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
BACKGROUND: Persecutory delusions are the most common type of delusions in psychosis and present in around 10-15% of the general population. Persecutory delusions are thought to be sustained by biased cognitive and emotional processes. Recent advances favour targeted interventions, focussing on specific symptoms or mechanisms. Our aim is to test the clinical feasibility of a novel psychological intervention, which manipulates biased interpretations toward more adaptive processing, in order to reduce paranoia in patients. METHODS: The 'Cognitive Bias Modification for paranoia' (CBM-pa) study is a feasibility, double-blind, randomised controlled trial (RCT) for 60 stabilised outpatients with persistent, distressing paranoid symptoms. Patients will be randomised at a 50:50 ratio, to computerised CBM-pa or a text-reading control intervention, receiving one 40-min session per week, for 6 weeks. CBM-pa involves participants reading stories on a computer screen, completing missing words and answering questions about each story in a way that encourages more helpful beliefs about themselves and others. Treatment as Usual will continue for patients in both groups. Patients will be assessed by a researcher blind to allocation, at baseline, each interim session, post treatment and 1- and 3-month follow-up post treatment. The primary outcome is the feasibility parameters (trial design, recruitment rate and acceptability) of the intervention. The secondary outcomes are clinical symptoms (including severity of paranoia) as assessed by a clinical psychologist, and 'on-line' measurement of interpretation bias and stress/distress. The trial is funded by the NHS National Institute for Health Research. DISCUSSION: This pilot study will test whether CBM-pa has the potential to be a cost-effective, accessible and flexible treatment. If the trial proves feasible and demonstrates preliminary evidence of efficacy, a fully powered RCT will be warranted. TRIAL REGISTRATION: Current Controlled Trials ISRCTN: 90749868 . Retrospectively registered on 12 May 2016.
Asunto(s)
Terapia Cognitivo-Conductual/métodos , Deluciones/terapia , Trastornos Paranoides/terapia , Terapia Asistida por Computador/métodos , Adolescente , Adulto , Anciano , Protocolos Clínicos , Terapia Cognitivo-Conductual/economía , Análisis Costo-Beneficio , Deluciones/diagnóstico , Deluciones/economía , Deluciones/psicología , Método Doble Ciego , Estudios de Factibilidad , Femenino , Costos de la Atención en Salud , Humanos , Londres , Masculino , Persona de Mediana Edad , Trastornos Paranoides/diagnóstico , Trastornos Paranoides/economía , Trastornos Paranoides/psicología , Proyectos Piloto , Escalas de Valoración Psiquiátrica , Proyectos de Investigación , Terapia Asistida por Computador/economía , Factores de Tiempo , Resultado del Tratamiento , Adulto JovenRESUMEN
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.