Abstract
426 - FindMyApps: Protocol for a randomized controlled trial with community-dwelling people with dementia, evaluating the effectiveness and cost-effectiveness of an intervention to improve self-management and social participation
- David P. Neal, Yvonne J. F. Kerkhof, Teake P. Ettema, Majon Muller, Judith Bosmans, Evelyn Finnema, Maud Graff, Karin Tanja-Dijkstra, Max L. Stek, Rose-Marie Dröes
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- Published online by Cambridge University Press:
- 04 November 2020, p. 142
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Background: For the rising number of people living with dementia, cost-effective community-based interventions to support psychosocial care are needed. The FindMyApps program helps people with dementia and their caregivers learn to use tablet computers and find user-friendly apps that facilitate self-management and engagement in meaningful activities. This definitive trial builds on previous feasibility pilot trials of FindMyApps and further evaluates cost-effectiveness.
Method: This is a protocol for a non-blinded randomized controlled trial (RCT) with two arms (intervention and usual care). 150 dyads (person with dementia and their carer) will be recruited. Participants must be resident in the community, with a diagnosis of Mild Cognitive Impairment or mild dementia (Mini Mental-State Examination 17-26, or Global Deterioration Scale 3-4. Dyads will be randomly assigned in equal proportions to receive either the FindMyApps intervention (experimental arm) or usual care (control arm). Primary outcomes measured at 3 months will be: patient self-management and social participation; caregiver sense of competence. Data will be collected through questionnaires filled in by the researcher (patient outcomes) or participants themselves (carer outcomes). In addition to a main effect analysis, a cost-effectiveness analysis will take place. In line with Medical Research Council (MRC) guidance for the evaluation of complex interventions, a process analysis will be undertaken, to identify factors that may influence trial outcomes. Semi-structured interviews and remotely collected data regarding use of the FindMyApps app will support the process analysis.
Result: Results of this study are expected in 2022. The study will be adequately powered to detect at least a moderate effect size of the intervention with respect to the primary outcomes.
Conclusion: This study will investigate the effectiveness and cost-effectiveness of the FindMyApps intervention. The results of the study will provide strong evidence to support or oppose scaling up implementation of the intervention. This is also an example of how the MRC framework for the evaluation of complex interventions can be implemented in practice. In a field which is often criticized for a lack of high quality evidence, randomized controlled trials should be applied more frequently designed for the robust and transparent evaluation of digital tools and technologies.
427 - HARMONY study: pimavanserin significantly reduces risk of relapse of dementia-related psychosis
- Erin P Foff, Jeffrey L Cummings, Maria-Eugenia Soto-Martin, Pierre Tariot, Bradley McEvoy, Srdjan Stankovic
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- Published online by Cambridge University Press:
- 04 November 2020, p. 143
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Dementia-related psychosis (DRP) is common among patients with Alzheimer’s disease (AD), Parkinson’s disease (PD), dementia with Lewy bodies (DLB), frontotemporal dementia (FTD), and vascular dementia (VaD) and is associated with poor outcomes. HARMONY (NCT03325556) was a Phase 3, placebo-controlled, randomized, relapse-prevention study evaluating the efficacy and safety of pimavanserin for treating hallucinations and delusions associated with DRP. Patients with dementia and moderate-severe psychosis received open-label (OL) pimavanserin for 12 weeks. Patients with a sustained response (≥30% reduction in Scale for the Assessment of Positive Symptoms hallucinations+delusions Total Score AND Clinical Global Impression-Improvement score of much/very much improved) at Weeks 8 and 12 were randomized 1:1 to continue pimavanserin or receive placebo for up to 26 weeks in the double-blind (DB) period. The primary endpoint was time from randomization to relapse of DRP. 392 patients enrolled. 217 (61.8%) eligible patients experienced sustained response and were randomized. OL response was similar regardless of dementia subtype (randomization rates: 59.8% AD, 71.2% PDD, 71.4% VaD, 45.5% DLB, 50.0% FTD), baseline disease characteristics, age, dementia severity, or previous drug therapy. The study stopped early for superior efficacy when a prespecified interim analysis revealed >2.8-fold reduction in risk of relapse with pimavanserin (hazard ratio: 0.353; 95% CI: 0.172, 0.727; 1-sided p=0.0023). Adverse event rates were low and balanced (OL: 36.2%; DB: 41.0% pimavanserin, 36.6% placebo). No negative trends for worsening in cognition (as assessed by the Mini-Mental State Examination) or motor function were observed. The HARMONY study demonstrated a robust decrease in hallucinations and delusions and significant maintenance of efficacy with pimavanserin treatment in DRP.
Study Sponsored By: ACADIA Pharmaceuticals Inc.
DisclosuresThis study was funded by ACADIA Pharmaceuticals Inc.
Drs. Foff, McEvoy, and Stankovic are all employees of ACADIA Pharmaceuticals Inc. (San Diego, CA, USA).
Dr Cummings has provided consultation to ACADIA, Accera, Actinogen, AgeneBio, Alkahest, Allergan, Alzheon, Avanir, Axsome, Binomics, BiOasis Technologies, Biogen, Bracket, Cassava, Denali, Diadem, EIP Pharma, Eisai, Genentech, Green Valley, Grifols, Hisun, Idorsia, Lundbeck, Merck, Otsuka, Pain Therapeutics, Probiodrug, Proclara, QR, Resverlogix, Roche, Samumed, Shinkei Therapeutics, Sunovion, Suven, Takeda, and United Neuroscience pharmaceutical and assessment companies. He owns stock in ADAMAS, BioAsis, MedAvante, and QR Pharma. Dr. Cummings owns the copyright of the Neuropsychiatric Inventory (NPI). Dr. Cummings is supported by a COBRE grant from NIH/NIGMS #P20GM109025 and Keep Memory Alive.
Dr. Soto has provided consultation to ACADIA, Avanir, Eisai, Lundbeck, and Otsuka.
428 - DEMENTIA INPATIENT THERAPEUTIC INTERVENTIONS IN A SCOTTISH HEALTH REGION
- Gary Stevenson, Stephen Foster, Meroe Grove
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- 04 November 2020, p. 144
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Background: There is published evidence of the benefits and limitations, including potential harm, of psychotropic medication and benefits of non-pharmacological interventions for the management of challenging behaviours associated with dementia (BPSD).
Objectives: To examine the usage of such interventions in the management of BPSD within three National Health Service (NHS) ‘specialist’ dementia inpatient wards (56 beds) in a Scottish health region (Fife, population 370,000) and to identify targets for service improvements.
Methods: Patient demographic data, mental and physical health diagnoses, current and recent (within 3 months) psychotropic prescriptions, multidisciplinary team input, and evidence of individualised non-pharmacological interventions for BPSD were collected in February 2020 from patient notes, care plans and medication charts.
Results: 42 older patients (mean age 80 years, range 59-99) with dementia had spent on average 18.7 months within hospital, some categorised as ‘delayed discharges’ awaiting care home placements All lacked capacity to consent to their general care and medical treatments, most having multiple (average 5) medical co-morbidities. 36% were detained in hospital under Mental Health legislation, 29% prescribed medications so authorised, and 40% had medications administered covertly. 76% were prescribed an antipsychotic (Risperidone in 24%), 40% a cognitive enhancer (Memantine and/or a cholinesterase inhibitor), 48% an antidepressant (Trazodone in 19%), 26% a regular benzodiazepine. There was limited regular multi-professional team working in the wards (under 18% had any non-nursing input within the previous 3 months). Of non-pharmacological therapeutic interventions, 26% were receiving multisensory inputs, 19% soft toy, 12% massage, 7% music playlist and 7% cognitive stimulation therapy.
Conclusions: For this population with BPSD there were high rates of off -licence drug prescribing with limited investment in evidence-based non-pharmacological therapeutic alternatives. During ongoing review of staffing on these wards, it would appear appropriate to examine the expectation that wards serve multiple functions, such as transitional care and specialist continuing care. We suggest reviews contextualise prescribing within an increased availability of multi-disciplinary therapeutic interventions, to ensure this patient population is cared for in an evidence-based therapeutic environment. The Scottish Government’s publication3 (2018) “Transforming Specialist Dementia Hospital Care” should help raise the profile of this “overlooked” inpatient population.
3https://www.gov.scot/publications/transforming-specialist-dementia-hospital-care/
429 - Relationship between agitation and social isolation as a dimension of quality of life in residents with dementia living in German nursing homes – a secondary data analysis
- Kathrin Schmüdderich, Daniela Holle, Armin Ströbel, Diana Trutschel, Rebecca Palm
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- 04 November 2020, p. 145
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Background: Agitation is common in nursing home residents with dementia and is associated with high burden for the residents, their relatives and their caregivers. These consequences increase if symptoms of agitation are severe. Although it is assumed that agitation and quality of life are related, knowledge about severe agitation and its relation to single dimensions of quality of life is limited.
Objective: To examine the relationship between the severity of agitation and social isolation as a dimension of quality of life in people with dementia living in German nursing homes.
Methods: An explorative secondary data analysis of data from an observational study with 1947 residents from 66 German nursing homes was conducted. Agitation was defined as a construct of the items agitation/aggression, irritability and disinhibition of the Neuropsychiatric-Inventory Questionnaire (NPI-Q). Social isolation, as one of the dimensions of quality of life, was measured with a subscale of the short version of the QUALIDEM-instrument. First, a matching procedure was carried out to choose two groups with similar baseline characteristics, one with residents with severe agitation and one with residents with mild or no agitation. Second, a linear regression model and Mann-Whitney U tests were calculated to determine differences in the dimension of social isolation and its single items.
Results: A significant relationship was found between the severity of agitation and the dimension of social isolation (-1.92 (CI 95%: -2.41, -1.43)). Besides the finding in the total score of the dimension of social isolation, significant differences were found in all three items defining this dimension (calls out; openly rejects contact with others; is rejected by other residents). In particular, the item ‘is rejected by other residents’ was often rated as applicable for people with dementia with severe agitation.
Conclusion: Severe agitation is associated with lower values of quality of life in the dimension of social isolation and its defining items. In daily practice and in research, more attention should be paid to severe agitation. Furthermore, interventions that aim to influence both the severity of agitation and the quality of life should have a stronger focus on causes of social isolation.
430 - The Puzzled and Puzzling Self: Self-Perception of People With Dementia in the Residential Care Homes of Hong Kong
- Kenny Chui Chi Man, Dr
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- 04 November 2020, p. 146
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In Hong Kong, people aged 65 years or more was approximately 17.7% of the total population which is identified as “super-aged” city. The prevalence of dementia in Hong Kong aged 70 years or older had risen from 6.1% to 9.3% between 1998 and 2008. However, only 11% of people with dementia are diagnosed and receive medical follow-up. Although people live longer than they once did, their increased longevity can be a mixed blessing, both for themselves and for their societies. How people perceive dementia and interpret people with dementia will be one of the key elements to develop the 21st century’s dementia care culture in the Chinese society.
A qualitative research in understanding how people with dementia perceive themselves always requires interpreting how others in their daily lives perceive them was conducted. Twenty in-depth interviews and two focus groups between people with dementia and the care staff in the residential care homes in Hong Kong were done. Indeed, if someone in your daily life perceives you differently from how you perceive yourself, then how do you make sense of the discrepancy? People with dementia tend to struggle with understanding not only situations occurring around them but also who they are, especially when others’ reactions to them are unexpected.
Interpretivism and thematic analysis was applied whereas the difference between real and perceived selves was found. The findings included (1) Doubt About One’s Trustworthiness; (2) Doubt About One’s Value; (3) Doubt About One’s Capability. From their perspective, residents with dementia were trustworthy, but the care staff ignored their requests and prerogatives nonetheless. They also interpreted that they were valuable, but the staff overlooked their needs and did not show them any respect, either. Beyond that, they thought that they were capable, but the staff did not recognise their abilities and disregarded their input in decision-making. Puzzled about whether they should accept or reject the staff’s responses in interpreting who they were, the residents with dementia experienced heightened confusion about their circumstances. This research become one of the directions to explore the implementation of person-centred care in the Hong Kong’s residential care homes.
431 - DEMENTIA IN PRIMARY CARE AND DOCTOR-PATIENT-CARER INTERACTIONS: PRELIMINARY FINDINGS
- Conceição Balsinha, Steve Iliffe, Sónia Dias, Manuel Gonçalves-Pereira
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- 04 November 2020, p. 147
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INTRODUCTION: Primary care visits of persons with dementia involve different types of communication, bringing together the patient, the family carer and the general practitioner (GP). A particular challenge is the necessary involvement of a third person (the carer) in patient-doctor encounters (or the patient in carer-doctor encounters, as dementia advances). These triad dynamics should be better understood, as health outcomes are expected to result from or be mediated by them.
OBJECTIVE: Our aim is to explore triadic dynamics in Portuguese primary care consultations with persons with dementia, their family carers and GPs.
METHODS: This is the first part of an ongoing project (Dementia in Primary Care: the Patient, the Carer and the Doctor in the Medical Encounter - Bayer Investigation Grant | NOVAsaúde Ageing 2018). Consultations with persons with dementia, their carers and GPs (purposive sampling) are audio-recorded, transcribed verbatim and thematically analysed. We report the analysis of interactions of the first six consultations, using NVIVO® software.
RESULTS: The most frequent type of interaction was between GPs and carers, followed by interactions involving the whole triad. The patients who had more recent relationships with their GPs tended to participate less, irrespective of the stage of dementia. Carers were the ones most often initiating triadic interactions, and GPs the ones most often terminating them by directly addressing the patients. Doctor-carers interactions were very sparse in some consultations.
DISCUSSION AND CONCLUSION: These preliminary findings suggest that doctor-patient interactions may be limited in a number of GPs’ consultations, seemingly compromising patient-centred approaches. Nevertheless, even when GPs were involved in triadic interactions they often tried to address the patient directly. We are looking forward to complete this part of the project: to our knowledge, there is practically no evidence from live-recorded primary care consultations about these triadic dynamics.
432 – Correlation between regional brain volume and olfactory function in very mild amnestic patients
- Tetsuo Kashibayashi
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- 04 November 2020, p. 148
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Background & Aims: We aimed to determine neural correlates of olfactory detection and identification and analyze associations between cognitive function and olfactory identification or detection in very mild amnestic patients.
Methods: We recruited 70 patients with chief complaints of memory impairment diagnosed as amnestic mild cognitive impairment (MCI) or Alzheimer’s disease (AD) with a clinical dementia rating of 0.5. Olfactory detection and identification were assessed using T&T olfactometry. A voxel-wise correlation analysis of gray matter volume and olfactometry scores was performed. We also analyzed correlations between neuropsychological results and olfactometry scores.
Results: A significant negative correlation was observed between detection scores and nucleus accumbens and left parahippocampal gyrus volumes and between identification scores and orbitofrontal, right frontal, and right anterior temporal cortex volumes (p<0.001). No significant correlation existed between detection and cognitive assessment scores. Identification score was significantly correlated with the Alzheimer’s Disease Assessment Scale-Cognitive Part word recall score (r=0.305, p=0.01).
Conclusions: Olfactory detection and identification dysfunction were attributable to impairments in different regions in MCI and very early AD; the former was attributed to the olfactory circuit, while the latter to neocortices. The dysfunction of identification of olfactory information was associated with episodic memory in those patients.
433 - Burden of Disease Associated with Dementia-related Psychosis and Dementia-related Agitation & Aggression Using a National Long-term Care US Database
- Nazia Rashid, Sherry Andes, Vic Abler, Leslie Citrome
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- Published online by Cambridge University Press:
- 04 November 2020, pp. 149-150
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Objective: Compare burden of disease among patients with dementia-related psychosis (DRP), dementia without psychosis (dementia only), and dementia-related agitation/aggression (DAA) in long-term care (LTC) facilities.
Background: Patients with dementia often experience neuropsychiatric symptoms (NPS), including psychosis and agitation/aggression. Real-world data on the comorbidity profile of DRP and DAA patients are limited.
Design/Methods: Dementia patients were identified from a US LTC database based on ?2 dementia diagnosis codes or 1 dementia diagnosis code and antidementia therapy prescription during 1 Jan 2013 to 30 May 2017. Patients were categorized into DRP (?2 psychosis or 1 psychosis diagnosis code and prescription of antipsychotic therapy and no history of agitation/aggression diagnosis), dementia only (no psychosis or agitation/aggression diagnosis and no history of antipsychotic therapy [dementia only]), and DAA (?2 diagnosis codes of agitation/aggression and no history of psychosis diagnosis or antipsychotic therapy) groups (index date). Comorbidities and concomitant therapies were defined during 12 months prior to index date.
Results: There were 26,002 dementia residents: DRP (n=11,921; 46%); dementia only (n=11,432; 44%); DAA (n=2649; 10%). DRP patients were younger (mean age 80.8 years) than dementia only (84.3 years) or DAA (83.8 years). DRP patients were sicker overall versus dementia only: anemia (32% vs 29%); anxiety (55% vs 33%); bladder disorders (19% vs 13%); depression (75% vs 58%); hypertension (43% vs 33%); diabetes (43% vs 38%); insomnia disorders (32% vs 19%); (all P<0.05). More DAA patients had anxiety (43%), depression (66%), hypertension (43%), and insomnia disorders (26%) than dementia only (all P<0.05). Most DRP patients (94.3%) received off-label treatment for DRP; approximately one third (31.6%) of DAA patients received off-label treatment for DRP.
Conclusions: This study, the first of its type to use a US LTC database, demonstrated a significant comorbidity burden associated with DRP or DAA compared with dementia only, which should be considered when using off-label treatments. These data highlight the need for safe and effective treatments for dementia NPS.
Study Sponsored By: ACADIA Pharmaceuticals Inc.
DisclosuresNR, SA, VA are employees of ACADIA Pharmaceuticals
LC has served as a consultant, speaker, holds stock in, or receives royalties from: Acadia, Alkermes, Allergan, Avanir, BioXcel, Eisai, Impel, Indivior, Intra -Cellular Therapies, Janssen, Lundbeck, Luye, Merck, Neurocrine, Noven, Osmotica, Otsuka, Pfizer, Sage, Shire, Sunovion, Takeda, Teva, Vanda, Bristol-Myers Squibb, Eli Lilly, J & J; Wiley (Editor-in-Chief, International Journal of Clinical Practice), UpToDate (reviewer), Springer Healthcare (book)
This submission is an encore of a poster abstract originally presented at ISPOR 2019, New Orleans, LA, USA, May 18–22, 2019; original presentation under the same title.
434 - Treatment Patterns and Needs for Dementia-related Psychosis Described by Patients and Care Partners (Caregivers): an Observational, Prospective Study to Describe the Patient Experience
- Teresa Brandt, Theresa Frangiosa, Virginia Biggar, Angela Taylor, Bill Keller, Vic Abler
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- 04 November 2020, p. 151
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Background:
We aimed to describe current treatment patterns and unmet needs of persons with DRP from a patient and care partner (CP) perspective.
Methods:This observational, non-interventional, prospective study used a mixed-methods approach with qualitative interviews and a quantitative online survey. Persons with DRP and CP of persons with DRP reported the effectiveness of current treatments using a visual analog scale (VAS) of 0 (“not at all well”) to 5 (“extremely well”) and ranked benefits of an ideal treatment. CP burden was outside the scope of this study.
Results:The qualitative interview was completed by 1 patient and 15 CP. Current treatments included atypical antipsychotics, antidepressants, anxiolytics, and benzodiazepines. Participants commonly indicated a need to improve patients’ ability to know what is real vs not real.
The online survey was completed by 26 patients and 186 CP on behalf of patients under their care. Common treatments used included atypical antipsychotics (27% of patients, 41% of CP) and psychological/ behavioral therapy (23% of patients, 8% of CP). Many participants reported no current treatment (42% of patients, 42% of CP). Participants reported that current treatment methods were less than moderately helpful in treating patients’ most impactful symptoms with a median VAS score of 2.0/5 reported by patients and CP (mean VAS score [standard deviation] = 2.33 [1.0] for patients [n=15], mean [standard deviation] VAS score = 2.4 [1.3] for CP [n=104]). Discontinuation of a treatment was reported by 11 patients and 115 CP, most commonly due to a side effect (27% of patients, 31% of CP), doctor’s recommendation (27% of patients, 14% of CP), or lack of symptom improvement (9% of patients, 28% of CP). Participants ranked the ability to distinguish what is real vs not real (35% of patients, 49% of CP) and overall symptom improvement (42% of patients, 23% of CP) as the most important benefits of an ideal treatment.
Conclusions:Patients and CPs reported either not taking any DRP treatments or that current treatments were associated with side effects along with limited efficacy. There is an unmet need for safe and effective treatments for DRP.
Study Sponsored By:ACADIA Pharmaceuticals Inc.
DisclosuresTF is a consultant with Frangiosa & Associates, LLC.
VB and AT have no relevant financial relationships to disclose.
TB, BK, and VA are employees of and may hold stock and/or stock options with ACADIA Pharmaceuticals Inc.
435 - Perspectives of the general public on dementia risk reduction (DRR) and implications for implementation: a qualitative evidence synthesis
- Eleanor Curran, Kali Godbee, Terence W.H. Chong, Charles Abraham, Nicola T. Lautenschlager, Victoria J. Palmer
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- Published online by Cambridge University Press:
- 04 November 2020, pp. 152-153
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There is limited understanding of which factors most influence take-up of DRR behaviour in the general population. This evidence gap may limit the effectiveness of DRR implementation and, hence, impede translation of increasing evidence for DRR1 into real-world public health benefits.
Reviews of quantitative studies have identified poor knowledge and persistence of myths about ageing2,3 as important. However, these findings are limited by the scope of included questionnaires.
Qualitative literature reporting the perspectives of the general public offers an opportunity to increase this understanding. Qualitative studies can examine poorly understood phenomena in greater depth and with fewer a priori assumptions. Qualitative evidence synthesis (QES) is increasingly recognised as valuable, particularly in relation to complex interventions like DRR.
We will present a QES regarding the perspectives of dementia- free members of the general public towards DRR. Searches indicate that no QES for this topic currently exists.
Systematic searches of Medline, PsycINFO, Embase and CINAHL for studies published since 1995 that have used qualitative methods to explore DRR perspectives in the general public were undertaken, supplemented by hand searches of included studies’ reference lists. Following independent screening by two reviewers, 41 publications based on 37 individual studies meeting inclusion criteria have been identified.
Data will be analysed using thematic synthesis, as outlined by Thomas and Harden (2008)4 and recommended for QES regarding complex health interventions5. ‘Line-by-line’ inductive coding and development of descriptive themes across studies will produce a summary of the perspectives of the general public for DRR. A conceptual framework explaining the relationships between key themes and considering the implications for implementation will be proposed.
The Critical Appraisal Skills Programme (CASP) tool will be used to appraise included studies. Rather than imposing an arbitrary quality cut-off point for inclusion, sensitivity analyses will be used to examine the influence of lower quality studies on review findings. Finally, the Confidence in the Evidence from Qualitative Reviews (CERQual) approach will facilitate assessment of confidence in review findings to aid future use. Data extraction is ongoing.
Findings from this synthesis will support better targeted quantitative examination of DRR implementation determinants and more strategic intervention design.
1. World Health Organisation. Risk reduction of cognitive decline and dementia: WHO guidelines. World Health Organisation. 2019. Geneva. Licence CC BY-NC-SA 3.0 IGO
2. Cahill, S., Pierce, M., Werner, P., Darley, A., Bobersky, A. A systematic review of the public’s knowledge and understanding of Alzheimer’s disease and dementia. Alz Dis Assoc Disord. 2015; 29:255-275
3. Cations, M., Radisic, G., Crotty, M., Laver, K.E. What does the general public understand about prevention and treatment of dementia? A systematic review of population-based surveys. PLoS One. 2018, 13(4):e0196085
4. Thomas, J. and Harden, A. (2008). Methods for the thematic synthesis of qualitative research in systematic reviews, BMC Medical Research Methodology. 2008 July; 8:45. doi 10.1186/1471-2288-8-45
5. Noyes, J., Booth, A., Cargo, M., et al. (2018). Cochrane Qualitative and Implementation Methods Group guidance series – paper 1: introduction. J of Clin Epidemiol. 2018; 97:35-38
437 - COGNITIVE, PATHOLOGICAL, GENETIC AND NEURO-RADIOLOGICAL CORRELATES OF CEREBRAL AMYLOID ANGIOPATHY
- Kasia G. Rothenberg
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- 04 November 2020, pp. 154-155
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Background:
Cerebral Amyloid Angiopathy related inflammatory process (CAA-ri), a rare condition caused by an inflammatory reaction occurring within essential cerebral blood vessels against beta-amyloid deposits, leads to subclinical cognitive decline. Often misdiagnosed as dementia, this process can be treated through aggressive immunosuppression, thereby reversing much of the cognitive impairment.
Case Report:We report a 69 year old female who came to the clinic for a second opinion and had received a previous diagnosis of Alzheimer’s Dementia (AD) from an outside hospital two years prior. She presented with her husband who provided some key aspects of the history. The husband reported two years of worsening of memory, while the patient denied her symptoms. Per husband and patient, she was able to perform activities of daily living (ADLs), including bathing, dressing and toileting, but had difficulties with many instrumental ADLs (IADLs). The clinical course was somewhat fluctuating with progressive cognitive symptoms and significant word-finding difficulties. Patient had been started on Donepezil 5 mg daily by her primary provider.
Results:On examination, the patient did exhibit significant word-finding difficulties and scored 12/30 on the Montreal Cognitive Assessment (MoCA), indicating moderate cognitive impairment. The Patient was as well confused and disoriented to time and place. Neurological examination was otherwise unremarkable. Magnetic Resonance Imaging (MRI) studies were ordered and showed patchy and diffuse T2/FLAIR hyper intensities and particularly concentrated in the posterior cerebral artery and inferior division of the middle cerebral artery. These findings were consistent with cerebral amyloid angiopathy related inflammation (CAA-ri). Besides susceptibility weighted image (SWI) was showing multiple widely distributed microhemorrhages typical for CAA.
To address the acute inflammatory reaction the patient was hospitalized and received high dose, 3 day course of intravenous steroids, followed by an oral steroid taper. The treatment had to be monitored due to an unrelated hypertensive emergency and WPW syndrome (both newly diagnosed and treated emergently) thus the Patient was hospitalized for a 3 days and discharged on oral steroids tapper in improved condition.
Additionally, imaging showed that the patient’s hippocampal volumes were within normal range so this particular imaging biomarker didn’t support the diagnosis of AD. CSF biomarkers analysis didn’t support the diagnosis of AD either since had p-Tau levels were found to be within normal limits. Patient was found to be homozygous for the APOE e4 gene. Follow-up evaluation (including a repeat MRI study) was performed 2 months later showed clinical recovery and near complete resolution of diffuse hyperintensities, suggesting inflammation had resolved. Both the patient and the husband reported significant improvement in orientation and other aspects of cognition including working memory. The Patient scored 26/30 on MoCA.
Discussion:Cerebral amyloid angiopathy (CAA) has been commonly associated with brain hemorrhages in the elderly, but the inflammatory subtype CAA-I occur much less frequently and may be often misdiagnosed as a cancerous process (Ronsin et al. 2016). In a recent systematic review by Caldas A et al. 2015, of the 155 patients with documented CAA-I, almost half displayed some form of cognitive impairment and 86% received corticosteroids. Nearly half of the cases improved following treatment.
Conclusion:We present a case of a patient previously diagnosed with AD, upon further investigation, likely CAA-I, treated aggressively with intravenous steroids to good effect. Although rare, CAA-I is a reversible disorder that may be masked by a dementia or/and delirious process and should be considered in patients showing relatively rapid and fluctuating cognitive decline.
438 - Nigerian women are more susceptible to the impact of diabetes-and-dementia: State-of-art, Future perspectives and Directions
- L Giménez-Llort, EK Oghagbon, F Dogo, M Ogiator, J Prieto-Pino
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- Published online by Cambridge University Press:
- 04 November 2020, p. 156
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Among the preventable complications of diseases that require urgent effective health literacy programs in sub-Saharan Africa, crosstalk between diabetes and dementia stands out for women's health. Type 2 diabetes mellitus (DM2) in midlife is a recognised risk factor for dementia. This crosstalk is more significant in persons of African ancestry. Globally, the prevalence of DM will increase dramatically in the next few years with 75% of cases living in low-to-middle-income countries. Some major risk factors for DM2 accelerates the development of dementia in Africa-Americans, thus leading to higher prevalence of dementia compared to Caucasians. It is known that 58% of the global 46.8 million dementia subjects lives in economically developing countries. This proportion may reach 63% and 68% in 12 and 32 years' time, respectively. Females are 1.5 times likely to develop dementia, but sub-Saharan Africa women have a disproportionately two-to-eight fold increased dementia risk. In the eye of this storm is Nigeria which is home to the highest number of diabetics in Africa. Diabetes prevalence in the country is rising parallel to increased incidence of obesity, hypertension and rising population age. The socioeconomic impact of increasing prevalence of DM2 and dementia will be unsustainable for Nigeria healthcare system, given the experiences in developed economies. This study analyses the current situation of women's health in Nigeria, and explore future policy directions. The complex interplay of factors involved in the DM2-dementia crosstalk in Nigerian women include those due to biological processes (metabolic syndrome, vascular damage, inflammation, oxidative stress, insulin resistance and anaemia), nutritional habits and sedentary lifestyles. Other factors that predisposes Nigerian diabetic women to dementia are, restricted resources, lack of visibility and poor health management. They add up to increase the burden of disease in the Nigerian woman, irrespective of age. We advise urgent implementation of heath policies and actions that will increase ratio of mental health professionals / number of patients, especially in rural areas and the establishment of proactive primary healthcare centres. Importantly, interventions targeting adolescents and adult women, and others specific to mother- child interactions, are strongly needed in Nigeria and the sub-region for mitigating dementia in women.
439 - Sex-dependent increase of cerebral blood flow in cortex and hippocampus as a compensatory mechanism in end-of-life dementia: A MRI-ASL translational approach in models of normal and pathological aging
- A Muntsant-Soria, F Jiménez-Altayó, E Jiménez-Xarrié, L Giménez-Llort
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- Published online by Cambridge University Press:
- 04 November 2020, p. 157
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Alzheimer’s disease (AD) is associated with brain oxidative stress, inflammation, and cerebrovascular disease. Structural and functional abnormalities in cerebral microvasculature have been described in both patients and animals models. New tools and biomarkers for the detection of the disease are still emerging, such as Arterial Spin Labeling (ASL), a magnetic resonance imaging (MRI) technique for non-invasive measurements of cerebral blood blow (CBF) whose alteration may be involved in AD-pathogenesis. Nevertheless, more studies in the field are needed since both hypoperfusion and hyperperfusion in different brain areas are reported and can be involved in different brain functions. Recently, we reported in our colony of 3xTg-AD mice modeling Alzheimer’s disease a higher number of β-amyloid plaques in the hippocampus and entorhinal cortex in middle-aged females and extensive regions of hypoxia which were not seen in males. In the present study, we evaluated CBF in five different brain regions (hippocampus, cortex, striatum, caudate putamen and amygdala) in older male and female surviving until very advanced-stages of disease and as compared with age-matched counterparts with normal aging. AD-phenotype was evaluated by a comprehensive screening of three main functional impairments: physical (frailty), BPSD-like and cognitive deficits. CBF was measured using MRI-ASL and meaningful correlations between AD-phenotype and CBF were performed to better understand the relation between the level of perfusion and frailty, the BPSD-like behaviors and cognitive impairments. The results indicated sex- and brain region-associated changes in CBF. Among all, 3xTg-AD female mice survivors had increased CBF in cortex and hippocampus as compared with their wildtype counterparts. Here, we also report, for the first time, asymmetry between left -right hemispheres in the female’s cortex, in the hippocampus of control males and 3xTg-AD females, as well as in the striatum of control females. Cortex was the area that better correlated with behavior, with asymmetry being associated with worse memory performance. Moreover, hemisphere CBF asymmetry in limbic system was related with copying-with-stress strategies and associated locomotor activity in anxiety tests. The present study suggests a potential compensatory hemodynamic mechanism in end-of-life dementia which is sex- and brain region dependent and can be target for pharmacological and non-pharmacological interventions.
440 - Dementia villages: rethinking dementia care
- Catarina Pedro, Mariana Duarte, Beatriz Jorge, Daniela Freitas
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- Published online by Cambridge University Press:
- 04 November 2020, p. 158
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Introduction:
Over the past 20 to 30 years, alternative dementia care models have been developed. Dementia villages challenge popular perceptions about life with dementia and contrast to the traditional model of long-term care facilities that are often seen as institutional, impersonal, and risk-averse. The first dementia village, De Hogeweyk, was developed in 2009 and is located in Weesp, Netherlands. Hogeweyk aims to create a safe environment, enabling the person with dementia to live an “ordinary life” with as much autonomy as possible and also maintaining integration with the local community. Other dementia villages have been established in several countries, following De Hogeweyk model.
Objectives:The aim of this presentation is to describe the functioning of dementia villages and evaluate its benefits on dementia patients.
Methods:A non-systematic review of the literature was performed on PubMed, PsycINFO and Web of science using selected keywords. We also consult the official websites of the institutions.
Results:Dementia villages seem to improve functioning and reduce the need for medication. Anxiety, restlessness and homesickness can still persist, but are reduced by the homelike and hospitable setting in which residents live. In fact, antipsychotic medication use at the residence has decreased from approximately 50% of residents, before the dementia village was introduced, to approximately 12% in 2019. The staff also reported greater job satisfaction. Although dementia villages are growing throughout the Western world, this concept has also been criticized, arguing that this type of living is dishonest, misleading the residents to believe that they are still living in the ‘real community’.
Conclusions:Dementia villages are guided by the principles “deinstitutionalize, transform and normalize” care for people with advanced dementia. Although its intuitive advantages, there is no research evidence to demonstrate that this environment has any beneficial effect in behaviour, functional ability or cognition. In future studies, clinical outcomes could be used as a measure of quality of care. Hogeweyk concept has made societies rethinking dementia care and has been inspiring the development of other innovative models of dementia care.
441 - Treatment adequacy for depression and anxiety disorders affects quality of life in older adults consulting in primary care
- Catherine Lamoureux-Lamarche, Djamal Berbiche, Helen-Maria Vasiliadis
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- Published online by Cambridge University Press:
- 04 November 2020, p. 159
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Background
Previous studies show that less than 50% of adults in Canada receive guideline- concordant care for depression and anxiety disorders. Studies on the long-term effects of receiving adequate care for depression and anxiety disorders are scarce, particularly in older adults. This study aimed to assess the 3-year change in health-related quality of life (HRQOL) and satisfaction with life associated with receipt of adequate care for depression and anxiety disorders.
MethodThis study was conducted among a sample of 219 older adults recruited in primary care with a common mental disorder (depression or an anxiety disorder) who participated in Quebec’s longitudinal ESA-Services (2011-2016) study. The definition of adequacy of care was based on Canadian guidelines and relevant literature. Administrative and self-reported data were used to measure treatment adequacy at baseline. HRQOL was measured using a Visual Analog Scale (VAS) and satisfaction with life was assessed with the Satisfaction With Life Scale (SWLS). HRQOL and satisfaction with life were measured at baseline and follow-up, 3 years later. Multivariate fixed-effects models were carried out to assess the association between adequacy of care and change in quality of life controlling for individual and healthcare system factors in the overall sample as well as separately for depression and anxiety.
ResultsThe results showed that 56%, 37% and 40% of participants received adequate pharmacological or psychological treatment for depression, anxiety, and overall. Receipt of adequate treatment was associated with on average 4 more points on the VAS (0-100) and 1.7 points on the SWLS (5-25). After controlling for potential confounders, patients receiving adequate care for depression had on average 11 more points on the VAS. Treatment adequacy for anxiety disorders and depression or anxiety disorders overall were not associated with change in HRQOL or satisfaction with life.
ConclusionOlder adults receiving adequate mental health care had better HRQOL and satisfaction with life. Treatment adequacy for depression was associated with change in quality of life; but not for individuals with anxiety. Future studies should focus on different patient indicators of quality of care which may better predict long-term effects of treatment for people with anxiety.
442 - Neurocognitive markers of passive suicidal ideation in late life depression
- Joshua T. Jordan, Christina F. Chick, Camarin E. Rolle, Nathan Hantke, Christine E. Gould, Julie Lutz, Makoto Kawai, Isabelle Cotto, Rosy Karna, Sophia Pirog, Michelle Berk, Keith Sudheimer, Ruth O’Hara, Sherry A. Beaudreau
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- Published online by Cambridge University Press:
- 04 November 2020, p. 160
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Aims:
Late life suicide is an international public health crisis, yet the mechanisms underlying late life suicide risk are far less understood compared to younger age groups. Executive dysfunction is widely documented in late life depression (LLD), and cognitive flexibility and inhibition are specifically hypothesized as vulnerabilities for suicide risk. There is some evidence that LLD patients with suicidal ideation or attempt suicide have worse executive dysfunction than LLD patients that do not; however, it is unknown whether these differences exist in Passive Suicidal Ideation (PSI), which may be an important early stage of suicide risk. Delineating the mechanisms of risk for PSI in LLD is a crucial direction for late life suicide research. The purpose of our study was to examine whether cognitive flexibility and inhibitory ability are neurocognitive markers of PSI. The secondary purpose of our study was to determine if neurocognitive differences due to PSI are mediated by volumetric differences in the prefrontal cortex.
Methods:Forty community-dwelling middle- and older-aged adults with LLD (18 with PSI, 22 without) completed a neurocognitive battery that assessed cognitive flexibility, inhibitory ability, as well as other neurocognitive domains, and underwent structural neuroimaging.
Results:The PSI group performed significantly worse on cognitive flexibility and inhibitory ability, but not on other neurocognitive tasks which included other measures of executive function. The PSI group had a larger left mid-frontal gyrus (LMFG) than those without PSI, but there was no association between LMFG and cognitive flexibility or inhibitory ability, nor was there statistical evidence of mediation.
Conclusions:Our findings implicate a unique neurocognitive signature in LLD with PSI: poorer cognitive flexibility and poorer inhibitory ability not better accounted for by other domains of cognitive dysfunction and not mediated by volumetric differences in the prefrontal cortex. Volumetric brain differences in the LMFG appear unrelated to differences in cognitive flexibility and inhibitory ability, which suggests two specific but independent risk factors for PSI in middle- and older-aged adults.
443 - Measuring frailty in older psychiatric patients
- Robert M. Kok, Steven Smeele, Elsbeth-Nynke Bos, Jamila Douairi, Richard Christiaan Oude Voshaar
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- Published online by Cambridge University Press:
- 04 November 2020, p. 161
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Introduction
Frailty is a common clinical syndrome in older adults that carries an increased risk for poor health outcomes. Early identification of frailty may help optimizing quality of care. Fried's frailty criteria are often used as the gold standard of frailty. However, it takes too much time and the availability of a hand grip strength meter to measure these criteria in daily practice. Screening instruments for frailty such as the Groningen Frailty Indicator (GFI) and the Tilburg Frailty Indicator (TFI), are available. However, it is not yet certain whether the usual cut-off values are applicable to older psychiatric patients.
AimTo determine internal consistency, sensitivity, specificity and area under the curve (AUC) of the receiver operating characteristic-curve (ROC- curve) of the GFI and TFI using validated cut-off values, and to determine the optimal cut-off value in older psychiatric patients.
MethodsBaseline data of an ongoing prospective cohort study were used. In this study GFI, TFI and Fried-criteria were determined in hospitalized and non-hospitalized psychiatric patients over 65 years old.
ResultsA total of 145 participants were enrolled, 90 of which were hospitalized and 55 were non-hospitalized. Median age of participants was 75.2 (SD =7) years, 108 were female. Prevalence of frailty according to Fried-criteria was 29.7%. Internal consistency (Cronbach's alpha) of the GFI was 0.76 and TFI = 0.75. Using the validated cut-off value and the Fried- criteria as reference, sensitivity of the GFI (≥4) was 0.95 (95% CI 0.83 - 0.99) and specificity 0.27 (95%CI 0.19 - 0.37). Sensitivity of the TFI (≥5) was 0.98 (95% CI 0.86 - 1.00) and specificity 0.31 (95% CI 0.23 - 0.41). The optimum cut-off value for both the GFI and TFI was ≥8. The AUC of the ROC-curve of GFI and TFI were 0.82 (95% CI 0.75 - 0.90) and 0.79 (95% CI 0.72 - 0.87), respectively.
ConclusionWe found an acceptable internal consistency and AUC of both the GFI and the TFI in older psychiatric patients. Increasing the cut-off values of both GFI and TFI seems necessary to lower the amount of false positives in this population.
444 - A Picture is worth a thousand words! Adventure beyond the MMSE
- Hugh Fairfull-Smith
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- Published online by Cambridge University Press:
- 04 November 2020, p. 162
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Aim:
To demonstrate the clinical and diagnostic insights provided through administration of a simple pen and paper exercise as part of Geriatric assessment and what this offers to understanding cognitive impairment in our patients.
Method:A retrospective file review was conducted to select illustrative case studies of de-identified patients who presented for Geriatric assessment. Each patient had been administered a brief selection of visual tasks, in addition to the Mini-Mental State Examination (MMSE) and medical/radiological investigations required to inform diagnosis. The visual tasks of interest in this paper consisted of copying a 3D box, drawing a clock face, and drawing ‘ramparts’.
Results:Comparisons of results were made across numbers of different clinical conditions, providing qualitative insights to inform diagnosis. Results varied across different conditions, as will be demonstrated in this paper. Results on these tasks were sometimes surprising, and unrelated to verbal testing. Examples will be presented of task performances which informed diagnoses such as Posterior Cortical Atrophy.
Conclusions:The addition of these simple pen and paper tasks to the standard MMSE can help inform clinical diagnostic decisions. The low verbal demands of these tasks facilitates examination of patients with impaired language functioning. The tests are quick and repeatable, and patients are generally willing to attempt this even when they are uncooperative with further questioning. This approach adds little time commitment but can offer valuable insights, particularly into executive, visuospatial and constructional abilities.
445 - The factors associated with the presence of psychotic symptoms in the HELIAD Greek community study of older adults
- Helen-Maria Vasiliadis, Rossettos Gournelis, Vassia Efstathiou, Nikos Stefanis, Mary H. Kosmidis, Mary Yannakoulia, Efthimios Dardiotis, Georgios Hadjigeorgiou, Paraskevi Sakka, Eva Ntanasi, Ioanna Pachi, Leonidas Stefanis, Nikolaos Scarmeas
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- Published online by Cambridge University Press:
- 04 November 2020, pp. 163-164
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Background:
The prevalence and associated factors related to psychotic symptoms in older adults are understudied. The objectives were to assess the prevalence, incidence and factors associated with psychotic symptoms in a representative Greek sample of community living older adults.
Methods:This study includes older adults aged ≥ 65 years participating in the Hellenic Longitudinal Investigation of Aging and Diet. The analysis is based on n=1,904 participants with available data at baseline and n=947 participants at the 3-year follow-up. The presence of delusions and hallucinations in the past month was assessed on the grounds of the 17 symptoms of the Columbia University Scale for Psychopathology in Alzheimer's Disease and of the 14 symptoms of the Neuropsychiatric Inventory Questionnaire. An affirmative answer to any of these 31 symptoms defined the presence of psychotic symptoms. A comprehensive neuropsychological assessment for probable diagnosis of dementia and physical comorbidity was carried out by neurologists. Study factors included age, education, marital status, widowed in the past year, occupation, hearing impairment and number of chronic comorbidities. Penalized logistic regression analyses were carried out to assess the socio-demographic and clinical factors associated with the prevalence and incidence of psychotic symptoms.
Results:The past-month prevalence of any psychotic symptom was 1.9% and 1.0% when excluding cases of dementia. The prevalence of any delusion and hallucination was 1.5% and 0.7%, and 0.8% and 0.3% when excluding cases with dementia. Paranoid delusions were the most prevalent. The incidence at the follow-up of any psychotic symptom was 2.1% and 1.3% when excluding dementia. Individuals not married had twice the odds and, farmers/breeders had three times the odds than public servants/teachers/executives of experiencing psychotic symptoms. Hearing impairment and the number of comorbidities increased the odds of the presence of psychotic symptoms. In addition to age and recent widowhood, these factors remained significantly associated with the presence of psychotic symptoms in cases without dementia.
Conclusion:Dementia was not related to over half of the cases observed with psychotic symptoms. Paranoid delusions were the most prevalent. Socio-economic and health status factors are significant predictors of psychotic symptoms.
446 - Persistent Delusional Disorder (Late Paraphrenia) - An innovative and cost effective clinical model in the community by older adult‘s mental health crisis and home treatment team
- Sabarigirivasan Muthukrishnan, Kate Hydon
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- Published online by Cambridge University Press:
- 04 November 2020, pp. 165-166
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Aims
To review the various available clinical models of care delivery for patients with persistent delusional disorder (PDD) in community and economically evaluate the REACT model of safe care delivery- REACT’s Assertive and Prudent- Model of Safe Care (RAP–MoSC).
MethodsREACT (Response Enhanced Assessment Crisis and Home Treatment Team) is the only bespoke crisis and home treatment team for older adults with mental health problems in the whole of Wales available only for the residents of Cardiff and Vale of Glamorgan through Cardiff and Vale University Health Board..
It was set up on 28 February 2012. The cases of PDD in REACT service since its inception to 31 Dec 2016 were studied in relation to the assertive and prudent health care model. The economic evaluation of this service model for PDD patients was studied in detail.
Results of the studyThe RAP-MoSC model is economically effective in avoiding patients getting admitted to hospital under Mental Health Act by managing them safely in the community.
During the period between 28 February 2012 and 31 December 2016 there were 44 patients with a diagnosis of PDD in REACT’s case load. Only 3 patients got admitted to mental health assessment ward with the average length of stay period of 120 days. 41 patients were safely managed in the community with REACT with an average length of stay period of 21 days in REACT.
A PDD patient will cost NHS £21,000 if admitted to a mental health bed. If the patient is managed in the community with RAP-MoSC model of care the cost will be £1533.
REACT saved £793,548 by avoiding 41 PDD patients being admitted into hospital during an episode of delusional intensification in the period February 2012 to December 2016. PDD patients need under the RAP-MoSC model a bespoke MDT approach with better communication between secondary mental health and primary care services. Assertive and Prudent Clinical leadership is needed to sustain the RAP-MoSC in the community. Clinical reflections of this model of care will be presented in the conference.
ConclusionsOn reflection REACT found that the key points in working with PDD are;
Using a ‘foot in the door approach’
Mental health professionals introducing themselves as Health professionals
Remote prescribing