Effectiveness and costs-effectiveness of post-diagnosis treatment in dementia coordinated by memory...

Developing Topics e51

P4-396 COGNITIVE FUNCTION IN AFRICAN-AMERICAN

VERSUS WHITE WOMEN OF SIMILAR

EDUCATIONAL ATTAINMENTAND

HEALTHCARE ACCESS

Elizabeth Devore, Fran Grodstein, Mary Townsend, Brigham andWomen’s

Hospital, Boston, Massachusetts, United States.

Background:Whileworse rates of cognitive declinewith aging in African-

Americans than Caucasians have been consistently observed, the explana-

tion for discrepancies is unclear. In most studies, differences in education

and healthcare access between races can yield difficulties in differentiating

underlying roots of this discrepancy. We report late-breaking results from

the Nurses’ Health Study - a unique cohort in which all participants have

similar education, healthcare access and knowledge - regarding the relation

of race to cognition in older women. Methods: We assessed baseline cog-

nition among 19,033 white and 247 African-American, registered nurses

age 70-81 years, including 6 tests of global cognition, episodic memory,

verbal fluency, and working memory. A follow-up assessment was com-

pleted 2 years later. Participation and follow-up were > 90% in both races.

We used linear regression to estimate mean differences in initial cognition

and cognitive decline by race. Results: Healthcare access was very similar

across races (eg, recent physical exam was reported by 82% of black and

81% of white women). After adjusting for age and education, African-

Americans had significantly worse initial cognition than whites. For exam-

ple, mean difference in a global composite score (averaging all cognitive

tests) in African Americans versus whites was -0.31 standard units (95%

CI -0.39, -0.23) for initial cognitive function; this effect estimate was

equivalent to the difference in global composite score between women 7

years apart in age - that is, the effect of African American race was cogni-

tively equivalent to the effect of 7 years of aging. Similarly, cognitive de-

cline over 2 years was significantly worse by -0.14 units (95% CI -0.22,

-0.07). Adjustment for numerous health and lifestyle variables, including

vascular factors, depression, BMI, physical activity, father’s occupation

in nurses’ childhood, and psychosocial variables (eg, stress at home/

work, caregiving stress, social networks) only somewhat attenuated rela-

tions. For example, in the full multivariable model, mean difference in

global composite score in blacks versus whites was -0.26 standard units

(95% CI -0.34,-0.18). Conclusions: The large disparity in cognitive health

across races, even within a cohort of health professionals, underscores this

pressing public health issue. Further research is needed to ameliorate

cognitive health in older African Americans.

P4-397 AGITATED BEHAVIORS IN ELDERLY PERSONS

WITH DEMENTIA AND THE SELF-EFFICACY OF

THEIR CAREGIVERS IN THE ILLNESS STAGE

Huei-Ling Huang1, Yea-Ing Shyu2, 1Department of Gerontological Care

and Management, Chang-Gung Institute of Technology, Taoyuan, Taiwan;2Chang Gung University, Taoyuan, Taiwan.

Background: The purpose of this study was to model the agitated behaviors

of the elderly with dementia and the self-efficacy of the family caregiver to

manage this behavior in the illness stage.Methods: Secondary data analysis

was performed of two databases for advanced analysis. The data were ana-

lyzed using exploratory factor analysis, one way analysis of variance, and

structural equation modeling. Results: The results showed that among the

221 participants the majority of the agitated behaviors were presented by

the elderly with moderate to severe dementia. Verbally and physically,

non-aggressive agitated behaviors were the most frequently presented agi-

tated behaviors for all stages. Aggressive behaviors increased significantly

in the case of severe dementia. The self-efficacy of the family caregiver

for managing agitated behaviors was lowest in the case of mild dementia.

The results also showed that the caregivers’ self-efficacy for managing des-

tructed behaviors was the lowest among agitated behaviors in all stages of

dementia. A structural equation model was used to test the theoretical

models. The overall model fit of the agitated behaviors and the caregiver’s

self-efficacy was a fair fit. Agitated behavior was directly influenced by the

characteristics of the caregiver (ß¼ .27; p<.01) and the care relationship (ß

¼ - .614; p <.001). Younger caregiver and having more care distress pre-

dicted more agitated behavior of the demented elder. The self-efficacy of

the caregiver was directly influenced by the illness stage (ß ¼ .61; p

<.05) and the care relationship (ß¼ .47; p <.01). The more progressive ill-

ness stage of the demented elder and less care distress of caregiver predicted

the better caregiver self-efficacy for managing agitated behavior. Conclu-

sions: The results of this study will help family caregivers and medical pro-

fessionals to understand the changes and the predictors of the agitated

behaviors of the elderly with dementia as well as the self-efficacy of the

caregiver for managing this behavior in the different stages of the illness.

The Agitated Behavior Model (ABM) and the Agitation Management

Self-efficacyModel (AMSM) can serve as a guideline for professional care-

givers to manage the agitated behaviors and to provide health care sugges-

tions to the family caregiver of the elderly person with dementia.

P4-398 EFFECTIVENESS AND COSTS-EFFECTIVENESS

OF POST-DIAGNOSIS TREATMENT IN DEMENTIA

COORDINATED BY MEMORY CLINICS IN

COMPARISON TO TREATMENT COORDINATED

BY GENERAL PRACTITIONERS

Els Meeuwsen1, Ren�e Melis1, Geert van der Aa2, Gertie Gol€uke-

Willemse3, Benoit de Leest4, Frank van Raak5, Philip Scheltens6,

Carla Sch€olzel-Dorenbos7, Desiree Verheijen8, Frans Verhey9,

Marieke Visser6, 1Radboud University Nijmegen Medical Centre/Alzheimer

Centre Nijmegen, Nijmegen, Netherlands; 2Catharina Hospital, Eindhoven,

Netherlands; 3Alysis Group/Rijnstate Hospital, Arnhem, Netherlands;4Elkerliek Hospital, Helmond, Netherlands; 5GGZ Oost-Brabant, centrum

Land van Cuijk, Boxmeer, Netherlands; 6VU Medical Centre

Amsterdam/Alzheimer Centre Amsterdam, Amsterdam, Netherlands;7Memory Clinic Slingeland Hospital, Doetinchem, Netherlands; 8Gelderse

Vallei Hospital, Ede, Netherlands; 9Maastricht University Medical

Centre/Alzheimer Centre Limburg, Maastricht, Netherlands.

Background:With increasing numbers of memory clinics performing treat-

ment and care co-ordination for dementia patients, the question arises

whether this care is more efficient than dementia care provided by general

practitioners. In this study we determined the effectiveness and cost-effec-

tiveness of post-diagnosis treatment and care co-ordination of dementia pa-

tients and their caregivers performed by memory clinics compared with

general practitioners.Methods:This study is a pragmatic multi-centre rand-

omised controlled trial with a cost effectiveness study alongside. 175 Pa-

tients with a new diagnosis of mild to moderate dementia living in the

community and their informal caregivers were included in the study. Partic-

ipants (patient-caregiver pairs) were assigned for post-diagnosis dementia

care to either the memory clinic or the general practitioner by web-based

randomisation after baseline measurements. The intervention consisted of

usual care provided by either the memory clinic or the general practitioner.

Primary outcome measures were quality of life of the patient as rated by the

caregiver using the Quality of Life in Alzheimer’s Disease instrument (QoL-

AD), and self-perceived caregiver burden of the informal caregiver

measured using the Sense of Competence Questionnaire (SCQ) in an inten-

tion-to-treat analysis. A cost-effectiveness analysis using utilities generated

by the EuroQol instrument (EQ-5D) established efficiency from a societal

point of view. Results: Quality of life of the patients in the memory clinic

group was 0.5 point higher (95% CI: -0.6 - 1.6), and caregiver burden was

2.4 points lower (95% CI: -5.8 - 1.0) than of patients in the general practi-

tioner group. Compared to general practitioner care, treatment by the mem-

ory clinics was on average V1.024 (95% CI: V-7.723 - V5.674) cheaper, at

a loss of 0.025 (95% CI: -0.114 - 0.064) Quality Adjusted Life Years

(QALYs). The estimated incremental cost-effectiveness was 41.442 euro

saved per QALY lost for the memory clinic compared with the general prac-

titioner. Conclusions: There were no statistically significant differences in

effectiveness and cost-effectiveness between memory clinics and general

practitioners with regard to treatment and care co-ordination of patients

with dementia and their caregivers. Both modalities can be applied inter-

changeably; patient preferences and regional health service planning should

determine which type of dementia care is offered.