***TASK*** the task is to summarize an input biomedical literature in six sentences 
    ***INPUT*** the input is a biomedical literature 
    ***OUTPUT*** the output is the summary of an input biomedical literature in six sentences 
    ***DOCUMENTATION*** 
    ***EXAMPLES*** 
    Input: OBJECTIVES There is a lack of large-scale , nationwide data describing clinical characteristics and quality of dying of nursing home residents dying with dementia . We set out to investigate quality of end-of-life care and quality of dying of nursing home residents with dementia in Fl and ers , Belgium . DESIGN / SETTING / PARTICIPANTS To obtain representativity , we conducted a postmortem study ( 2010 ) using r and om cluster sampling . In selected nursing homes , all deceased residents with dementia in a period of 3 months were reported . For each case , a structured question naire was filled in by the nurse most involved in care , the family physician , and the nursing home administrator . We used the Cognitive Performance Scale and Global Deterioration Scale to assess dementia . Main outcome measures were health status , clinical complications , symptoms at the end of life , and quality of dying . MEASUREMENTS Health status , clinical complications , symptoms at the end of life , and quality of dying . RESULTS We identified 198 deceased residents with dementia in 69 nursing homes ( 58 % response rate ) . Age distribution was the same as all deceased residents with dementia in Fl and ers , 2010 . Fifty-four percent had advanced dementia . In the last month of life , 95.5 % had 1 or more sentinel events ( eg , eating/drinking problems , febrile episodes , or pneumonia ) ; most frequently reported symptoms were pain , fear , anxiety , agitation , and resistance to care . In the last week , difficulty swallowing and pain were reported most frequently . Pressure sores were present in 26.9 % , incontinence in 89.2 % , and cachexia in 45.8 % .  Physical restraints  were used in 21.4 % of cases , and 10.0 % died outside the home . Comparing stages of dementia revealed few differences between groups regarding clinical complications , symptoms , or quality of dying . CONCLUSION Regardless of the dementia stage , many nursing home residents develop serious clinical complications and symptoms in the last phase of life , posing major challenges to the provision of optimum end-of-life care CONTEXT Most older adults with dementia will be cared for by primary care physicians , but the primary care practice environment presents important challenges to providing quality care . OBJECTIVE To test the effectiveness of a collaborative care model to improve the quality of care for patients with Alzheimer disease . DESIGN , SETTING , AND PATIENTS Controlled clinical trial of 153 older adults with Alzheimer disease and their caregivers who were r and omized by physician to receive collaborative care management ( n = 84 ) or augmented usual care ( n = 69 ) at primary care practice s within 2 US university-affiliated health care systems from January 2002 through August 2004 . Eligible patients ( identified via screening or medical record ) met diagnostic criteria for Alzheimer disease and had a self-identified caregiver . INTERVENTION Intervention patients received 1 year of care management by an interdisciplinary team led by an advanced practice nurse working with the patient 's family caregiver and integrated within primary care . The team used st and ard protocol s to initiate treatment and identify , monitor , and treat behavioral and psychological symptoms of dementia , stressing nonpharmacological management . MAIN OUTCOME MEASURES Neuropsychiatric Inventory ( NPI ) administered at baseline and at 6 , 12 , and 18 months . Secondary outcomes included the Cornell Scale for Depression in Dementia ( CSDD ) , cognition , activities of daily living , re source use , and caregiver 's depression severity . RESULTS Initiated by caregivers ' reports , 89 % of intervention patients triggered at least 1 protocol for behavioral and psychological symptoms of dementia with a mean of 4 per patient from a total of 8 possible protocol s. Intervention patients were more likely to receive  cholinesterase inhibitors  ( 79.8 % vs 55.1 % ; P = .002 ) and  antidepressants  ( 45.2 % vs 27.5 % ; P = .03 ) . Intervention patients had significantly fewer behavioral and psychological symptoms of dementia as measured by the total NPI score at 12 months ( mean difference , -5.6 ; P = .01 ) and at 18 months ( mean difference , -5.4 ; P = .01 ) . Intervention caregivers also reported significant improvements in distress as measured by the caregiver NPI at 12 months ; at 18 months , caregivers showed improvement in depression as measured by the Patient Health Question naire-9 . No group differences were found on the CSDD , cognition , activities of daily living , or on rates of hospitalization , nursing home placement , or death . CONCLUSIONS Collaborative care for the treatment of Alzheimer disease result ed in significant improvement in the quality of care and in behavioral and psychological symptoms of dementia among primary care patients and their caregivers . These improvements were achieved without significantly increasing the use of antipsychotics or sedative-hypnotics . TRIAL REGISTRATION clinical trials.gov Identifier : NCT00246896 Background Advance care planning is considered a central component of good quality palliative care and especially relevant for people who lose the capacity to make decisions at the end of life , which is the case for many nursing home residents with dementia . We set out to investigate to what extent ( 1 ) advance care planning in the form of written advance patient directives and verbal communication with patient and /or relatives about future care and ( 2 ) the existence of written advance general practitioner orders are related to the quality of dying of nursing home residents with dementia . Methods Cross-sectional study of deaths ( 2010 ) using r and om cluster-sampling . Representative sample of nursing homes in Fl and ers , Belgium . Deaths of residents with dementia in a three-month period were reported ; for each the nurse most involved in care , GP and closest relative completed structured question naires . Findings We identified 101 deaths of residents with dementia in 69 nursing homes ( 58 % response rate ) . A written advance patient directive was present for 17.5 % , GP-orders for 56.7 % . Controlling for socio-demographic/ clinical characteristics in multivariate regression analyses , chances of having a higher mean rating of emotional well-being ( less fear and anxiety ) on the Comfort Assessment in Dying with Dementia scale were three times higher with a written advance patient directive and more specifically when having a do-not-resuscitate order ( AOR 3.45 ; CI,1.1–11 ) than for those without either ( AOR 2.99 ; CI,1.1–8.3 ) . We found no association between verbal communication or having a GP order and quality of dying . Conclusion For nursing home residents with dementia there is a strong association between having a written advance directive and quality of dying . Where wishes are written , relatives report lower levels of emotional distress at the end of life . These results underpin the importance of advance care planning for people with dementia and beginning this process as early as possible OBJECTIVES To determine whether community care of people with dementia can be prolonged with a 2-year multicomponent intervention program and to analyze effects of the intervention on total usage and expenses of social and healthcare services . DESIGN R and omized controlled trial . SETTING Community-dwelling couples with one spouse caring for the other spouse with dementia . PARTICIPANTS Couples with dementia ( N=125 ) were allocated at r and om to the intervention ( n=63 ) or control group ( n=62 ) . INTERVENTION Intervention couples were provided with a multicomponent intervention program with a family care coordinator , a geriatrician , support groups for caregivers , and individualized services . MEASUREMENTS Time from enrollment to institutionalization of spouses with dementia and use of services and service expenditure of couples . RESULTS At 1.6 years , a larger proportion in the control group than in the intervention group was in long-term institutional care ( 25.8 % vs 11.1 % , P=.03 ) . At 2 years , the difference was no longer statistically significant . The 2-year adjusted hazard ratio for the intervention group was 0.53 ( 95 % confidence interval (CI)=0.23 - 1.19 , P=.12 ) . Intervention led to reduction in use of community services and expenditures . The difference for the benefit of intervention group was -7,985 Euro ( 95 % CI=-16,081 to -1,499 , P=.03 ) . When the intervention costs were included , the differences between the groups were not significant . CONCLUSION Although the intervention did not result in a significant difference in the need for institutional care after 2 years , individualizing services in collaboration with families may lead to reduction in use of and expenditures on municipal services OBJECTIVES To assess whether a dementia care coordination intervention delays time to transition from home and reduces unmet needs in elders with memory disorders . DESIGN 18-month r and omized controlled trial of 303 community-living elders . SETTING 28 postal code areas of Baltimore , MD . PARTICIPANTS Age 70 + years , with a cognitive disorder , community-living , English-speaking , and having a study partner available . INTERVENTION 18-month care coordination intervention to systematic ally identify and address dementia-related care needs through individualized care planning ; referral and linkage to services ; provision of dementia education and skill-building strategies ; and care monitoring by an interdisciplinary team . MEASUREMENTS Primary outcomes were time to transfer from home and total percent of unmet care needs at 18 months . RESULTS Intervention participants had a significant delay in time to all-cause transition from home and the adjusted hazard of leaving the home was decreased by 37 % ( Hazard ratio : 0.63 , 95 % Confidence Interval : 0.42 - 0.94 ) compared with control participants . Although there was no significant group difference in reduction of total percent of unmet needs from baseline to 18 months , the intervention group had significant reductions in the proportion of unmet needs in safety and legal/advance care domains relative to controls . Intervention participants had a significant improvement in self-reported quality of life ( QOL ) relative to control participants . No group differences were found in proxy-rated QOL , neuropsychiatric symptoms , or depression . CONCLUSIONS A home-based dementia care coordination intervention delivered by non- clinical community workers trained and overseen by geriatric clinicians led to delays in transition from home , reduced unmet needs , and improved self-reported QOL PURPOSE This demonstration evaluates the effects of integrating  Alzheimer 's Association care consultation service with health care services offered by a large managed care system . The primary hypothesis is that Association care consultation will decrease service utilization , increase satisfaction with managed care , and decrease caregiver depression and care-related strain . Secondary modifying-effects hypotheses posit that the effects of the intervention will be intensified when patients have not received a firm dementia diagnosis , patients have more severe memory problems , caregivers use other Association services in t and em with care consultation , and caregivers are not patients ' spouses . DESIGN AND METHODS The demonstration is a r and omized trial that examines outcomes after a 12-month study period . Interview data from 157 primary family caregivers are combined with data abstract ed from medical/administrative records . RESULTS Support for the primary hypothesis is found for selected , but not all , service utilization outcomes and for caregiver depression . Support for secondary modifying-effects hypotheses is found for satisfaction outcomes and care-related strain outcomes . IMPLICATION S Care consultation delivered within a partnership between a managed care health system and an Alzheimer 's Association is a promising strategy for improving selected outcomes for patients with dementia and their caregivers Objectives We report the use of difference in differences ( DiD ) methodology to evaluate a complex , system-wide healthcare intervention . We use the worked example of evaluating the  Marie Curie Delivering Choice Programme ( DCP ) for advanced illness in a large urban healthcare economy . Methods DiD was selected because a r and omised controlled trial was not feasible . The method allows for before and after comparison of changes that occur in an intervention site with a matched control site . This enables analysts to control for the effect of the intervention in the absence of a local control . Any policy , seasonal or other confounding effects over the test period are assumed to have occurred in a balanced way at both sites . Data were obtained from primary care trusts . Outcomes were place of death , inpatient admissions , length of stay and costs . Results Small changes were identified between pre- and post-DCP outputs in the intervention site . The proportion of home deaths and median cost increased slightly , while the number of admissions per patient and the average length of stay per admission decreased slightly . None of these changes was statistically significant . Conclusions Effects estimates were limited by small numbers accessing new services and selection bias in sample population and comparator site . In evaluating the effect of a complex healthcare intervention , the choice of analysis method and output measures is crucial . Alternatives to r and omised controlled trials may be required for evaluating large scale complex interventions and the DiD approach is suitable , subject to careful selection of measured outputs and control population Objective : The primary objective is to report on the efficacy of an individualized dementia care consultation intervention for family caregivers of patients with diagnosed dementia living in the community . The secondary objective is to present evidence on the intervention process to inform the feasibility and sustainability of the model featuring collaboration between primary care physicians and a voluntary sector organization . Method : R and omization was based on primary care physician practice site . In the intervention group , dementia care consultants located at an Alzheimer 's association chapter  provided individualized counseling and support over a 12-month period , and sent copies of care plans developed with family caregivers to referring primary care physicians . In the control group , family caregivers received educational and community re source information but no care consultation . Nursing home admission of 
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Overall reported benefits were mixed .
Conclusions Quality statements relevant to EOL care are useful to advance practice however they have a limited evidence base .