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BACKGROUND/OBJECTIVES: Caregiving for persons with dementia (PWD) results in a variety of psychological symptoms ranging from strain to depression. To better capture the scope of caregiver burden, we created a composite from 3 existing measures that assess different domains. DESIGN: Prospective follow-up study. SETTING: University-based dementia care management program PARTICIPANTS: 1091 caregivers of PWD. MEASUREMENTS: The Dementia Burden Scale - Caregiver (DBS-CG) composite measure was based on the Modified Caregiver Strain Index, Neuropsychiatric Inventory Questionnaire Distress Scale, and Patient Health Questionnaire (PHQ-9). ANALYSIS: Alternative measure structures were evaluated with two confirmatory factor analysis (CFA) models: 1) bifactor model and 2) a correlated 3 factor model. Good model fit was defined as a root mean squared error of approximation (RMSEA) value of < 0.06 and comparative fit index (CFI) value of >0.95. ω was calculated as an estimate of the scale reliability. Minimally important differences (MIDs) were estimated by anchoring the magnitude of DBS-CG change to change in caregiver self-efficacy and functional ability of PWD. RESULTS: The bifactor CFA model fit best, with RMSEA = 0.04 and CFI = 0.95. Based on this model, a DBS-CG scale was created wherein all items were transformed to a 0–100 possible range and then averaged. Higher scores indicate higher burden. The mean DBS-CG score was 27.3. The ω reliability was 0.93, indicating excellent reliability. MID estimates ranged from 4–5 points (effect sizes: 0.20 ≤ d < 0.50). CONCLUSIONS: This study provides support for the reliability and validity of the DBS-CG. It can be used as an outcome measure to assess the effect of interventions to reduce dementia caregiver burden.

The clinically detailed risk information system for cost (CD-RISC) contains definitions for several hundred severity-adjusted conditions that can be used to predict future health care costs. We develop a prospective Medicare CD-RISC model using a 5-percent sample of Medicare beneficiaries and data that contain 1996 diagnostic information and 1997 annualized costs. The CD-RISC model has a hierarchical structure that implies that only the most expensive condition-severity variable within a body system affects payments. This minimizes incentives to game the system by entering multiple related codes for the same condition. The R² for the CD-RISC model is 11 percent.

To evaluate effects of a multicomponent intervention on fecal incontinence (FI) and urinary incontinence (UI) outcomes.Randomized controlled trial.Six nursing homes (NHs).One hundred twelve NH residents.Intervention subjects were offered toileting assistance, exercise, and choice of food and fluid snacks every 2 hours for 8 hours per day over 3 months.Frequency of UI and FI and rate of appropriate toileting as determined by direct checks from research staff. Anorectal assessments were completed on a subset of 29 residents.The intervention significantly increased physical activity, frequency of toileting, and food and fluid intake. UI improved (P=.049), as did frequency of bowel movements (P.001) and percentage of bowel movements (P.001) in the toilet. The frequency of FI did not change. Eighty-nine percent of subjects who underwent anorectal testing showed a dyssynergic voiding pattern, which could explain the lack of efficacy of this intervention program alone on FI.This multicomponent intervention significantly changed multiple risk factors associated with FI and increased bowel movements without decreasing FI. The dyssynergic voiding pattern and rectal hyposensitivity suggest that future interventions may have to be supplemented with bulking agents (fiber), biofeedback therapy, or both to improve bowel function.

Many elderly persons have drug benefits with coverage gaps, such as in Medicare Part D. Because beneficiaries who have such gaps must pay all drug costs, an accurate knowledge of gap thresholds and communication with providers about exceeding caps is important for elderly persons to manage out-of-pocket drug costs.Cross-sectional survey.Health plan.One thousand three hundred eight health plan members aged 65 and older. The study was a 2002 cross-sectional survey of elderly persons with capped drug benefits in a managed care plan in one state. Participants were sampled so that half reached coverage caps and half did not.Participants reported cap levels, communication with providers about exceeding caps, and decreased medication use due to cost.Of the 1,308 participants (65.4%response rate), 68.6%did not know their correct cap level. Rates were similar in those who exceeded caps (66.2%), reported difficulty paying for medications (63.9%), or decreased medication use (66%). For participants who exceeded caps, 59.1% did not know beforehand that they were close to exceeding caps and 50.2% did not tell providers afterward. In multivariate analyses accounting for demographics and health, the oldest participants (or =85 vs 65-74) were at greater risk for not knowing cap levels (odds ratio (OR)=2.0, 95% confidence interval (CI)=1.2-3.4) and not telling providers about exceeding caps (OR=2.2, 95% CI=1.1-4.5).Elderly patients often did not know correct cap levels and did not tell providers about exceeding caps. Providers, plans, and policymakers should actively assess and improve Medicare beneficiaries' knowledge of Part D coverage gaps.

To compare the costs of mobile and stationary mammography and examine the incremental cost-effectiveness of using mobile mammography to increase screening rates.A cost-effectiveness analysis was performed using effectiveness data from a randomized clinical trial and modeling of costs associated with the mobile mammography intervention.The trial involved 60 community-based meal sites, senior centers, and clubs.Four hundred ninety-nine individuals were enrolled in the study, of whom 463 had outcome data available for analysis.Costs were calculated for stationary and mobile mammography, as well as costs due to differences in technology and film versus digital. Incremental cost-effectiveness (cost per additional screen) was modeled, and sensitivity analysis was performed by altering efficiency (throughput) and effectiveness based on subgroup data from the randomized trial.The estimated annual costs were $435,162 for a stationary unit, $539,052 for a mobile film unit, and $456, 392 for a mobile digital unit. Assuming mobile units are less efficient (50% annual volume), the cost per screen was $41 for a stationary unit, $86 for a mobile film unit, and $102 for a mobile digital unit. The incremental cost per additional screen were $207 for a mobile film unit and $264 for a mobile digital unit over a stationary unit.Although mobile mammography is a more effective way to screen older women, the absolute cost per screen of mobile units is higher, whereas the reimbursement is no different. Financial barriers may impede the widespread use of this approach.

To determine the effects of a feeding assistance intervention on food and fluid intake and body weight.Crossover controlled trial.Four skilled nursing homes (NHs).Seventy-six long-stay NH residents at risk for unintentional weight loss.Research staff provided feeding assistance twice per day during or between meals, 5 days per week for 24 weeks.Research staff independently weighed residents at baseline and monthly during a 24-week intervention and 24-week control period. Residents' food and fluid intake and the amount of staff time spent providing assistance to eat was assessed for 2 days at baseline and 3 and 6 months during each 24-week period.The intervention group showed a significant increase in estimated total daily caloric intake and maintained or gained weight, whereas the control group showed no change in estimated total daily caloric intake and lost weight over 24 weeks. The average amount of staff time required to provide the interventions was 42 minutes per person per meal and 13 minutes per person per between-meal snack, versus usual care, during which residents received, on average, 5 minutes of assistance per person per meal and less than 1 minute per person per snack.Two feeding assistance interventions are efficacious in promoting food and fluid intake and weight gain in residents at risk for weight loss. Both interventions require more staff time than usual NH care. The delivery of snacks between meals requires less time than mealtime assistance and thus may be more practical to implement in daily NH care practice.

To determine whether elderly patients with high drug expenditures want and receive providers' help in managing drug costs.Cross-sectional survey.A Medicare managed care plan (400,000 members) in one state in 2002.One thousand one hundred six seniors (62% response rate) sampled so that half exceeded caps on their drug benefits the previous year, and all had total drug expenditures in the top quartile of members in their cap level.Participants' preferences and experiences with providers discussing costs and participation in choosing medications.Two-thirds reported difficulty paying for medications, and one-fourth decreased medication use because of cost. Most wanted providers to ask about medication affordability (81%), consider cost (86%), offer choices (70%), and to persuade them or decide for them which medication to use (88%), but few said providers asked about affordability (17%), usually or always discussed prices (19%), or offered choices (45%), although nearly all said providers chose their medications (93%). Sixty-two percent had asked providers for help with drug costs, although 34% who used less medication because of cost or had difficulty paying for medications had not asked for help.Providers should be aware that elderly patients want their help in managing drug costs but do not always receive it or ask for help when they need it. Providers could improve communication by initiating conversations about cost and by asking patients about preferences when prescribing.

Generic-only drug benefits are a way to provide some coverage, as opposed to no coverage.To examine how switching from brand name to generic-only drug coverage affected seniors' medication use and financial burden.Data are from a 2002 cross-sectional survey conducted for a separate study on benefit caps. Participants belonged to a Medicare managed care plan in one state and had $2000 capped brand name benefits in 2001 but generic-only benefits in 2002.Participants reported their cost-cutting strategies before and after the change to generic-only coverage, the medications affected, and their financial burden. We conducted bivariate and multivariate analyses of cost-cutting strategies and financial burden before and after implementation of generic-only benefits.Among 611 participants (63% response), rates of switching medications increased after discontinuation of brand name coverage (27% vs 8%, P.001). Switches were from brand name drugs to generic equivalents (14%) (eg, Prozac to fluoxetine hydrochloride), to nonequivalent generics (26%) (eg, Paxil to fluoxetine), and to different brand name drugs (45%) (eg, Paxil to Zoloft). Ninety percent of brand name switches remained in the same therapeutic class (eg, selective serotonin reuptake inhibitors). After discontinuation of brand name coverage, participants reported higher rates of decreased medication use (28% vs 17%) and greater difficulty paying for prescriptions (65% vs 37%) (P.001 for both).Changing from brand name benefits to generic-only drug coverage led many participants to switch to less expensive medications but also decreased medication use and increased financial burden. Insurers need to actively help patients adjust to a discontinuation of brand name coverage.

To evaluate the benefit of eyeglasses and magnifiers in elderly patients with uncorrected refractive errors.A single-center, randomized, prospective, controlled trial (September 2001 to August 2003).Los Angeles County, California.One hundred thirty-one community-dwelling persons aged 65 and older who had habitual distance visual acuity of 20/32 or worse and whose distant visual acuity, near visual acuity, or both could be improved with eyeglasses, a magnifier, or both by two lines of acuity or more.Sixty-six were randomized to receive a prescription and voucher for free eyeglasses, a magnifier, or both immediately, and 65 were randomized to receive a prescription and voucher after the 3-month follow-up visit (the control group).Primary outcome was vision-specific functioning as measured using the 25-item National Eye Institute-Visual Functioning Questionnaire (NEI-VFQ). Secondary outcomes were distance and near visual acuity and overall functioning as measured using the Rosow-Breslau function questionnaire.In the intention-to-treat analysis of 3-month follow-up data, participants who received the eyeglasses prescription and voucher immediately had greater improvement in NEI-VFQ composite scores than the control group (P.01). They also had greater improvement in perceptions of their general vision (P.01), distance visual acuity (P=.03), near visual acuity (P=.04), and mental health (P=.02).Correction of uncorrected refractive error, one of the leading causes of visual impairment in older people, improved the vision-specific quality of life of community-dwelling older persons.

To examine hospital use for patients with evidence of cognitive decline indicative of early cognitive impairment.Medicare Part A hospital utilization data were linked to data from the MacArthur Research Network on Successful Aging Community Study to examine the association between baseline cognition and decline in cognitive function over a 3-year period and any hospitalization over that same period.New Haven, Connecticut, and East Boston, Massachusetts.Subjects (N=598) were from two sites of the MacArthur Research Network on Successful Aging Community Study, a 7-year cohort study of community-dwelling older persons with high physical and cognitive functioning.Multivariate logistic regression was used to determine the association between any hospitalization over 3 years (1988-91) as the outcome variable and baseline cognitive function and decline in cognition over 3 years as primary predictor variables. Decline was based upon repeated (1988 and 1991) measures of delayed verbal recall and the Short Portable Mental Status Questionnaire (SPMSQ).Of 598 subjects, 48 died between 1988 and 1991. No baseline (1988) delayed recall scores or change in recall scores (1988-91) were associated with hospitalization. Although 48.2% declined on verbal memory scores, decline was not associated with risk of hospitalization. Of 494 subjects with complete 3-year data, 31.2% declined at least one point on the SPMSQ, and 4.7% declined more than two points. Among individuals aged 75 and older at baseline, the adjusted odds ratio for hospitalization for those who declined more than 2 points compared with those who declined less was 7.8 (95% confidence interval=2.0-30.8).Although specific memory tests were not associated with hospitalization, high-functioning older persons who experienced decline in overall cognitive function were more likely to be hospitalized. Variation in baseline cognitive function in this high-functioning cohort did not affect hospitalization, but additional research is needed to evaluate associations with other healthcare costs.

Additional medical manpower will be required to meet the growth in the elderly segment of the United States population over the next 50 years. This paper provides estimates of the needs for medical geriatric manpower under four different models: continuation of the status quo; academic geriatricians only; provision of care by academic and consultant geriatricians; and provision of care by academic, consultant, and primary-care geriatric practitioners. Each option is further analyzed in terms of three levels of delegation to nonphysician clinicians. We project the implications of these 12 patterns through the year 2030, assuming present usage levels and allowing for improved care of the elderly. The need for geropsychiatric care is explored separately. We think that geriatricians should provide improved care, including both consultant and primary care, to people aged 75 years and older, and that they should delegate a moderate amount of responsibility to nurse practitioners, physician assistants, and social workers. On the basis of these assumptions, and allowing for an academic role as well, we estimate that the United States will require between 7000 and 10,300 geriatricians by the year 1990; the best intermediate figure is about 8000.