Health affairs
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The number of older adults with cognitive impairment is increasing, and such adults often require a surrogate to make decisions about health care. However, little is known about the aggressiveness of end-of-life care for these people, especially those who reside in the community. ⋯ In contrast, advance directives were not associated with differences in care for people with normal cognition or mild dementia, whether they resided in the community or in a nursing home. Timely advance care planning after a diagnosis of cognitive impairment may be particularly important for older adults who reside in the community.
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Alzheimer's disease confronts us with an ethical challenge: How do we live with dignity and quality of life in the face of progressive disability and, ultimately, death? Patients' cognitive and decision-making impairments often make them unable to answer this question, and when professionals who provide services for older adults fail to recognize and accommodate these impairments, patients suffer. Patients and their caregivers need a health care system that fosters caregiving so that each will live with dignity and well-being. Another way to answer this question is to discover treatments that prevent disabling cognitive impairments, but this strategy will require expanding the Alzheimer's label to include people who do not have dementia or who are even cognitively normal. Controversies are likely to occur over how best to describe the Alzheimer's problem, measure the value of early diagnosis and treatment, and live with a brain at risk.
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North Dakota's state-funded Dementia Care Services Program provides individualized assistance to caregivers of persons with dementia. Caregivers can contact program representatives at any time and may continue to contact them throughout the years they are caring for the person with dementia. During the program's first forty-two months of operation (January 2010 to June 2013), care consultants assisted 1,750 caregivers, primarily family members, of 951 persons with dementia. ⋯ The program's estimated potential savings were $39.2 million from delayed long-term care placement and $0.8 million from reduced use of medical services, and its two-year costs were $1.2 million. The program's success with its rural service population, for which travel tends to be difficult and resources limited, provides a model for others to adapt. It also encourages further research on impacts of individualized support programs on persons with dementia and their caregivers.