Bartley, Mairead M.

Context: Early palliative care can improve end-of-life outcomes, but referrals to palliative care specialists can be delayed in the primary care setting. Objective: This pilot study assessed the effect of a machine-learning algorithm on time to palliative care in a primary care population. Methods: Patients (aged ≥18 years) were eligible if they were empaneled with a primary care provider (PCP) from July 20, 2020, through May 30, 2021. The algorithm evaluated their health records and presented patients who were predicted to have the greatest need for palliative care. Records were then reviewed by palliative care specialists, and patients were randomized in a stepped-wedge fashion to have a referral notification sent to their PCPs if unmet palliative care needs were verified. Time-to-event outcomes were evaluated with Poisson regression models. Results: Of the 127,080 patients evaluated, 934 had their health records presented for review. Some patients were repeatedly presented by the algorithm (total presentations: 1592). In the intervention arm, PCPs were prompted to order a palliative care consultation for 142 patients. The time to 0.1% of the population receiving a palliative care consultation was 60.9 days for the intervention arm versus 71.8 days for the control arm (probability of a shorter time with the intervention, 0.88). Conclusion: A machine-learning algorithm to identify palliative care needs was successfully integrated into a primary care practice. More work is needed to improve the workflow.

Introduction People most likely to be affected by Alzheimer’s disease and related dementias (ADRD) are underrepresented in clinical research. Identifying and addressing factors which may influence their research participation is important to advance science and promote diversity. We examined the influence of social determinants of health (SDOH) on research participation among people living with ADRD. Methods We included those age 55 years and older living with ADRD, followed in our community practice in Rochester, Minnesota, who completed a questionnaire assessing SDOH and had at least one clinic visit between June 1, 2019 and June 1, 2020. Demographic and SDOH factors were examined by research participation. Results Among 3273 people included, research participation was low overall (265/3273; 8.1%). People participating in research were more likely to be socially integrated and of higher educational attainment (p < 0.05). Conclusion Promoting social interaction is a potential area for focus to increase research participation in at risk populations.

People living with dementia have high rates of hospitalizations. Identifying factors that influence hospitalization is important. This study examines the influence of physical activity levels on risk of hospitalization and emergency department (ED) use among older people living with mild cognitive impairment (MCI) or dementia followed in our primary care practice in Rochester, Minnesota, United States. We included those age 55 years and older, who had a clinic visit between June 1, 2019 and June 30, 2021 and completed a social determinants of health questionnaire about physical activity levels ( n = 3090). Physical activity was classified as sufficiently active, insufficiently active, or physically inactive. Risk of hospitalization and ED visits by physical activity levels were examined. People who were physically inactive were at higher risk of hospitalization and ED visits ( p < .001) compared with those who were sufficiently active. This highlights an area for health promotion in people living with MCI and dementia.

Abstract Background and Objectives Social isolation is commonly experienced by older people and is associated with adverse health outcomes. Little is known about the influence of social isolation on the risk of acute care utilization among people living with mild cognitive impairment (MCI) or dementia. Our objective was to investigate the impact of social isolation on the risk of death, hospitalization, and emergency department (ED) use among people living with MCI or dementia who are followed in our Community Internal Medicine practice at Mayo Clinic, Rochester, Minnesota. Research Design and Methods We included people living with MCI or dementia, 55 years and older, who had a clinic visit between June 1, 2019, and June 30, 2021, and who had completed questions about social connections. The risk of death, hospitalization, and ED use was examined by levels of social connection (socially isolated, moderately isolated, moderately integrated, or socially integrated). Results Of 2,320 people included (1,010 with MCI and 1,310 with dementia), 455 (19.6%) were classified as socially isolated and 591 (25.5%) were moderately isolated. Compared with those who were socially integrated, people who were socially isolated were at higher risk of death, hospitalization, and ED visits (p &lt; .001). Discussion and Implications Social isolation is associated with an increased risk of acute health care utilization and death in people living with MCI or dementia. Interventions to address social isolation in this population are needed.

AbstractBackgroundPhysical activity can improve the physical health of people living with mild cognitive impairment (MCI) and dementia and may have cognitive benefits. Identifying modifiable social factors inhibiting physical activity among this group is important. We examined the relationship between reported physical activity levels and social determinants of health (SDOH) in a population of older adults living with MCI or dementia.MethodWe included people with a diagnosis of MCI or dementia, age 55 years and older, who were empaneled to Community Internal Medicine at Mayo Clinic (Rochester, Minnesota), had a clinic visit between June 1, 2019 and June 30, 2021 and had completed a SDOH questionnaire. We focused on 8 SDOH domains: education, depression, alcohol use, stress, financial resource strain, social connections, food insecurity and transportation needs. Self‐reported activity levels were categorized as inactive (0 minutes of exercise per week), insufficiently active (10‐140 minutes per week) or sufficiently active (≥150 minutes per week). SDOH domains were compared according to physical activity level using χ2 tests and multinomial logistic regression.ResultA total of 3224 persons with MCI (n = 1371) or dementia (n = 1853) who had completed questions on physical activity were included. Of these, 1936 (60%) were characterized as physically inactive and 837 (26%) insufficiently active. Characteristics associated with an increased likelihood of physical inactivity were older age, female sex, obesity, lower education, dementia diagnosis, depression risk and increased social isolation (all p<0.001).ConclusionPhysical inactivity is common among people living with MCI and dementia. Physical activity levels may be influenced by many modifiable factors, highlighting potential areas for intervention in this population.

Abstract Objectives People with dementia often have high care needs at end of life. We compared care delivery in the last year of life for people living with dementia in the community (home/assisted living facilities, ALF) to those in skilled nursing facilities (SNF). Methods This was a retrospective study of people who died with a diagnosis of dementia in the community compared with SNF between 2013 and 2018. Primary outcomes of hospitalizations/ED visits in the last year of life were measured. Secondary outcomes included advance care planning (ACP) completion, hospice enrollment, provider visits and ICU admissions. Results Of 1203 people with dementia, 581 (48.3%) were living in a SNF and 622 (51.7%) in the home/ALF. At least one hospitalization was recorded for 70.7% in the home/ALF compared with 50.8% in the SNF (p&lt; 0.01), similar to ED visits (80.2% versus 58% in home/ALF and SNF groups, respectively, p&lt; 0.01). People in the SNF had more provider visits (median 9 (IQR 6, 12) compared with 5 (IQR 3,9) in the home/ALF group (p&lt; 0.01). There was no ACP for 12% of those in the home/ALF, compared with 4.6% in the SNF(p&lt; 0.01). Approximately half (56.5%) in the SNF were enrolled in hospice compared with 68.3% in the home/ALF group (p&lt; 0.01), Median time in hospice was 26.5 days in the SNF versus 30 days in the home/ALF (p=0.67). Conclusions People living with dementia have frequent acute care utilization in the last year of life. Hospice care was more common in the home/ALF. Time in hospice was short.

Objective People living with dementia often have high care needs at the end-of-life. We compared care delivery in the last year of life for people living with dementia in the community (home or assisted living facilities [ALFs]) versus those in skilled nursing facilities (SNFs). Methods A retrospective study was performed of older adults with a dementia diagnosis who died in the community or SNFs from 2013 through 2018. Primary outcomes were numbers of hospitalizations and emergency department visits in the last year of life. Secondary outcomes were completed advance care plans, hospice enrollment, time in hospice, practitioner visits, and intensive care unit admissions. Results Of 1203 older adults with dementia, 622 (51.7%) lived at home/ALFs; 581 (48.3%) lived in SNFs. At least 1 hospitalization was recorded for 70.7% living at home/ALFs versus 50.8% in SNFs ( P < .001), similar to percentages of emergency department visits (80.2% vs 58.0% of the home/ALF and SNF groups, P < .001). SNF residents had more practitioner visits than home/ALF residents: median (IQR), 9.0 (6.0-12.0) versus 5.0 (3.0-9.0; P < .001). No advance care plan was documented for 12.2% (n = 76) of the home/ALF group versus 4.6% (n = 27) of the SNF group ( P < .001). Nearly 57% of SNF residents were enrolled in hospice versus 68.3% at home/ALFs ( P < .001). The median time in hospice was 26.5 days in SNFs versus 30.0 days at home/ALFs ( P = .67). Conclusions Older adults with dementia frequently receive acute care in their last year of life. Hospice care was more common for home/ALF residents. Time in hospice was short.

Objectives To investigate the timing (mid‐ vs late life) of physical activity, apolipoprotein ( APO )E ε 4, and risk of incident mild cognitive impairment ( MCI ). Design Prospective cohort study. Setting Mayo Clinic Study of Aging (Olmsted County, MN ). Participants Cognitively normal elderly adults (N = 1,830, median age 78, 50.2% female). Measurements Light, moderate, and vigorous physical activities in mid‐ and late life were assessed using a validated questionnaire. An expert consensus panel measured MCI based on published criteria. Cox proportional hazards models were used to calculate hazard ratios ( HR s) and 95% confidence intervals ( CI s) with age as a time scale after adjusting for sex, education, medical comorbidity, and depression. Results Light ( HR = 0.58, 95% CI = 0.43–0.79) and vigorous ( HR = 0.78, 95% CI = 0.63–0.97) physical activity in midlife were associated with lower risk of incident MCI . The association between moderate activity and incident MCI was not significant ( HR = 0.85, 95% CI = 0.67–1.09). In late life, light ( HR = 0.75, 95% CI = 0.58–0.97) and moderate ( HR = 0.81, 95% CI = 0.66–0.99) but not vigorous physical activity were associated with lower risk of incident MCI . A synergistic interaction was also observed between mid‐ and late‐life activity in reducing risk of incident MCI . Furthermore, APOE ε 4 carriers who did not exercise had a higher risk of incident MCI than noncarriers who reported physical activity. Conclusion Physical activity reduced the risk of incident MCI . Exercising in mid‐ and late life had an additive synergistic interaction in reducing the risk of MCI .