Risk factors for nursing home placement in cholinesterase inhibitor treated naturalistic Alzheimer patients (original) (raw)
Related papers
BMC neurology, 2016
The survival time in nursing homes (NHs) in Alzheimer's disease (AD) might be affected by sociodemographic/clinical characteristics, rate of disease progression, and use of specific medications and community-based services. Whether different aspects of cholinesterase inhibitor (ChEI) therapy modify time spent in NHs is unclear. Therefore, we examined the relationship between these potential predictors and survival time in NHs. This prospective, multicenter study of ChEI treatment in clinical practice included 220 deceased patients clinically diagnosed with mild-to-moderate AD who were admitted to NHs during the study. Cognitive and activities of daily living (ADL) performance, ChEI dose, and amount of services used/week were evaluated every 6 months over 3 years. Dates of nursing-home placement (NHP) and death were recorded. Variables that determined survival time in NHs were analyzed using general linear models. The mean survival time in NHs was 4.06 years (men, 2.78 years; wom...
The Gerontologist, 2011
To identify risk factors for early nursing home placement (NHP) in Alzheimer's disease (AD), focusing on the impact of longitudinal change in cognition, activities of daily living (ADL), service utilization, and cholinesterase inhibitor treatment (ChEI). Design and Methods: In an open, 3-year, prospective, multicenter study in a routine clinical setting, 880 AD patients were treated with either donepezil, rivastigmine, or galantamine. At baseline and every 6 months, they were assessed with several rating scales including Mini-Mental State Examination, Instrumental Activities of Daily Living scale (IADL), and Physical Self-Maintenance scale. Moreover, the dose of ChEI, the amount of weekly assistance (home help service and adult day care), and the date of NHP were recorded. Cox regression models were constructed to predict the risk of NHP. Results: During the study, 206 patients (23%) were admitted to nursing homes. Factors that precipitated institutionalization were lower cognitive and functional abilities at baseline, faster rate of decline in IADLs, female gender, solitary living, and a lower mean dose of ChEI. The men living alone and patients with a substantial increase in adult day care also demonstrated shorter time to NHP. Implications: The rate of functional but not cognitive decline was a strong risk factor for NHP. The results could be used to identify the care recipients that might risk early NHP to ensure that these individuals receive a sufficient level of assistance. Furthermore, higher doses of ChEI might postpone institutionalization in AD.
Dementia and Geriatric Cognitive Disorders, 2015
Background/Aims: Factors including rate of disease progression, different aspects of cholinesterase inhibitor (ChEI) treatment, and use of community-based services might affect the longitudinal outcome of Alzheimer's disease (AD). Whether these factors alter life expectancy in AD is unclear. We therefore examined the association between long-term ChEI therapy and survival. Methods: The present study included 1,021 patients with a clinical diagnosis of AD and a Mini-Mental State Examination score of 10-26 at baseline from a 3-year, prospective, multicenter study of ChEI therapy in clinical practice. The relationship of potential predictors with mortality was analyzed using Cox regression models. Results: After up to 16 years of follow-up, 841 (82%) of the participants had died. In the Alzheimer's Disease Assessment Scale-cognitive subscale, a mean decline of ≥4 points/year or ≥2 points/year on the Physical Self-Maintenance Scale was a risk factor for an earlier death. In the ...
Journal of the American Geriatrics Society, 2000
OBJECTIVES: To describe the effect of cholinesterase inhibitors (CEIs) on the natural course of Alzheimer's disease (AD) using clinically meaningful outcomes. DESIGN: Cross-sectional and longitudinal study. SETTING: Referral dementia clinic. PARTICIPANTS: One hundred thirty-five matched pairs of patients with probable AD. MEASUREMENTS: The risk of AD patients being classified as slow progressors (Mini-Mental State Examination (MMSE) score change 2 at 1-year follow-up) was examined as a function of treatment with CEIs. A logistic regression analysis, controlling for age, sex, education level, MMSE score, Blessed Dementia Rating Scale (BDRS) for activities of daily living (ADLs), extrapyramidal signs, psychosis, major depression, and use of antidepressants, antipsychotics, and sedative/hypnotics determined the factors that best predict slow progression and nursing home admission. RESULTS: Eighty-one (60%) of the patients on CEIs and 53 (39%) of the patients who never used CEIs were considered slow progressors (P 5.001) at 1-year follow-up. Slow progression was associated only with CEI use (relative risk (RR) 5 2.45, 95% confidence interval (CI) 5 1. 45-4.16), and sedative/hypnotics use was associated with a MMSE change of 3 points or more (RR 5 0.35, 95% CI 5 0.13-0.93). CEI use had a protective effect on nursing home admission (RR 5 0.095, 95% CI 5 0.03-0.30), whereas higher scores on the BDRS for ADLs increased risk of admission at 24-and 36-month follow-up. CONCLUSION: CEI use had a clinically meaningful effect on the natural history of AD. Patients taking CEIs were 2.5 times more likely to progress slowly and had a lower risk of nursing home admission after 2 years, even after controlling for multiple factors that can alter the course of the disease, and a slower rate of decline during the first year of followup. J Am Geriatr Soc 53: 83-87, 2005.
Cholinesterase inhibitor treatment alters the natural history of Alzheimer's disease
Journal of Neurology, Neurosurgery & Psychiatry, 2002
Objective: To describe the effect of cholinesterase inhibitors (CEIs) on the natural course of Alzheimer's disease (AD). Methods: The short and long term effects of CEIs were evaluated in 135 patients with probable Alzheimer's disease relative to 135 patients who were never exposed to CEIs matched by age, education, duration of the symptoms, and cognitive status. We measured 1 year change in cognitive and functional performance, and the likelihood of arriving at each of four end points: (1) mini mental state examination (MMSE) of 9 or lower, (2) Blessed dementia rating scale for activities of daily living of 12 or higher, (3) nursing home admission, and (4) death, over an average 3 years of observation (36.7 (SD 21.5) months). Results: Patients on CEIs were better cognitively and functionally after 1 year compared with those patients who never used CEIs. A proportional hazard analysis with CEI use as a time dependent covariate showed that the use of CEIs decreased the risk of nursing home admission. There was no association, however, between use of CEIs and time to cognitive and functional end points, or to death. Conclusions: This observational study showed that there was an initial cognitive and functional benefit from the use of CEIs in Alzheimer's disease, which waned as the disease progressed. However, the results suggest that there is a long term beneficial effect of the use of CEIs, as indicated by the delay in adsmission to nursing homes.
Cholinesterase inhibitors for Alzheimer disease: do they provide more than symptomatic benefits?
The American journal of geriatric psychiatry : official journal of the American Association for Geriatric Psychiatry, 2011
This study aims to examine survival of patients with Alzheimer disease (AD) receiving clinical efficacy of cholinesterase inhibitors (ChEIs) and to compare their survival with those of patients with AD who never received ChEIs and cognitively intact old psychiatric outpatients. The retrospective cohort study used national mortality data provided by the Korean National Statistics Office and electronic database of 15 general hospitals on older patients who began outpatient treatment with psychiatric medications including ChEIs (N = 3,813). The authors controlled for confounding by using multivariate models and propensity scoring methods. Mortality rate of patients with AD receiving ChEIs was compared with those of patients with AD who never received ChEIs and cognitively intact old psychiatric outpatients. Observed additional survival of patients with AD receiving ChEIs (mortality rate: 13.1%), when compared with patients with AD who never received ChEIs (15.4%) was not statistically ...
2011
Introduction: Dementia may be caused by Alzheimer’s disease (AD), cerebrovascular disease (CVD), or a combination of both. When CVD is associated with dementia, survival is thought to be reduced. It is unclear whether treatment with cholinesterase inhibitors (ChEIs), which has been found to improve cognitive symptoms and global function in AD patients, has similar benefits in vascular forms of dementia. Objectives: The present study was designed to determine whether co-existing CVD is associated with survival or time to nursing home placement (NHP) among AD patients treated with ChEIs. Findings of poorer outcomes in patients with versus without CVD might argue against the use of ChEIs for AD patients in whom CVD co-exists. The objective of a second analysis was to assess for the first time in patients with AD the potential impact of immortal time (and followup) bias on risk for these outcomes. Methods: A retrospective cohort study was undertaken using the Régie de l’Assurance Maladi...
American Journal of Geriatric Pharmacotherapy, 2009
Background: Cholinesterase inhibitors (CHEIs) ameliorate some types of behavioral symptoms in patients with Alzheimer's disease. However, there has been little previous study of the outcomes associated with discontinuing these medications.Objective: The primary aim of this study was to evaluate the extent to which discontinuing CHEI therapy affected behavioral and mood symptoms in a cohort of nursing home residents with a diagnosis of dementia compared with residents receiving longer-term CHEI therapy.Methods: This was a retrospective cohort study using Rhode Island Medicaid prescription claims and the Minimum Data Set (MDS). Participants were Rhode Island nursing home residents aged ≥60 years with a diagnosis of Alzheimer's disease or non-Alzheimer's dementia, treated with CHEI monotherapy, and enrolled in the Medicaid program between January 1, 2004, and December 31, 2005. The discontinuation cohort (CHEI-DC) was selected by identifying residents who received 3 to 9 months of uninterrupted CHEI therapy. The continuation cohort (CHEI-CONT) was prescribed continuous CHEI therapy for >9 months. Changes in scores on the Aggressive Behavior Scale (ABS) and the Depression Rating Scale (DRS) for CHEI-DC residents were compared with changes in scores for CHEI-CONT residents. Secondary outcomes included change over time for individual behavioral symptoms and indicators of cognitive and functional status coded on the MDS.Results: The final matched sample (N = 178) included 62 CHEI-DC cases and 116 CHEI-CONT controls. More than half of the cohort was aged ≥85 years, and the sample was predominantly female. A diagnosis of Alzheimer's disease was documented in 40.3% of the CHEI-DC patients and in 46.5% of the CHEI-CONT patients. Behavioral worsening, indicated by an increase in the estimated mean monthly point change in ABS score, occurred in the CHEI-DC group (0.08; 95% CI, 0.01 to 0.16) but not in the CHEI-CONT group (−0.01; 95% CI, −0.06 to 0.04), and the between-group difference was significant (0.09; 95% CI, 0.01 to 0.18). There were no significant between-group differences in the mean monthly point change in mood symptoms on the DRS (0.04; 95% CI, −0.03 to 0.12). For the secondary outcomes, the mean monthly MDS point change for frequency of repetitive verbal behaviors indicated that CHEI-DC patients exhibited significantly more episodes of repetitive questioning (0.17; 95% CI, 0.05 to 0.29) and repetitive health complaints (0.16; 95% CI, 0.04 to 0.27) compared with CHEI-CONT residents. Continued use of CHEIs was associated with more time spent in leisure-related activities over the study period (−0.26; 95% CI, −0.50 to −0.02), with the CHEI-DC group spending less time in activities (0.11; 95% CI, 0 to 0.23); the between-group difference was also significant (0.37; 95% CI, 0.10 to 0.65).Conclusion: Results of this retrospective analysis suggest that, compared with longer duration of CHEI therapy, discontinuation of CHEIs in these nursing home residents with dementia was associated with some adverse behavioral changes and decreased time spent engaging in leisure-related activities.
Role of cholinesterase inhibitors in dementia care needs rethinking
BMJ, 2006
The NHS focus on memory clinics driven by drugs that slow cognitive decline is taking resources away from services offering long term integrated care. The role of these clinics needs reconsideration alongside availability of the drugs The National Institute for Health and Clinical Excellence (NICE) is approaching the end of a controversial consultation process on proposed radical revisions to its guidelines on drugs for dementia. Since 2001 the institute has recommended that the National Health Service in England and Wales should make the licensed cholinesterase inhibitors donepezil, rivastigmine, and galantamine available to people with mild to moderate Alzheimer's disease. 1 The available research in 2001 could not provide guidance on which patients would respond to these drugs. 2 However, when compared with placebo these drugs slowed cognitive decline. Over six months there was an average advantage of 2-3 points on the cognitive section of the Alzheimer's disease assessment scale, which has a range of 70 to 0. Rates of progression vary widely, but the expected average annual decline on this scale in placebo treated patients is 5-6 points. 1 2 Outside trials the mean annual rate of change is about 8-9 points. 3 Carers often report improvements in behavioural disturbances, neuropsychiatric symptoms, motivation, and activities of daily living when their relatives start taking cognitive enhancers but also when they are prescribed placebo. A combination of these features plus cognitive function influence clinicians' global ratings of change, which have usually favoured the active treatments in controlled trials. 2