Background:Drug-related problems (DRP) are common in the elderly population, especially in people living with dementia (PwD). DRP are associated with adverse outcomes that could result in increased costs. Objective:The objective of the study was to analyze the association between DRP and healthcare costs in PwD. Methods:The analysis was based on the cross-sectional data of 424 PwD. Compliance, adverse effects, and drug administration of prescribed and over-the-counter drugs taken were assessed. DRP were identified and classified by pharmacists using an adapted German version of “PIE-Doc®”. Healthcare utilization was assessed retrospectively used to calculated costs from a public payer perspective using standardized unit costs. The associations between DRP and healthcare costs were analyzed using multiple linear regression models. Results:394 PwD (93%) had at least one DRP. An inappropriate drug choice was significantly associated with increased total costs (b = 2,718€; CI95% 1,448–3,988) due to significantly higher costs for hospitalization (b = 1,936€; 670–3,202) and for medications (b = 417€; 68–765). Problems with medication dosage and drug interactions were significantly associated with higher medication costs (b = 679€; 31–1,328; and b = 630€; 259–1,001, respectively). Conclusions:DRP could significantly lead to adverse outcomes for PwD and healthcare payers, reflected by a higher hospitalization and costs, respectively. Further research is needed to clarify on interventions and approaches efficiently avoiding DRP and on the effect on patient-reported and economic outcomes.

BACKGROUND Dementia care management (DCM) aims to provide optimal treatment for people with dementia (PwD). Treatment and care needs are dependent on patients' sociodemographic and clinical characteristics and thus, economic outcomes could depend on such characteristics. OBJECTIVE To detect important subgroups that benefit most from DCM and for which a significant effect on cost, QALY, and the individual cost-effectiveness could be achieved. METHODS The analysis was based on 444 participants of the DelpHi-trial. For each subgroup, the probability of DCM being cost-effective was calculated and visualized using cost-effectiveness acceptability curves. The impact of DCM on individual costs and QALYs was assessed by using multivariate regression models with interaction terms. RESULTS The probability of DCM being cost-effective at a willingness-to-pay of 40,000€ /QALY was higher in females (96% versus 16% for males), in those living alone (96% versus 26% for those living not alone), in those being moderately to severely cognitively (100% versus 3% for patients without cognitive impairment) and functionally impaired (97% versus 16% for patients without functional impairment), and in PwD having a high comorbidity (96% versus 26% for patients with a low comorbidity). Multivariate analyses revealed that females (b = -10,873; SE = 4,775, p = 0.023) who received the intervention had significantly lower healthcare cost. DCM significantly improved QALY for PwD with mild and moderate cognitive (b = +0.232, SE = 0.105) and functional deficits (b = +0.200, SE = 0.095). CONCLUSION Patients characteristics significantly affect the cost-effectiveness. Females, patients living alone, and those being moderately cognitively and functionally impaired benefit most from DCM. For those subgroups, healthcare payers could gain the highest cost savings and the highest effects on QALYs when DCM will be implemented.

Abstract Background Although there are a number of support services accessible for most family dementia caregivers, many caregivers reject available and affordable support. Previous research suggests that rejections of support services may result from insufficient fit of available services with caregivers’ unmet needs and a lack of acknowledgement of caregivers’ unmet needs and associated support services. The present study investigates (a) the number, proportion and types of caregivers’ rejection on recommended tailored support, (b) socio-demographic and clinical determinants of caregiver’s rejection of both people with dementia (PwD) and caregivers, and (c) caregivers’ health-related variables related to caregivers’ rejection. Methods Caregivers’ rejection of tailored support services was identified based on a standardized, computerized unmet needs assessment conducted by dementia-specific qualified nurses. The present analysis is based on data of n = 226 dyads of caregivers and their community-dwelling PwD who participated in a general practitioner (GP)-based, cluster-randomized intervention trial. The trial was approved by the Ethical Committee of the Chamber of Physicians of Mecklenburg-Western Pomerania, registry number BB 20/11. Data analyses were conducted using Stata/IC 13.1. We conducted Welch’s t-test, Pearson’s product-moment correlation, and conditional negative binomial regression models with random effects for GP to account for over-dispersed count data. Results In sum, n = 505 unmet needs were identified and the same number of tailored recommendations were identified for n = 171 family dementia caregivers from the intervention group at baseline. For n = 55 family dementia caregivers not a single unmet need and recommendation were identified. A total of 17.6% (n = 89) of the recommendations were rejected by caregivers. Rejection rates of caregivers differed by type of recommendation. Whereas caregivers’ rejection rate on recommendations concerning mental health (3.6%), physical health (2.5%), and social, legal, and financial affairs (0%) were low, caregivers’ rejection rates concerning social integration (especially caregiver supporting groups) was high (71.7%). Thus, the rejections of family dementia caregivers are mainly linked to the delegation to caregiver supporting groups. Caregivers’ rejections were mainly related to personal factors of caregivers (n = 66), service-related factors (n = 6), relational factors (n = 1), and other factors (n = 17). Furthermore, our results showed that the number of caregivers’ rejections was associated with a higher functional status of the PwD and are mainly associated with the rejection of caregiver supporting groups. Thus, caregivers visit supporting groups more often when the PwD shows low abilities in activities of daily living. Importantly, this is independent of the status of cognition and depression of the PwD as well as the physical and mental health of the family dementia caregivers. Conclusions Our results underline the importance of understanding factors that determine caregivers’ rejection of support services. These need to be specifically addressed in tailored solutions for caregivers’ support services. Trial registration ClinicalTrials.gov Identifier: NCT01401582 (date: July 25, 2011, prospective registered).

Background: Caregivers providing informal care for people with dementia (PwD) often report unmet needs, burden, and health impairments.Optimal support for family dementia caregivers will likely benefit from better understanding and assessment of the prevalence and types of caregivers' unmet needs and associated socio-demographic and clinical characteristics.Objective: The present study investigates 1) the number and types of caregivers' unmet needs, 2) socio-demographic and clinical characteristics of both PwD and caregivers, and 3) caregivers' burden and health-related outcomes that are related to caregivers' unmet needs.Methods: The present analyses are based on cross-sectional data of n = 226 dyads of caregivers and their communitydwelling PwD participating in a comprehensive standardized, computer-based caregivers' needs assessment within a general practitioner (GP)-based, cluster-randomized intervention trial.Results: A total of n = 505 unmet needs were identified for n = 171 caregivers from the intervention group at baseline.Only 24.3% caregivers reported no unmet need (n = 55), whereas 75.7% caregivers had at least one unmet need (n = 171).Caregivers had on average 2.19 unmet needs (mean = 2.19, SD = 2.15).Specifically, 53.1% of caregivers had one up to three unmet needs (n = 120), 18.6% (n = 42) had three up to six unmet needs, and 4.0% (n = 9) had more than six unmet needs.Discussion: Our results underline the importance of a comprehensive needs assessment for family dementia caregivers to develop and implement concepts that can provide family dementia caregivers with optimal support.

BACKGROUNDPeople with dementia (PwD) suffer from coexisting medical conditions, creating complex clinical challenges and increasing the risk of poor outcomes, which could be associated with high healthcare cost.OBJECTIVETo describe the prevalence of comorbidity in PwD and to analyze the association between comorbidity in dementia diseases and healthcare costs from a payer's perspective.METHODSThis cross-sectional analysis was based on n = 362 PwD of the DelpHi-MV trial (Dementia: Life-and person-centered help in Mecklenburg-Western Pomerania). Comorbidity was assessed using the Charlson comorbidity index (CCI) and was categorized into low, high, and very high comorbidity. Healthcare resource utilization and unit costs were used to calculate costs. Multivariable regression models were applied to analyze the association between comorbidity and costs.RESULTSComorbidity was highly prevalent in the sample. 47% of PwD had a very high, 37% a high, and 16% a low comorbidity in addition to dementia. The most prevalent co-existing comorbidity were diabetes mellitus (42%), peripheral vascular disease (28%) and cerebrovascular disease (25%). Total costs significantly increased by 528€ (SE = 214, CI95 = 109-947, p = 0.014) with each further comorbidity, especially due to higher cost for medication and medical aids. Compared with a low comorbidity, a very high comorbidity was significantly associated with 818€ (SE = 168, CI95 = 489-1147, p < 0.001) higher medication costs and 336€ (SE = 161, CI95 = 20-652, p = 0.037) higher cost for medical aids. There were no significant association between a higher comorbidity and cost for formal care services.CONCLUSIONSComorbidity in PwD represents a substantial financial burden on healthcare payers and is a challenge for patients, healthcare providers, and the health systems. Innovative approaches are needed to achieve a patient-oriented management of treatment and care in comorbid PwD to reduce long-term costs.

INTRODUCTION:The purpose of this study was to determine the cost-effectiveness of collaborative dementia care management (DCM).METHODS:The cost-effectiveness analysis was based on the data of 444 patients of a cluster-randomized, controlled trial, conceptualized to evaluate a collaborative DCM that aimed to optimize treatment and care in dementia. Health-care resource use, costs, quality-adjusted life years (QALYs), and incremental cost per QALY gained were measured over a 24-month time horizon.RESULTS:DCM increased QALYs (+0.05) and decreased costs (-569€) due to a lower hospitalization and a delayed institutionalization (7 months) compared with usual care. The probability of DCM being cost-effective was 88% at willingness-to-pay thresholds of 40,000€ per QALY gained and higher in patients living alone compared to those not living alone (96% vs. 26%).DISCUSSION:DCM is likely to be a cost-effective strategy in treating dementia and thus beneficial for public health-care payers and patients, especially for those living alone.

BACKGROUNDMain objective was to analyze the associations of patient variables (depression, quality of life, anti-dementia drug treatment, knowledge about dementia) with the assignment of a formal diagnosis of dementia to community-dwelling primary care patients who have screened positive for dementia.METHODSDelpHi-MV (Dementia: life- and person-centered help in Mecklenburg-Western Pomerania) is a general practitioner based randomized controlled intervention trial. Present analyses are based on cross-sectional data of 319 positively screened patients (age 70+, living at home) who had not been formally diagnosed with dementia before the screening. The medical diagnoses (ICD-10) were retrieved from the patient's medical records. Depression (Geriatric Depression Scale; GDS), quality of life in Alzheimer's disease (Qol-AD), knowledge about dementia, and anti-dementia drug treatment were assessed after the screening test at the baseline examination.RESULTSAt the baseline examination, 171 out of 319 patients (54%) had been formally diagnosed with dementia after they have screened positive. Univariate comparisons showed no statistically significant differences between diagnosed and undiagnosed patients regarding depression (GDS≥6: 11% vs. 15%; p=0.396), quality of life (mean (SD): 2.8 (0.3) vs. 2.8 (0.4); p=0.833), and the knowledge about dementia (75% vs. 75%; p>0.999). Patients who had received a formal diagnosis were more often treated with anti-dementia drugs (20% vs. 11%; p=0.040). Multivariate analyses controlled for confounding variables confirmed these findings.CONCLUSIONPresent findings do not support concerns that the assignment of a formal dementia diagnosis after screening is associated with potential harms. If confirmed in a prospective study, our data would suggest that patients may benefit from being formally diagnosed regarding anti-dementia drug treatment.

Dementia disease is associated with substantial health care costs. Since causal treatment is still out of sight, there is a considerable need for effective ways of care. Dementia care management programms can increase the quality of treatment and care for dementia. However, methodologically rigorous clinical trials on DCM are lacking and economic evaluations of such care management programs have produced inconclusive evidence. The objective of this analysis is to conduct a cost-utility-analysis of a dementia care management programm for primary care patients with dementia. Analyses are based on 634 patients and baseline, follow up 1 and follow up 2 data of the DelpHi-MV study (Dementia: life- and person-centred help in Mecklenburg-Western Pomerania), a general practitioner-based, cluster-randomized controlled intervention trial in a primary care setting. The main outcome after one year of intervention of this trial were recently published demonstrating significant improvement in behavioral and psychological symptoms of dementia, quality of life, antidementia drug treatment and caregiver burden as compare to controls. For the cost-utility-analysis, frequency of healthcare resource utilization was measured by using the Resource Utilization in Dementia questionnaire and health related quality of life using the Short Form 12. Quality adjusted life years were calculated using the area under the curve and the subject based approach. Healthcare costs were assessed from the payer perspective as well as from societal perspective. There were no significant differences in resource utilization/costs or health-related quality of life between intervention and control group at baseline. The Incremental-Cost-Effectiveness-Ratio (ICER) after two years of intervention will be presented at the conference by using a cost-effectiveness-plane and a cost-effectiveness-acceptability curve. Differences in quality adjusted life years, hospitalization and institutionalization between intervention and control group will be analyzed and presented in more detail. This analysis can add evidence to the existing inconclusive results of cost-effectiveness analyses of dementia care management programs.

Objective: The primary aim of the study was to determine accuracy, sensitivity and specificity of the Clock Drawing Test (CDT) in detecting probable dementia as compared to the multi-domain dementia screening test DemTect. Methods: The sample was derived from the general practitioner (GP)-based, cluster-randomized controlled intervention trial DelpHi-MV (Dementia: life-and person-centered help in Mecklenburg-Western Pomerania). Selected from 6.440 patients systematically screened for dementia in primary care, we examined three groups (a,b,c) where the CDT (as index test) as well as the DemTect (as reference standard) were available. After excluding cases with missing values, we included a sample of n=462 with "probable dementia", n=586 with "mild cognitive impairment" and n=553 with "no cognitive impairment" matched for age and gender. We analyzed the accuracy of the CDT in identifying people with probable dementia by the DemTect and report sensitivity, and specificity for the CDT. We further analyzed age and gender differences associated with the groups. Results: In comparison to the DemTect the CDT identified more than twice as many of the screened patients as cognitively impaired (63.1% in the CDT vs. 28.9% in the DemTect). The sensitivity and specificity for the CDT were 84.4% and 45.6% respectively. We found considerable age and gender differences for the performance of the CDT. Higher age (p < 0.001) and female sex (p < 0.001) were associated with incorrect clock drawings. Conclusion: The CDT shows a considerably high rate of false positive screening outcomes compared to the DemTect and disadvantages older people and women. Thus, in contrary to previous findings our results indicate that the CDT should not be used as exclusive instrument to screen for probable dementia in primary care.

The objectives of this cross-sectional analysis were to determine healthcare resource utilization and cost for community-dwelling patients with dementia (PWD) from a payer’s and societal perspective, and to analyze the associations between costs and sociodemographic and clinical variables. Analysis of healthcare costs from a payer’s perspective was based on a sample of 425 PWD, analysis of healthcare costs from societal perspective on a subsample of 254 PWD and their informal caregivers. Frequency of healthcare resource utilization was assessed by means of questionnaires. Informal care and productivity losses were assessed by using the Resource Utilization in Dementia questionnaire (RUD). Costs were monetarized using standardized unit costs. To analyze the associations, multiple linear regression models were used. Total annual costs per PWD valued 7016€ from a payer’s and 25,877€ from a societal perspective, meaning that societal cost is approximately three and a half times as much as payer’s expenditures. Costs valuated 5456 € for medical treatments, 1559 € for formal care, 18,327€ for informal care. Productivity losses valued 1297€ for PWD caregivers. Informal care could vary substantially (−21%; +33%) concerning different valuation methods. Medical care costs decreased significantly with progression of dementia and with age. Costs of care double over the stages of dementia. Formal care costs were significantly higher for PWD living alone and informal care costs significantly lower for PWD with an employed caregiver. For all cost categories, deficits in daily living activities were major cost drivers.

Importance:Dementia care management (DCM) can increase the quality of care for people with dementia. Methodologically rigorous clinical trials on DCM are lacking. Objective:To test the effectiveness and safety of DCM in the treatment and care of people with dementia living at home and caregiver burden (when available). Design, Setting, and Participants:This pragmatic, general practitioner-based, cluster-randomized intervention trial compared the intervention with care as usual at baseline and at 12-month follow-up. Simple 1:1 randomization of general practices in Germany was used. Analyses were intent to treat and per protocol. In total, 6838 patients were screened for dementia (eligibility: 70 years and older and living at home) from January 1, 2012, to March 31, 2016. Overall, 1167 (17.1%) were diagnosed as having dementia, and 634 (9.3%) provided written informed consent to participate. Interventions:Dementia care management was provided for 6 months at the homes of patients with dementia. Dementia care management is a model of collaborative care, defined as a complex intervention aiming to provide optimal treatment and care for patients with dementia and support caregivers using a computer-assisted assessment determining a personalized array of intervention modules and subsequent success monitoring. Dementia care management was targeted at the individual patient level and was conducted by 6 study nurses with dementia care-specific qualifications. Main Outcomes and Measures:Quality of life, caregiver burden, behavioral and psychological symptoms of dementia, pharmacotherapy with antidementia drugs, and use of potentially inappropriate medication. Results:The mean age of 634 patients was 80 years. A total of 407 patients received the intended treatment and were available for primary outcome measurement. Of these patients, 248 (60.9%) were women, and 204 (50.1%) lived alone. Dementia care management significantly decreased behavioral and psychological symptoms of dementia (b = -7.45; 95% CI, -11.08 to -3.81; P < .001) and caregiver burden (b = -0.50; 95% CI, -1.09 to 0.08; P = .045) compared with care as usual. Patients with dementia receiving DCM had an increased chance of receiving antidementia drug treatment (DCM, 114 of 291 [39.2%] vs care as usual, 31 of 116 [26.7%]) after 12 months (odds ratio, 1.97; 95% CI, 0.99 to 3.94; P = .03). Dementia care management significantly increased quality of life (b = 0.08; 95% CI, 0 to 0.17; P = .03) for patients not living alone but did not increase quality of life overall. There was no effect on potentially inappropriate medication (odds ratio, 1.86; 95% CI, 0.62 to 3.62; P = .97). Conclusions and Relevance:Dementia care management provided by specifically trained nurses is an effective collaborative care model that improves relevant patient- and caregiver-related outcomes in dementia. Implementing DCM in different health care systems should become an active area of research. Trial Registration:clinicaltrials.gov Identifier: NCT01401582.

BACKGROUND:Potentially inappropriate medication (PIM) in older people is a risk factor for adverse drug effects. This risk is even higher in older people with dementia (PWD). OBJECTIVE:Our study aimed to determine (1) the prevalence of PIM among primary care patients who were screened positive for dementia and (2) the sociodemographic and clinical variables associated with the use of PIM. METHODS:DelpHi-MV (Dementia: life- and person-centered help in Mecklenburg-Western Pomerania) is a general practitioner-based, cluster-randomized, controlled intervention study to implement and evaluate an innovative concept of collaborative dementia care management in Germany. The comprehensive baseline assessment includes a home medication review. The present analyses are based on the data from 448 study participants (age 70+, DemTect <9). PIMs were identified using the list of Potentially Inappropriate Medications in the Elderly (Priscus). RESULTS:(1) A total of 99 study participants (22%) received at least one PIM. The highest prevalence was found for antidepressants, benzodiazepines, and analgetics. The most frequently prescribed PIMs were amitriptyline, etoricoxib, and doxazosin. (2) Use of a PIM was significantly associated with a diagnosis of a mental or behavioral disorder. CONCLUSIONS:The prescription rate of PIMs for community-dwelling PWD was comparable with the rates found for the general population of older people in Germany (20-29%). Antidepressants with anticholinergic properties and long-acting benzodiazepines were the most prescribed PIMs, despite having an unfavorable benefit-risk ratio. This high prevalence of PIM prescriptions in a vulnerable population of PWD indicates that standard care for dementia should include careful medication review and management.

Background There is evidence about the benefits of early detection of dementia and subsequent provision of adequate treatment and care. However, there is a lack of knowledge about the acceptance of detection and intervention procedures. These analyses describe the attitudes of general physicians [GPs] toward 1) dementia in general, 2) systematic detection of people with dementia, and 3) an intervention approach after they have experienced both. Comparisons are made based on experience with systematic screening and dementia-specific intervention. Methods Postal, cross-sectional survey to all n=1,252 GPs in the Mecklenburg-Western Pomerania, Germany. A subsample was drawn based on participation in the randomized, controlled, prospective intervention DelpHi-MV trial (Dementia: life- and person-centered help in Mecklenburg-Western Pomerania). In this trial, systematic screening is implemented and an intervention group receives support through dementia care management (DCM). GPs were categorized into either GPs with DCM and systematic screening (DCM-GP), GPs with systematic screening only (DelpHi-GP), or GPs not participating in the trial. Data from n=257 GPs were available. Attitudes toward dementia were assessed using a validated questionnaire. Results There was strong agreement toward the helpfulness of implementing a brief cognitive screening test (89.9% agreed). Approximately two-thirds of the respondents indicated that they had identified at least some patients as being cognitively impaired for the first time. The majority of the respondents indicated agreement toward DCM. It was described as supportive and helpful. The qualified nurses were perceived as competent in dementia care and 79.3% would like to be supported with DCM. Attitudes toward dementia are positive and do not differ between groups. Conclusion The results indicate that early recognition and DCM is highly appreciated by GPs and is considered feasible or wanted to be implemented in routine care.

There is a lack of data describing caregiver burden in primary care where most (informal) caregiving is provided.

Background: A substantial increase of people with dementia (PwD) is predicted for the future. Nurses are taking over important tasks to support PwD, which requires a specialized qualification.Objectives: The aim was to identify points for revision and to further improve the Dementia Care Manager (DCM) curriculum as a basis for probable qualification of nurses caring for PwD.Design: We conducted a summative evaluation study to revise the first version of the DCM curriculum.Setting: The study was conducted in the primary health care setting.Participants: Nurses and lecturers of the first theoretical and practical implementation were involved.Methods: Questionnaire-based interviews with nurses and lecturers after every module during the theoretical qualification. Besides, nurses rated the curriculum after the end of the theoretical part and evaluated the DCM tasks and the usefulness of the curriculum contents after the practical phase in questionnaire-based interviews. Descriptive statistics were used for analysis.Results: A total of five nurses and 33 lecturers participated in the first theoretical and practical implementation of the DCM qualification. Generally, nurses and lecturers assessed the curriculum contents as "very important" or "important." In particular, the job-related issues, the variety of course topics and the close combination of theory and practice were highly valued. The practical implementation of the DCM was rated predominantly as "important" by nurses for the delivery of care for PwD. To optimize the theoretical DCM curriculum, participants suggested increasing the number of lessons for two of the modules (gerontopsychiatry, interdisciplinary case reviews). Furthermore, nurses preferred a longer practical phase, whereas some lecturers called for larger group sizes of participants.Conclusions: The DCM qualification enhances nurses' competencies to care for PwD. The curriculum regards an interprofessional, cooperative team approach as the potential to improve health care supply for demented people and to better support their caregivers. (C) 2015 Elsevier Ltd. All rights reserved.

BACKGROUND Little is known about the proportion and the characteristics of community-dwelling people with dementia (PWD) living alone in Germany. OBJECTIVES To analyze the prevalence of PWD living alone (with and without the support of an informal caregiver) and socio-demographical and clinical characteristics as well as health and nursing care utilization associated with living alone. METHODS DelpHi-MV (Dementia: Life- and person-centered help in Mecklenburg-Western Pomerania) is a general practitioner-based, randomized controlled intervention trial. The present analyses are based on baseline data of 511 patients (≥70 years, community-dwelling) who had screened positive for dementia (DemTect <9). RESULTS N = 251 (51%) of the patients lived alone. PWD living alone were statistically significantly more often female, older, and more often widowed than those not living alone. About 9% of the patients (n = 24) were not supported by any informal caregiver. Regarding the clinical variables (cognitive and functional impairment, depression, falls, number of drug-related problems, malnutrition, quality of life), there were no statistically significant group differences. Patients living alone utilized professional services such as home care, help with medication, home-delivered meals, or housekeeping assistance significantly more often. Multivariate analyses confirmed these findings. CONCLUSION Our results reveal the high proportion of PWD living alone in Germany. PWD living alone did not seem to be at an increased health risk. Our findings indicate that living alone with dementia is possible. In order to ensure the sufficient provision of health and nursing care services for PWD living alone, providers should consider the present results for future planning.

In the above mentioned article by Michalowsky et al., Johannes Hertel was mistakenly omitted from the authorship list. This error has been corrected in the print, PDF and HTML versions of the original article.