Publications

A variety of modifications of the living environment have been proposed as beneficial for minimizing the psychological and behavioral symptoms of dementia, as well as promoting maximal functional independence. Potential modifications include physical design elements such as wandering pathways, electronically controlled exits, and secured outdoor courtyards as well as alterations of other environmental components such as bright light exposure, ambient noise, music, and color. Interventions targeted at normalizing the circadian abnormalities found in dementia patients include modification of activity timing, exercise, light exposure, nocturnal darkness, and ambient temperature adjustment.

BACKGROUND

Medicare claims as the basis for health condition adjustments is becoming a method of choice in capitation reimbursement. A recent study has found that claims-based beneficiary classification for Alzheimer's disease produces lower prevalence estimates and higher average costs than previous healthcare cost studies in this population. These sets of studies differ in data sources, period length, and in their specification of dementia.

OBJECTIVES

Participants in the Medicare Alzheimer's Disease Demonstration (MADDE) provide a sample of persons known to have some form of dementia. This group is used to test the adequacy of claims data for identifying eligible cases and any bias in expenditure differences between those flagged or not flagged by a claim in a given period.

DESIGN

A prospective cohort design using up to 36 months of claims data.

SETTING

The demonstration enrolled 4166 participants in treatment, and 3942 in a control group in eight communities across the US. Cases were combined in this analysis.

PARTICIPANTS

Persons with available Medicare Part A & B claims data: those receiving care under fee for service reimbursement were used in the analysis. A total of 5379 MADDE cases received fee for service care during 1991 and 1992, the period of primary interest in the analysis.

MEASUREMENT

Client health and functional status interviews and Medicare Part A & B claims.

RESULTS

Less than 20% of MADDE participants were classified with Dementia of the Alzheimer type (DAT) from a single year of claims although 68% had a DAT diagnosis from a referring physician. Annualized expenditures were 1.7 times higher among those with DAT from claims compared with those known otherwise to have dementia but who had not been identified with this condition from Medicare claims.

CONCLUSION

Underclassification of dementia from claims records can be partially remedied by increasing the period during which claims are compiled, but additional diagnostic sources will likely be needed to increase prevalence counts closer to 100% of true cases. Risk adjustment based on a single year of reported claims expenditures may overpay providers, at least in the short term, because payment incentives will likely increase prevalence reporting.

BACKGROUND

Agitation includes wandering, crying out, abusive vocalization, and assaultive behavior and occurs in up to 70% of patients with dementia. Although the neuroleptic haloperidol has been used for decades to control disruptive behavior in psychotic and demented patients, the effectiveness of this drug for agitated dementia remains in question. The first meta-analysis on the effectiveness of haloperidol for agitated dementia, published in 1990, was limited in scope and was unable to provide clear guidelines for the use of haloperidol for demented patients who are agitated. Meta-analyses in 1998 and 2000 examined haloperidol compared with other neuroleptics as well as with placebo and omitted a number of databases, including non-English language publications. To determine the effect of haloperidol, compared with placebo, in the control of agitated dementia and to make recommendations for future research in this area a more widely based, yet more highly focussed review was carried out.

OBJECTIVES

The main objective was to determine whether evidence supports the use of haloperidol to treat agitation in demented patients.

SEARCH STRATEGY

The CDCIG Specialized Register was searched to identify all available reports on haloperidol treatment of agitated dementia.

SELECTION CRITERIA

We examined randomized, placebo-controlled trials, with concealed allocation, where subjects' dementia and agitation were assessed. Trials involving treatment of less than one week were not included.

DATA COLLECTION AND ANALYSIS

1. Two reviewers extracted data from included trials. 2. Data were pooled, where possible, and analysed using appropriate statistical methods. 3. Odds ratios or average differences were calculated. 4. Only 'intention to treat' data were included. Where a cross-over design was employed (Devanand, 1998), only the initial phase of the study was used to compare haloperidol versus placebo. 5. Sensitivity analysis was applied to heterogeneity of results and to gauge the effect of the included studies of small sample size. 6. In addition to the overall meta-analysis, individual analyses of the reports were carried out to examine the effect of degree of dementia, dose of haloperidol, and duration of therapy on agitated dementia. Analysis included the following groups: All patients treated with haloperidol compared with placebo.

MAIN RESULTS

There were five included trials. All studies stated "intention to treat" analysis of their results. Three studies were from the United States, and two studies were from Europe. Two studies examined patients with various forms of dementia, and three studies included only patients with diagnosed Alzheimer's dementia. 1. Overall meta-analysis of the response of agitated patients to haloperidol, compared with controls, showed no improvement in agitation. There is some evidence that haloperidol helps to control aggression. Adverse reactions and dropouts were more frequent among haloperidol treated patients, compared with controls. This meta-analysis provided no information about the relationship between the degree of dementia, the kind of agitation manifested, or the dosage and duration of therapy with haloperidol and response to treatment of demented patients with agitation. 2. The results of this meta-analysis were too broad to permit specific recommendations for treatment of agitated dementia with haloperidol. 3. Higher dose haloperidol, or prolonged haloperidol (12 weeks compared with 3 - 6 weeks) was associated with increased side effects, largely related to Parkinsonian symptoms of rigidity and bradykinesia.

REVIEWER'S CONCLUSIONS

1. Haloperidol appeared to provide no improvement in agitation among demented patients compared with placebo, but side effects were frequent. 2. Dropout rates were higher for haloperidol compared with placebo treated patients, suggesting that side effects led to discontinuation of treatment in some patients. 3. Because of the wide focus of this meta-analysis, not enough information was provided to permit recommendations linking haloperidol treatment of agitated dementia to degree of dementia, manifestations of agitation, or dosage and duration of treatment of haloperidol. 4. Individual analysis of reports indicated that higher dose haloperidol (more than 2 mg per day) may have been more effective than lower dose haloperidol (less than 2 mg per day) in controlling aggression, but not other manifestations of agitation, among patients with mild to moderate dementia. 5. Similar analysis suggested that prolonged therapy with haloperidol (more than 3 - 6 wks) or higher dosage (more than 2 mg per day) was more likely to result in side effects than were short term therapy (3 weeks) or lower dose haloperidol (less than 2 mg per day). 6. The reports provided too little information to permit interpretation of the effect of degree or type of dementia on response to haloperidol. Except for a favorable response of aggression to haloperidol, no other manifestations of agitated dementia were found to have improved following therapy with haloperidol, compared with controls.

OBJECTIVE

To evaluate an innovative approach to maintaining physical, cognitive, and social functioning in frail, elderly nursing home residents at risk for transfer from a minimal care unit.

SUBJECTS/SETTING

Nineteen Russian-speaking residents of the Jewish Home in San Francisco who were newly enrolled in an on-site adult day care program.

METHODS

A formal evaluation of the program employed a repeated measures design with assessments at baseline and at Months 2, 3, 4, 6, and 9. Outcomes included stability of living situation, functional status, physical and mental health, cognitive functioning, sense of well-being and quality of life, and satisfaction with the program.

RESULTS

During this period, the cohort was medically stable and, although some evidenced cognitive decline, there was little change in their functional status. Nearly all of the residents reported improvement from baseline in some aspects of their lives, with the greatest proportions reporting positive changes in social support and quality of life.

CONCLUSIONS

Findings from this evaluation suggest that activities programming using the model described here may enhance the quality of life for some nursing home residents and enable them to remain in the least restrictive, as well as the least costly, living situation possible.

BACKGROUND

Agitation occurs in up to 70% of demented patients. Haloperidol has been used for decades to control agitation in dementia, but its effectiveness remains unclear. Previous meta-analyses examined only English language publications or compared haloperidol with other drugs rather than with placebo. To study the effectiveness of haloperidol a more widely based review was performed.

OBJECTIVES

To determine whether evidence supported the use of haloperidol in agitated dementia.

SEARCH STRATEGY

The CDCIG Specialized Register which contains references from medical databases (MEDLINE, EMBASE, PsycInfo and CINAHL) as well as from many trials databases was searched on 26 July 2000 to identify reports of randomised controlled trials on haloperidol treatment of agitation in dementia.

SELECTION CRITERIA

Randomized, placebo-controlled trials, with concealed allocation, where subjects' dementia and agitation were assessed.

DATA COLLECTION AND ANALYSIS

1. Two reviewers extracted data from included trials 2. Data were pooled where possible, and analysed using appropriate statistical methods 3. Odds ratios of average differences were calculated 4. Only 'intention to treat' data were included 5. Analysis included haloperidol treated patients, compared with placebo

MAIN RESULTS

The five included trials led to the following results: 1. There was no significant improvement in agitation among haloperidol treated patients, compared with controls. 2. Aggression decreased among patients with agitated dementia treated with haloperidol; other aspects of agitation were not affected significantly in treated patients, compared with controls. 3. Although two studies showed increased dropouts due to adverse effects among haloperidol patients, there was no significant difference in dropout rates, comparing all haloperidol treated patients with controls. 4. The data were insufficient to examine response to treatment in relation to length of treatment, degree of dementia, age or sex of patients, and cause of dementia.

REVIEWER'S CONCLUSIONS

1. Evidence suggests that haloperidol was useful in the control of aggression, but was associated with increased side effects; there was no evidence to support the routine use of this drug for other manifestations of agitated dementia. 3. Similar dropout rates among haloperidol and placebo treated patients suggested that poorly controlled symptoms, or other factors, may be important in causing treatment discontinuation. 4. Variations in degree of dementia, dosage and length of haloperidol treatment, and in ways of assessing response to treatment suggested caution in the interpretation of reported effects of haloperidol in the management of agitated dementia. 4. The present study confirmed that haloperidol should not be used routinely to treat patients with agitated dementia. Treatment of agitated dementia with haloperidol should be individualized and patients should be monitored for side effects of therapy.