Patient and Caregiver characteristics and nursing home placement in patients with dementia
Patient and Caregiver characteristics and nursing home placement in patients with dementia
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DOI：
10.1001/jama.287.16.2090
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发表时间：
2002-04-24
影响因子：
120.7
通讯作者：
Covinsky, KE
中科院分区：
文献类型：
--
作者：
Yaffe, K;Fox, P;Covinsky, KE
背景
将痴呆患者送进养老院的决定是复杂的，它基于患者和照顾者的特征以及患者和照顾者的社会文化背景。大多数研究主要仅根据患者或照顾者的特征来确定养老院安置的预测因素。
目的
开发并验证一种预后模型，以确定不同种族的痴呆患者群体中安置的综合预测因素。
设计、地点和参与者
医疗保险阿尔茨海默病示范与评估研究，这是一项在美国8个地点进行的前瞻性研究，在1989年12月至1994年12月期间招募了5788名患有晚期痴呆的社区居住者。
主要观察指标
在36个月的随访期内进入养老院的时间，通过访谈和医疗保险记录审查进行评估，以及它与在招募时通过访谈获得的患者和照顾者特征的关联。
结果
患者被分为开发队列（n = 3859）和验证队列（n = 1929）。在开发队列中，1年、2年和3年时进入养老院的卡普兰 - 迈耶估计值分别为22%、40%和52%。经过多变量调整后，与进入养老院相关的患者特征如下：黑人种族（风险比，0.60；95%置信区间[CI]，0.48 - 0.74），西班牙裔种族（HR，0.40；95% CI，0.28 - 0.56）（这两个种族与安置呈负相关），独居（HR，1.74；95% CI，1.49 - 2.02），1项或多项日常生活活动依赖（HR，1.38；95% CI，1.20 - 1.60），高度认知障碍（对于简易精神状态检查表评分小于或等于20：HR，1.52；95% CI，1.33 - 1.73），以及1项或多项不良行为（HR，1.30；95% CI，1.11 - 1.52）。与患者安置相关的照顾者特征为年龄65 - 74岁（HR，1.17；95% CI，1.01 - 1.37），年龄75岁及以上（HR，1.55；95% CI，1.31 - 1.84），以及高扎里特负担量表评分（对于最高四分位数：HR，1.73；95% CI，1.49 - 2.00）。根据该模型将患者分为风险四分位数。在开发队列中，第一、第二、第三和第四四分位数的患者在3年时进入养老院的比率分别为25%、42%、64%和91%。在验证队列中，相应的比率分别为21%、50%、64%和89%。3年进入养老院的C统计量在开发队列中为0.66，在验证队列中为0.63。
结论
患者和照顾者的特征都是痴呆患者长期护理安置的重要决定因素。旨在延迟安置的干预措施，如减轻照顾者负担或改善患者不良行为，需要将患者和照顾者作为一个整体来考虑。
Context The decision to institutionalize a patient with dementia is complex and is based on patient and caregiver characteristics and the sociocultural context of patients and caregivers. Most studies have determined predictors of nursing home placement primarily according to patient or caregiver characteristics alone.Objective To develop and validate a prognostic model to determine the comprehensive predictors of placement among an ethnically diverse population of patients with dementia.Design, Setting, and Participants The Medicare Alzheimer's Disease Demonstration and Evaluation study, a prospective study at 8 sites in the United States, with enrollment between December 1989 and December 1994 of 5788 community-living persons with advanced dementia.Main Outcome Measures Time to nursing home placement throughout a 36-month follow-up period, assessed by interview and review of Medicare records, and its association with patient and caregiver characteristics, obtained by interview at enrollment.Results Patients were divided into a development (n=3859) and validation (n=1929) cohort. In the development cohort, the Kaplan-Meier estimates of nursing home placement throughout 1, 2, and 3 years were 22%, 40%, and 52%, respectively. After multivariate adjustment, patient characteristics that were associated with nursing home placement were as follows: black ethnicity (hazard ratio, 0.60; 95% confidence interval [CI], 0.48-0.74), Hispanic ethnicity (HR, 0.40; 95% Cl, 0.28-0.56) (both ethnicities were inversely associated with placement), living alone (HR, 1.74; 95% Cl, 1.49-2.02), 1 or more dependencies in activities of daily living (HR, 1.38; 95% Cl, 1.20-1.60), high cognitive impairment (for Mini-Mental Status Examination score less than or equal to20: HR, 1.52; 95% Cl, 1.33-1.73), and 1 or more difficult behaviors (HR, 1.30; 95% Cl, 1.11-1.52). Caregiver characteristics associated with patient placement were age 65 to 74 years (HR, 1.17; 95% Cl, 1.01-1.37), age 75 years or older (HR, 1.55; 95% Cl, 1.31-1.84), and high Zarit Burden Scale score (for highest quartile: HR, 1.73; 95% Cl, 1.49-2.00). Patients were assigned to quartiles of risk based on this model. In the development cohort, patients in the first, second, third, and fourth quartile had a 25%, 42%, 64%, and 91% rate of nursing home placement at 3 years, respectively. In the validation cohort, the respective rates were 21%, 50%, 64%, and 89%. The C statistic for 3-year nursing home placement was 0.66 in the development cohort and 0.63 in the validation cohort.Conclusions Patient and caregiver characteristics are both important determinants of long-term care placement for patients with dementia. Interventions directed at delaying placement, such as reduction of caregiver burden or difficult patient behaviors, need to take into account the patient and caregiver as a unit.