% CI, 4% to 18%).Conclusions: Patients with stable chronic obstructive pulmonary disease receiving oral corticosteroid therapy have a 20% or greater improvement in baseline FEV1 approximately 10% more often than similar patients receiving placebo. [ABSTRACT FROM AUTHOR]

Objective: To determine whether depressive symptoms measured at baseline are associated with mortality and to describe the course of depressive symptoms and their relation to physical decline in patients over a 6-year period.Design: Prospective cohort study conducted from 1990 through 1996.Setting: Urban academic primary care group practice.Patients: A cohort of 3,767 patients aged 60 years and older screened for depressive symptoms during routine office visits using the Centers for Epidemiologic Studies Depression Scale (CES-D) participated in the mortality study. A subsample of 300 patients with CES-D scores 16 or above and a subsample of 100 patients with CES-D scores less than 16 participated in the study of the course of depressive symptoms and physical decline.Measurements and Main Results: Mortality by December 1995 was measured for all screened patients; reinterviewed patients completed the CES-D and the Sickness Impact Profile (SIP). The mean follow-up period was 45 months (+/- SD 12.2 months); 561 (14.9%) of the patients died by December 1995. In proportional hazards models, age, gender, race, history of smoking, serum albumin value, and an ideal body weight in the lowest 10% were significant correlates of time to death, but the baseline CES-D was not. Patients with depressive symptoms had significantly worse physical and psychosocial functioning scores on the SIP than did patients without depressive symptoms. Using the generalized estimating equation method, the strongest predictor of the current CES-D score was the patient's prior CES-D score. However, worsening physical functioning score on the SIP was also independently correlated with worse CES-D scores p < or = .001).Conclusions: Symptoms of depression were not associated with mortality in this cohort of older adults. However, patients with depressive symptoms reported greater functional impairment than did those without depressive symptoms. Moreover, decline in physical functioning was independently correlated with a concurrent increase in depressive symptoms. [ABSTRACT FROM AUTHOR]

The article relates the author's view on the ability of the primary care to meet the biopsychosocial needs of patients with dementia. The author shares that the current primary care system is experiencing big challenges in delivering safe, high quality and cost-effective services to its patients. He mentions that the qualitative study about the problem showed the operational structure of primary care which is not prepared to manage the biopsychosocial needs of patients suffering from dementia.

Effective health care is a core determinant of successful aging, and medications are one of the most important therapeutic tools of health care providers. Most older adults use at least one prescription drug. Costs for these drugs are a substantial out-of-pocket expense for Medicare beneficiaries, and low-income older adults must weigh these costs against those of other basic needs. Although medications bring welcome relief to millions of elderly persons with age-related conditions, adverse drug events are an important cause of illness and death in these patients. Thus, the appropriate, cost-effective use of medication is central to successful aging. Despite increasing attention to geriatric pharmacotherapy, there is an enormous need for additional research to improve the use of medications among older adults. The necessary research agenda encompasses much more than just the discovery of new drugs; better use of the current pharmacopeia has great potential to improve the lives of older adults. We review four domains of pharmaceutical research: drug discovery and delivery, drug efficacy and safety, pharmacoepidemiology and drug policy, and improved access to and use of drugs. These domains encompass both the pre- and postmarketing phases of drug research. Premarketing research currently has greater magnitude and a better infrastructure than postmarketing research, yet issues arising in the two phases of research are equally important to the health and safety of older adults. A national, federally supported pharmaceutical database could greatly enhance the infrastructure of postmarketing research. However, many major improvements in medication use among older adults will also depend on closing the gap between knowledge and practice and increasing the ability of older adults to manage their medications. [ABSTRACT FROM AUTHOR]

Background: Dementia affects over 4 million people in the US and is frequently unrecognized and underdiagnosed in primary care. Routine dementia screening in primary care is not recommended by the US Preventive Services Task Force due to lack of empirical data on the benefits and harms of screening. This trial seeks to fill this gap and contribute information about the benefits, harms, and costs of routine screening for dementia in primary care.Methods/design: Single-blinded, parallel, randomized controlled clinical trial with 1:1 allocation. A total of 4,000 individuals aged ≥65 years without a diagnosis of dementia, cognitive impairment, or serious mental illness receiving care at primary care practices within two cities in Indiana. Subjects will be randomized to either i) screening for dementia using the Memory Impairment Screen Telephone version or ii) no screening for dementia. Subjects who screen positive for dementia will be referred to the local Aging Brain Care program that delivers an evidence-based collaborative care model for dementia and depression. Research assistants will administer the 15-item Health Utility Index, Patient Health Questionnaire, Generalized Anxiety Disorder Scale, and Medical Outcomes Study at baseline, 1, 6, and 12 months. Information about advanced care planning will be collected at baseline and 12 months. All enrollees' medical records will be reviewed to collect data on health care utilization and costs.Discussion: We have two primary hypotheses; first, in comparison to non-screened subjects, those who are screened and referred to a dementia collaborative care program will have a higher health-related quality of life as measured by the Health Utility Index at 12 months post-screening. Second, in comparison to non-screened subjects, those who are screened and referred to a dementia collaborative care program will not have higher depression or anxiety at one month post-screening as measured by the Patient Health Questionnaire and Generalized Anxiety Disorder Scale scales. Our secondary hypothesis is that screened subjects will have an Incremental Cost-Effectiveness Ratio below the maximum acceptable threshold of $60,000 per quality adjusted life year saved at 12 months.Trial Registration: Ongoing; registered on September 19, 2012. ClinicalTrials.gov Identifier: 2012 NCT01699503. [ABSTRACT FROM AUTHOR]

Context: Although many family members who make surrogate decisions report problems with communication, there is no validated instrument to accurately measure surrogate/clinician communication for older adults in the acute hospital setting.Objectives: The objective of this study was to validate a survey of surrogate-rated communication quality in the hospital that would be useful to clinicians, researchers, and health systems.Methods: After expert review and cognitive interviewing (n = 10 surrogates), we enrolled 350 surrogates (250 development sample and 100 validation sample) of hospitalized adults aged 65 years and older from three hospitals in one metropolitan area. The communication survey and a measure of decision quality were administered within hospital days 3 and 10. Mental health and satisfaction measures were administered six to eight weeks later.Results: Factor analysis showed support for both one-factor (Total Communication) and two-factor models (Information and Emotional Support). Item reduction led to a final 30-item scale. For the validation sample, internal reliability (Cronbach's alpha) was 0.96 (total), 0.94 (Information), and 0.90 (Emotional Support). Confirmatory factor analysis fit statistics were adequate (one-factor model, comparative fit index = 0.981, root mean square error of approximation = 0.62, weighted root mean square residual = 1.011; two-factor model comparative fit index = 0.984, root mean square error of approximation = 0.055, weighted root mean square residual = 0.930). Total score and subscales showed significant associations with the Decision Conflict Scale (Pearson correlation -0.43, P < 0.001 for total score). Emotional Support was associated with improved mental health outcomes at six to eight weeks, such as anxiety (-0.19 P < 0.001), and Information was associated with satisfaction with the hospital stay (0.49, P < 0.001).Conclusion: The survey shows high reliability and validity in measuring communication experiences for hospital surrogates. The scale has promise for measurement of communication quality and is predictive of important outcomes, such as surrogate satisfaction and well-being. [ABSTRACT FROM AUTHOR]