This study uses 4 years of data from the Medicare Current Beneficiary Survey to compare the use of Medicare covered services for persons who report having a diagnosis of dementia or Alzheimer disease with those who do not, adjusting for the prevalence of comorbidities and functional limitations. Although overall rates of Medicare spending are higher for demented persons, when other factors such as functional status are included in the predictive model, there is no consistent relation between the presence of dementia and higher Medicare spending. In some years, dementia was associated with higher adjusted expenditures for community living persons, whereas nursing home residents with Alzheimer disease have lower Medicare expenditures.

Alzheimer Disease↗

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What older people want from long-term care, and how they can get it.

Seniors' long-term care preferences resemble those of younger persons with disabilities, but the two groups are treated differently. Younger persons with disabilities pursue the goal of social integration, whereas safety and efficiency receive undue emphasis and ageist differences prevail in the way older persons are served. Among the changes needed to help older consumers get what they want are empowering older persons and their agents to make better decisions, including providing them with more structure and better consumer information; revising attitudes toward safety and protection; and developing more vigorous advocacy by and for seniors.

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The challenge of providing comprehensive care to the elderly.

Explore the source record for details and available documents.

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Integrating an outcomes information system into managed care for substance abuse.

The following paper describes a program launched recently to combine the efforts of two very different sectors of the outcomes management field--a managed behavioral healthcare company and a research-oriented academic center--and to pragmatically integrate outcomes data collection into routine clinical assessment and treatment processes in the substance abuse treatment field. This program has important implications not only for the behavioral healthcare industry's ability to satisfy external demands for outcomes data, but also as a foundation for better internal management and quality improvement processes.

Ambulatory Care Information Systems↗

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Community based services key to effectiveness of Canadian long-term care.

Explore the source record for details and available documents.

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The cost effectiveness of post-acute care for elderly Medicare beneficiaries.

This study used a novel method to examine the cost effectiveness of post-acute care (PAC) in different settings. The analysis found that home health care was more cost effective than PAC in skilled nursing facilities (SNFs) or rehabilitation facilities. The cost effectiveness for home health care was also more favorable relative to being home without formal care. Post-acute care in SNFs was not cost effective compared to being home without formal care. The cost-effectiveness analysis showed mixed support for PAC in rehabilitation facilities. These results, and the use of cost-effectiveness analysis in general, provide a basis for a more efficient Medicare reimbursement system for PAC.

Aftercare↗

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Evaluation of neuroleptic drug use by nursing home elderly under proposed Medicare and Medicaid regulations.

Federal regulations for use of neuroleptic drugs in Medicare- and Medicaid-certified nursing homes throughout the United States were implemented October 1, 1990. These regulations constitute the first time that prescription drugs are required, by law, to be justified by indications documented in the medical chart. This study used extant data to estimate ineligible neuroleptic use at the individual and nursing home levels had these regulations been in effect in 1976 through 1985. Subjects, randomly sampled admissions (N = 5752) and residents (N = 3191), were followed up for up to 24 months in 60 nursing homes. One half of neuroleptic use in each cohort could be considered ineligible under the regulations; all but one of the nursing homes had one or more individuals who were treated with the ineligible use of neuroleptics. Improvements in documentation and/or prescription of neuroleptic drugs for nursing home elderly will be needed to ensure compliance with these new regulations.

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Career paths of geriatric nurse practitioners employed in nursing homes.

The career paths of geriatric nurse practitioners (GNPs) trained with support from the W. K. Kellogg Foundation through the Mountain States Health Corporation (MSHC) were studied. Under this program, GNPs were recruited from sponsoring nursing homes and returned to GNP positions in the sponsoring facilities following training. Training was carried out under a continuing education model offered through six university-based schools of nursing. Questionnaires were sent to the 111 GNPs trained. Of the 102 respondents, 97 provided complete information about past and present education, work experience, and job functions. The GNPs were women with a median age of 45 years, and they were employed in rural settings in the western United States. More than 45 percent of the nurses had at least a baccalaureate degree at the time of GNP training. The GNPs remained employed in long-term care positions that implemented the practitioner role. The median length of GNP employment in their first jobs after training was more than 4.5 years. The resignation rate from this first position was 1.66 resignations for each 10 years of GNP employment. Job changes were likely to be attributed to organizational changes with subsequent positions shifting toward a diversification of the GNP role. The study demonstrates the success of the MSHC program in introducing and retaining GNPs in nursing homes.

Career Mobility↗

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Dynamic assessment of cognitive and cardiovascular performance in the elderly.

Dynamic measures of cardiovascular and cognitive performance have been used as a preliminary step toward developing predictors of decline in functional performance in older persons. Both batteries use multiple measures to examine the cooperativity of various aspects of performance, and both examine the subject's response to naturally occurring stresses. In these two senses, the measures are dynamic. For the cardiovascular measure we conducted ambulatory monitoring of blood pressure and pulse at 7.5-min intervals over a 24-h period. These parameters were analyzed simultaneously to examine changes in one relative to the others, using spectroscopy. After appropriate filtering, several dominant ultradian rhythms were noted, with periods of 47 min, 180 min and 6 to 8 h, the latter rhythm being present only in subjects aged greater than or equal to 60. A battery of computer-administered cognitive tests was developed to assess reaction time, visual recognition memory and word recognition memory. This testing allows for both a time and performance level grading. The results of the computer battery correspond well with those for standard neuropsychological tests. In general, performance declined with age, and reaction time increased. The computerized tests are faster, more consistently administered, and do not rely on a skilled professional for administration or analysis. They also provide a wide variety of measures that can be used in isolating components of performance. Once the acceptability and tolerance of older subjects toward such testing was established, attention shifted to questions of measurement stability and discriminant validity. Since the project's primary purpose is to predict subtle measures of decline in function, the battery's ultimate test is in its ability to correctly identify those about to change functional status. However, many different measures of status change are possible, and the predictive accuracy will depend on the outcome chosen. Subsequent work will focus on the predictors to refine measures and compare data collected at one point in time with the predictive power of change scores that reflect the individual subject's "signature." By-products of this work include a wealth of longitudinal physiologic and neuropsychologic data on older persons and tools that may be useful to the practicing physician.

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