RESUMEN
OBJECTIVES: Explore the relationship between behavioral and psychological symptoms of dementia (BPSD; specifically, delusions, hallucinations, and agitation/aggression) and associated caregiver distress with emergency department (ED) utilization, inpatient hospitalization, and expenditures for direct medical care. DESIGN/SETTING/PARTICIPANTS: Retrospective cross-sectional cohort of participants with dementia (N = 332) and informants from the Aging, Demographics, and Memory Study, a nationally representative survey of U.S. adults >70 years old. MEASUREMENTS: BPSD of interest and associated informant distress (trichotomized as none/low/high) were assessed using the Neuropsychiatric Inventory (NPI). Outcomes were determined from one year of Medicare claims and examined according to presence of BPSD and associated informant distress, adjusting for participant demographics, dementia severity, and comorbidity. RESULTS: Fifty-eight (15%) participants with dementia had clinically significant delusions, hallucinations, or agitation/aggression. ED visits, inpatient admissions, and costs were not significantly higher among the group with significant BPSD. In fully adjusted models, a high level of informant distress was associated with all outcomes: ED visit incident rate ratio (IRR) 3.03 (95% CI: 1.98-4.63; p < 0.001), hospitalization IRR 2.78 (95% CI: 1.73-4.46; p < 0.001), and relative cost ratio 2.00 (95% CI: 1.12-3.59; p = 0.02). CONCLUSIONS: A high level of informant distress related to participant BPSD, rather than the symptoms themselves, was associated with increased healthcare utilization and costs. Effectively identifying, educating, and supporting distressed caregivers may help reduce excess healthcare utilization for the growing number of older adults with dementia.
Asunto(s)
Cuidadores/estadística & datos numéricos , Deluciones , Demencia , Servicio de Urgencia en Hospital/estadística & datos numéricos , Alucinaciones , Costos de la Atención en Salud/estadística & datos numéricos , Hospitalización/estadística & datos numéricos , Medicare/estadística & datos numéricos , Agitación Psicomotora , Estrés Psicológico/epidemiología , Anciano , Anciano de 80 o más Años , Agresión/fisiología , Cuidadores/psicología , Estudios Transversales , Deluciones/economía , Deluciones/etiología , Deluciones/terapia , Demencia/complicaciones , Demencia/economía , Demencia/terapia , Servicio de Urgencia en Hospital/economía , Femenino , Alucinaciones/economía , Alucinaciones/etiología , Alucinaciones/terapia , Hospitalización/economía , Humanos , Masculino , Medicare/economía , Agitación Psicomotora/economía , Agitación Psicomotora/etiología , Agitación Psicomotora/terapia , Estudios Retrospectivos , Estrés Psicológico/etiología , Estados UnidosRESUMEN
The negative implications of living in a socially unequal society are now well documented. However, there is poor understanding of the pathways from specific environmental risk to symptoms. Here we examine the associations between social deprivation, depression, and psychotic symptoms using the 2007 Adult Psychiatric Morbidity Survey, a cross-sectional dataset including 7,353 individuals. In addition we looked at the mediating role of stress, discrimination, trust and lack of social support. We found that the participants' neighbourhood index of multiple deprivation (IMD) significantly predicted psychosis and depression. On inspection of specific psychotic symptoms, IMD predicted paranoia, but not hallucinations or hypomania. Stress and trust partially mediated the relationship between IMD and paranoid ideation. Stress, trust and a lack of social support fully mediated the relationship between IMD and depression. Future research should focus on the role deprivation and social inequalities plays in specific manifestations of psychopathology and investigate mechanisms to explain those associations that occur. Targeting the mediating mechanisms through appropriate psychological intervention may go some way to dampen the negative consequences of living in an unjust society; ameliorating economic injustice may improve population mental health.
Asunto(s)
Trastorno Bipolar/psicología , Depresión/psicología , Alucinaciones/psicología , Trastornos Paranoides/psicología , Discriminación Social/psicología , Estrés Psicológico/complicaciones , Adolescente , Adulto , Anciano , Anciano de 80 o más Años , Trastorno Bipolar/economía , Trastorno Bipolar/epidemiología , Trastorno Bipolar/etiología , Depresión/economía , Depresión/epidemiología , Depresión/etiología , Femenino , Alucinaciones/economía , Alucinaciones/epidemiología , Alucinaciones/etiología , Encuestas Epidemiológicas , Humanos , Masculino , Persona de Mediana Edad , Trastornos Paranoides/economía , Trastornos Paranoides/epidemiología , Trastornos Paranoides/etiología , Discriminación Social/economía , Factores Socioeconómicos , Estrés Psicológico/economía , Estrés Psicológico/epidemiología , Reino Unido/epidemiologíaRESUMEN
OBJECTIVES: Neuropsychiatric symptoms (NPS) are common in Alzheimer disease (AD). It is important in terms of management to know their natural history and their effects on service use. The authors aimed to determine the persistence and change in severity of NPS over 6 months in participants with AD, and the relationship to initial severity, drug management, use of services, and cost of care. METHODS: NPS scores and data on cognition, psychotropic medication, service use, and costs of care were collected on 224 participants at baseline and on 198 at 6-month follow-up. RESULTS: Of 224 patients, 210 (93.8%) had NPS at baseline; 168 (75.0%) had at least one clinically significant symptom, 118 (80.4%) of whom had persistent significant symptoms at 6-month follow-up. There was no significant change in mean NPS score for any symptom over 6 months, but many individuals became better or worse; 61.2% of those with at least one significant baseline symptom in any domain improved. Those with persistent symptoms had more severe baseline symptoms. Deterioration in NPS was predicted by deterioration in MMSE. Those with at least one clinically significant symptom had higher care costs than those without. CONCLUSIONS: NPS were highly persistent overall, but many individuals became better or worse. Persistence was predicted by having more severe symptoms at baseline. Clinically significant levels of NPS were associated with greater costs of care. The relatively few associations found between specific psychiatric treatments and changes in NPS reflect both undertreatment and the complexity of symptoms.
Asunto(s)
Enfermedad de Alzheimer/diagnóstico , Trastornos de Ansiedad/diagnóstico , Deluciones/diagnóstico , Trastorno Depresivo/diagnóstico , Alucinaciones/diagnóstico , Pruebas Neuropsicológicas , Trastornos Psicóticos/diagnóstico , Anciano , Anciano de 80 o más Años , Enfermedad de Alzheimer/economía , Enfermedad de Alzheimer/epidemiología , Enfermedad de Alzheimer/psicología , Trastornos de Ansiedad/economía , Trastornos de Ansiedad/epidemiología , Trastornos de Ansiedad/psicología , Servicios Comunitarios de Salud Mental/economía , Servicios Comunitarios de Salud Mental/estadística & datos numéricos , Comorbilidad , Costo de Enfermedad , Estudios Transversales , Deluciones/economía , Deluciones/epidemiología , Deluciones/psicología , Trastorno Depresivo/economía , Trastorno Depresivo/epidemiología , Trastorno Depresivo/psicología , Inglaterra , Femenino , Alucinaciones/economía , Alucinaciones/epidemiología , Alucinaciones/psicología , Atención Domiciliaria de Salud/economía , Hogares para Ancianos/economía , Humanos , Entrevista Psicológica , Londres , Estudios Longitudinales , Masculino , Casas de Salud/economía , Agitación Psicomotora/diagnóstico , Agitación Psicomotora/economía , Agitación Psicomotora/epidemiología , Agitación Psicomotora/psicología , Trastornos Psicóticos/economía , Trastornos Psicóticos/epidemiología , Trastornos Psicóticos/psicología , Psicotrópicos/economía , Psicotrópicos/uso terapéuticoRESUMEN
OBJECTIVE: To examine the cost-effectiveness of Hallucination focused Integrative Treatment (HIT) in patients with schizophrenia and a history of persistent auditory hallucinations. METHOD: Costs, in and outside the health care sector, and outcomes were registered prospectively during a period of 18 months for patients who received the HIT programme and for patients in the care as usual (CAU) condition. The Positive and Negative Syndrome Scale (PANSS) was used as main outcome measure in the cost-effectiveness analysis. Bootstrap analyses provided additional information on the skewly distributed costs. RESULTS: Mean costs per patient in the HIT group (18,237 dollars) were lower than the mean costs per patient in the CAU group (21,436 dollars). Results of the PANSS were slightly in favour of the HIT group. CONCLUSION: There appears to be no significant cost-effectiveness advantage of the HIT programme over CAU. Additional analyses indicated that future application of the HIT programme will, in most cases, lead to a reduction of (non) medical costs.