Caregivers of people with dementia and mental health during COVID-19: findings from a cross-sectional study

Background There is sparse evidence on the impact on vulnerable populations of the COVID-19 pandemic. The aim of our study was to explore burden and mental wellbeing (including depressive, anxiety, and stress symptoms) in caregivers of people with dementia during the first wave of the pandemic in Italy and southern Switzerland, two bordering regions severely hit by the COVID-19 pandemic. Methods We conducted an online cross-sectional survey with family carers of people with dementia between May and June 2020. We registered socio-demographic characteristics, and information about the relationship with the care recipient, dementia subtype, care inputs from others, and the need of care of the person with dementia. We measured caregiver burden with the Zarit Burden Interview (ZBI), psychological distress with the Depression, Anxiety and Stress Scale (DASS-21), and perceived isolation with the 3-item UCLA Loneliness Scale (UCLALS3). Results Caregivers (N =571) reported moderate to severe care-related burden (mean=54.30; SD=18.33), moderate anxiety symptoms (mean=10.04; SD=6.93), mild depressive symptoms (mean=11.79; SD=6.12) and mild stress (mean=12.95; SD=5.53), and 72.3% of participants reported to feel lonely. All scores were significantly more severe in Swiss compared to Italian caregivers (all p values<0.001). Conclusions We found that caregivers’ burden, anxiety symptoms, depression and perceived loneliness were marked during the first wave of the COVID-19 pandemic, in two severely hit bordering countries. Regional differences in the impact of the epidemic on caregivers could be due to contextual, societal, and cultural circumstances. As the pandemic endures, support to caregivers of people with dementia should be proportionate and tailored to needs and adapted to contextual factors.

Four different frailty models predict health outcomes in older patients with stable chronic obstructive pulmonary disease

Background Frail patients with chronic obstructive pulmonary disease (COPD) face a higher risk of adverse outcomes, but there is no clear consensus on which frailty measures are most suitable for COPD patients. Herein we evaluated the ability of frailty measurements in predicting 1-year acute exacerbation, hospitalization, and mortality in older patients with COPD. Methods A total of 302 patients [median age: 86 years (IQR: 80–90), 22.2% female] were admitted to the Department of Geriatric Medicine were prospectively enrolled in this study. Frailty status was assessed using the Fried Frailty Phenotype (FFP), Clinical Frailty Scale (CFS), Frailty Index of Accumulative Deficits (FI-CD), and Short Physical Performance Battery (SPPB). Cox proportional hazard regression and Poisson regression were used to evaluating the association of the adverse outcomes with frailty as assessed using the four instruments. The discrimination accuracy of these tools in predicting the 1-year all-cause mortality was also compared. Results Prevalence of frailty ranged from 51% (using FFP) to 64.2% (using CFS). The four frail instruments were associated with 1-year mortality. After an average follow-up time of 2.18 years (IQR: 1.56–2.62 years), frailty as defined by four instruments (except for FI-CD), was associated with death [FFP: Hazard ratio (HR) = 3.11, 95% confidence interval (CI) 1.30–7.44; CFS: HR = 3.68, 95% CI 1.03–13.16; SPPB: HR = 3.74, 95% CI 1.39–10.06). Frailty was also associated with acute exacerbation (using FFP) and hospitalization (using FFP, CFS, and FI-CD). Frail showed a moderate predictive ability [area under the curve ranging (AUC) 0.70–0.80] and a high negative predictive value (0.98–0.99) for 1-year mortality. Conclusions With the four different frailty assessment tools, frailty was associated with poor prognosis in older patients with stable COPD. The FFP, CFS, FI-CD, and SPPB instruments showed similar performance in predicting 1-year mortality.

Adaptive support ventilation as an effective treatment option for central sleep apnea in an older adult with heart failure with preserved ejection fraction: a case report

Background Adaptive support ventilation (ASV) is a proposed treatment option for central sleep apnea (CSA). Although the effectiveness of ASV remains unclear, some studies have reported promising results regarding the use of ASV in patients with heart failure with preserved ejection fraction (HfpEF). To illustrate the importance of suspecting and diagnosing sleep-disordered breathing (SDB) in older adults unable to recognize symptoms, we discuss a case in which ASV was effective in a patient with CSA and HfpEF, based on changes in the Holter electrocardiogram (ECG). Case presentation. An 82-year-old man presented to our hospital with vomiting on April 19, 2021. Approximately 10 years before admission, he was diagnosed with type 1 diabetes mellitus and recently required full support from his wife for daily activities due to cognitive dysfunction. Two days before admission, his wife was unable to administer insulin due to excessively high glucose levels, which were displayed as “high” on the patient’s glucose meter; therefore, we diagnosed the patient with diabetic ketoacidosis. After recovery, we initiated intensive insulin therapy for glycemic control. However, the patient exhibited excessive daytime sleepiness, and numerous premature ventricular contractions were observed on his ECG monitor despite the absence of hypoglycemia. As we suspected sleep-disordered breathing (SDB), we performed portable polysomnography (PSG), which revealed CSA. PSG revealed a central type of apnea and hypopnea due to an apnea–hypopnea index of 37.6, which was > 5. Moreover, the patient had daytime sleepiness; thus, we diagnosed him with CSA. We performed ASV and observed its effect using portable PSG and Holter ECG. His episodes of apnea and hypopnea were resolved, and an apparent improvement was confirmed through Holter ECG. Conclusion Medical staff should carefully monitor adult adults for signs of or risk factors for SDB to prevent serious complications. Future studies on ASV should focus on older patients with arrhythmia, as the prevalence of CSA may be underreported in this population and determine the effectiveness of ASV in patients with HfpEF, especially in older adults.

Gender differences in positive screen for depression and diagnosis among older adults in Chile

Background Different factors are associated with late life depression and diagnosis, including gender. It has also been reported that depression among older people is underdiagnosed. As a result, the mental health needs of this group are insufficiently met. The aim of this study was to explore gender differences in the factors associated with positive screens for depression and self-reported diagnosis among older adults in Chile. Methods Data from 3786 older adults who participated in the Social Protection Survey in 2016 were analysed. PHQ-9 was used to identify screen-positive cases. Self-reported diagnosis of depression was used to determine the proportion of people with a screen-positive result who had received a diagnosis of depression. Logistic regression models were used to determine sociodemographic and health factors associated with depression and underdiagnosis in older men and women. Results The prevalence of a screen-positive result was 20.91% (5.83% major depressive disorder) among men, and 36.38% (12.43% major depressive disorder) among women. 18.77% of men and 34.11% of women with a positive depression screening had received a diagnosis. More educated men were more likely to receive a diagnosis. Older age was associated with a lower probability of diagnosis among older women. Conclusions Our results suggest that depressive disorders are undiagnosed in a high proportion of older adults in Chile. Gender is a relevant factor in the underdiagnosis of depression in this group. Further research is needed to understand the factors involved in these gaps, to improve detection and provide timely support and treatment.

The influence of primary care quality on nursing home admissions in a multimorbid population with and without dementia in Germany: a retrospective cohort study using health insurance claims data

Background Multimorbidity poses a challenge for high quality primary care provision for nursing care-dependent people with (PWD) and without (PWOD) dementia. Evidence on the association of primary care quality of multimorbid PWD and PWOD with the event of a nursing home admission (NHA) is missing. This study aimed to investigate the contribution of individual quality of primary care for chronic diseases in multimorbid care-dependent PWD and PWOD on the duration of ongoing residence at home before the occurrence of NHA. Methods We conducted a retrospective cohort study among elderly care-dependent PWD and PWOD in Germany for six combinations of chronic diseases using statutory health insurance claims data (2007–2016). Primary care quality was measured by 21 process and outcome indicators for hypertension, diabetes, depression, chronic obstructive pulmonary disease and heart failure. The primary outcome was time to NHA after initial onset of care-dependency. Multivariable Cox proportional hazard models were used to compare the time-to-event between PWD and PWOD. Results Among 5876 PWD and 12,837 PWOD 5130 NHA occurred. With the highest proportion of NHA for PWD with hypertension and depression and for PWOD with hypertension, diabetes and depression. Average duration until NHA ranged from 6.5 to 8.9 quarters for PWD and from 9.6 to 13.5 quarters for PWOD. Adjusted analyses show consistent associations of the quality of diabetes care with the duration of remaining in one’s own home regardless of the presence of dementia. Process indicators assessing guideline-fidelity are associated with remaining in one’s home longer, while indicators assessing complications, such as emergency inpatient treatment (HR = 2.67, 95% CI 1.99–3.60 PWD; HR = 2.81, 95% CI 2.28–3.47 PWOD) or lower-limb amputation (HR = 3.10, 95% CI 1.78–5.55 PWD; HR = 2.81, 95% CI 1.94–4.08 PWOD) in PWD and PWOD with hypertension and diabetes, increase the risk of NHA. Conclusions The quality of primary care provided to care-dependent multimorbid PWD and POWD, influences the time individuals spend living in their own homes after onset of care-dependency before a NHA. Health care professionals should consider possibilities and barriers of guideline-based, coordinated care for multimorbid care-dependent people. Further research on quality indicator sets that acknowledge the complexity of care for multimorbid elderly populations is needed.

Planning and designing a self-compassion intervention for family carers of people living with dementia: a person-based and co-design approach

Background This article describes the research activities undertaken to plan and design a self-compassion intervention for family carers of people living with dementia using a person-based and co-design approach. In providing this example, our aim is two-fold: to highlight the value of using qualitative research and co-design processes within intervention development; and to showcase systematic reporting of an intervention’s early planning and design stages. Methods A person-based and co-design approach informed the planning and design of the self-compassion intervention. In Stage 1, qualitative interviews were undertaken with 14 family carers of people living with dementia and 14 professional stakeholders. In Stage 2, intervention guiding principles were developed, psychological theory was incorporated, and six family carers of people living with dementia were engaged as co-designers. Results Knowledge generated during intervention planning identified that the intervention should be situated within the concept of compassion more broadly; address misperceptions, fears, blocks, and resistances to self-compassion; and target feelings of shame, guilt, and self-criticism. Subsequent intervention design activities determined that the needs of family carers of people living with dementia were best met by tailoring an existing intervention, namely group-based Compassion-Focused Therapy. Conclusions Our systematic approach highlights the value of incorporating in-depth qualitative research and co-design within the intervention development process to prioritise the perspectives and lived experiences of family carers of people living with dementia. The planning and design process outlined provides insight that is applicable to the development of our intervention and complex health interventions within gerontology and beyond.

Positive health during the COVID-19 pandemic: a survey among community-dwelling older individuals in the Netherlands

Background Coronavirus Disease 2019 (COVID-19) reached the Netherlands in February 2020. To minimize the spread of the virus, the Dutch government announced an “intelligent lockdown”. Older individuals were urged to socially isolate completely, because they are at risk of a severe disease course. Although isolation reduces the medical impact of the virus, the non-medical impact should also be considered. Aim To investigate the impact of COVID-19 pandemic and associated restrictive measures on the six dimensions of Positive Health in community-dwelling older individuals living in the Netherlands, and to identify differences within subgroups. Methods In May/June 2020, community-dwelling older individuals aged ≥ 65 years completed an online survey based on Huber’s model of Positive Health. Positive Health was measured regarding the appreciation of the six dimensions (categorized as poor/satisfactory/excellent) and a comparison with a year before (categorized as decreased/unchanged/increased) using frequencies (%) and a chi-square test. Results 834 older individuals participated (51% women, 38% aged ≥ 76 years, 35% living alone, 16% self-rated poor health). Most respondents assessed their bodily functions, mental well-being and daily functioning as satisfactory, their meaningfulness and quality of life (QoL) as excellent, and their social participation as poor. 12% of the respondents reported a deterioration of 4–6 dimensions and 73% in 1–3 dimensions, compared to the past year. Deterioration was most frequently experienced in the dimension social participation (73%), the dimension mental well-being was most frequently improved (37%) and quality of life was in 71% rated as unchanged. Women more often observed a deterioration of 4–6 dimensions than men (15% vs. 8%, p = 0.001), and individuals with self-rated poor health more often than individuals with self-rated good health (22% vs. 10%, p < 0.001). Older individuals living alone experienced more frequently a decrease in meaningfulness compared to older individuals living together. Conclusion The COVID-19 pandemic and associated restrictive measures had a substantial impact on all six dimensions of Positive Health in community-dwelling older individuals, especially in women, respondents living alone and respondents with self-rated poor general health.

Assessing and disclosing test results for ‘mild cognitive impairment’: the perspective of old age psychiatrists in Scotland

Background Mild cognitive impairment (MCI) is a condition that exists between normal healthy ageing and dementia with an uncertain aetiology and prognosis. This uncertainty creates a complex dynamic between the clinicians’ conception of MCI, what is communicated to the individual about their condition, and how the individual responds to the information conveyed to them. The aim of this study was to explore clinicians’ views around the assessment and communication of MCI in memory clinics. Method As part of a larger longitudinal study looking at patients’ adjustment to MCI disclosure, we interviewed Old Age Psychiatrists at the five participating sites across Scotland. The study obtained ethics approvals and the interviews (carried out between Nov 2020–Jan 2021) followed a semi-structured schedule focusing on [1] how likely clinicians are to use the term MCI with patients; [2] what tests clinicians rely on and how much utility they see in them; and [3] how clinicians communicate risk of progression to dementia. The interviews were voice recorded and were analysed using reflective thematic analysis. Results Initial results show that most clinicians interviewed (Total N = 19) considered MCI to have significant limitations as a diagnostic term. Nevertheless, most clinicians reported using the term MCI (n = 15/19). Clinical history was commonly described as the primary aid in the diagnostic process and also to rule out functional impairment (which was sometimes corroborated by Occupational Therapy assessment). All clinicians reported using the Addenbrooke’s Cognitive Examination-III as a primary assessment tool. Neuroimaging was frequently found to have minimal usefulness due to the neuroradiological reports being non-specific. Conclusion Our study revealed a mixture of approaches to assessing and disclosing test results for MCI. Some clinicians consider the condition as a separate entity among neurodegenerative disorders whereas others find the term unhelpful due to its uncertain prognosis. Clinicians report a lack of specific and sensitive assessment methods for identifying the aetiology of MCI in clinical practice. Our study demonstrates a broad range of views and therefore variability in MCI risk disclosure in memory assessment services which may impact the management of individuals with MCI.

Self-management processes, sedentary behavior, physical activity and dietary self-management behaviors: impact on muscle outcomes in continuing care retirement community residents

Background Despite the known benefits of non-sedentary behavior, physical activity, and protein and caloric intake to health and muscle mass, strength, and function, many older adults do not meet physical activity and dietary recommendations. A better understanding of the factors associated with sedentary behavior, physical activity and dietary self-management behaviors, and muscle outcomes (muscle mass, strength, and function) is needed, particularly among continuing care retirement community residents. The objective of this study was to examine the factors associated with sedentary behavior, physical activity and dietary self-management behaviors, and muscle outcomes among continuing care retirement community residents. It also aimed to determine whether sedentary behavior and physical activity and dietary self-management behaviors mediate the relationships between self-efficacy, goal congruence, aging expectations, social support, and muscle outcomes. Methods A sample of 105 continuing care retirement community residents (age > 70 years) participated in this correlational, cross-sectional study. Questionnaires on pain, self-efficacy, goal congruence, aging expectation, social support, and daily protein and caloric intake were administered. Physical activity and sedentary behavior (ActiGraph wGT3X-BT), muscle mass (ImpediMed SFB7), muscle strength (Jamar Smart Digital Hand Dynamometer), and muscle function (Short Physical Performance Battery) were measured. Multiple regression, logistic regression, and mediation analyses were performed. Results Low goal congruence predicted engagement in sedentary behavior and light physical activity. Higher levels of self-efficacy and social support were associated with increased likelihoods of achieving greater moderate physical activity and meeting daily recommendations for caloric intake, respectively. Self-efficacy and goal congruence predicted muscle function and strength. Moreover, sedentary behavior and achieving greater moderate physical activity were found to partially but significantly mediate the relationship between self-efficacy and muscle function. Conclusion Future research should evaluate whether attempts to reduce sedentary behavior and promote physical activity and dietary self-management behaviors and muscle outcomes are more successful when modifications to the self-management process factors are also targeted.

Subsidy policy selection of elderly care service projects under uncertain actual demand: a real options analysis based on China’s experience

Background Elderly care service projects (ECSPs) aim to provide care services with the help of market forces on the supply side to satisfy the huge demand of the elderly. Subsidies play an important role in motivating the investors to invest in the ECSPs immediately. The optimal subsidy scheme should balance the policy costs and the investors’ interests. Methods Based on the policy background of China, this study applied the real options theory to compare the effects of construction subsidy and operating subsidy on achieving policy goals from the perspective of uncertain actual demand. It introduced numerical examples to identify the optimal subsidy scheme and embedded the data from the Chinese Longitudinal Healthy Longevity Survey (CLHLS) to verify the uncertainty of actual demand. Results The results showed that in the context of uncertain actual demand, operating subsidy has greater advantages in reducing investment thresholds, saving subsidy costs and increasing spillover values. Moreover, a sound quality supervision system, a differentiated operating subsidy scheme and a sustainable growth market demand environment are conducive to increasing the long-term interests of the government and the investors. Conclusions The study emphasized the importance of subsidy selection in the context of uncertain actual demand, and provided a practical reference for policy designers in China and other developing countries to choose the optimal subsidy scheme for the ECSPs.