- Email: [email protected]
P4-199
Poster P4:: Wednesday Posters chotic, 49 (14%) two and 5 (1%) three. Mean duration at baseline of antipsychotic utilization was 7.9 months. Risperidone was the most frequently prescribed antipsychotic (26% of patients), followed by promazine (25%), olanzapine (14%) and haloperidol (11%). In 40% of the cases, another hypnotic or sedative drug was simultaneously administered. Antipsychotic drug utilization was significantly associated with female sex, older age and higher NPI score. BPSD significantly associated with antipsychotic use were in order agitation, aberrant motor behavior, irritability/ lability, night-time behavior, and delusions. Though the number of patients studied was relatively small to sensitively detect infrequent adverse reactions, antipsychotic exposure did not significantly influence mortality, hospitalization, falls or use of physical restraint at follow-up. Conclusions: These results raise concern about the current use of antipsychotics and stress the need for a rational management and pharmacological treatment of BPSD. P4-199
EVALUATING PROCESS OF CARE, QUALITY INDICATORS IN AMBULATORY DEMENTIA CARE
Daniel L. Murman1, Jennifer Elston Lafata2, Elizabeth Dobie2, George Divine2, 1Univ. of Nebraska Med. Center, Omaha, NE, USA; 2 Henry Ford Health System, Detroit, MI, USA. Contact e-mail: [email protected] Background: We derived 18 ambulatory care, process quality indicators using evidence-based recommendations from the American Academy of Neurology and the Assessing Care of Vulnerable Elders (ACOVE) project. Objective: To examine how often insured patients of an integrated delivery system received recommended dementia care, and to look for evidence of disparities in ambulatory dementia care quality based on age, gender, and race. Methods: All patients of the integrated delivery system were identified who had at least one encounter with an ICD-9 code for dementia, were age 50 and older, and who had continuous health plan coverage including prescription drugs for the two years ending January, 2005. We used automated administrative and clinical data, including pharmacy claims, combined with responses from a mailed caregiver’s survey to evaluate the 18 process quality indicators. We used generalized estimating equations (GEE) to adjust for clustering effects based upon the provider and to adjust for covariates in multivariable analyses. Results: 351 patients were identified as study eligible, 180 (51%) of which had completed caregiver surveys returned. Patients with surveys differed significantly (p⬍0.05) from those without on demographic variables, but not on recommended care processes. Recommended care related to dementia diagnosis and psychosocial support occurred in 53% to 80% of patients. Seventy-eight percent of patients had filled a prescription for a cholinesterase inhibitor, but only 34% had evidence of persistent treatment. We did not find significant disparities in ambulatory dementia care quality based upon age or race in multivariable models that adjusted for education, marital status, income, Charleston Co-morbidity Index score, and Dementia Severity Rating Scale score. However, in multivariable models women were significantly (p⬍0.05) more likely to be dispensed an antidepressant medication, more likely to be dispensed an anti-cholinergic medication, and significantly less likely to have evidence of persistent cholinesterase inhibitor use. Conclusion: There is substantial room for improvement in providing recommended dementia care in the ambulatory care setting. The results of this study, including the disparities identified, can be used to better understand barriers to delivering quality dementia care and to target quality improvement efforts in healthcare systems. P4-200
THE PSYCHOLOGICAL IMPACT OF SUSCEPTIBILITY VERSUS DETERMINISTIC GENETIC TESTING FOR ALZHEIMER’S DISEASE
J. Scott Roberts1, Michael Cassidy1, Thomas D. Bird2, Ellen J. Steinbart2, Erin Linnenbringer1, Robert C. Green1, 1Boston
S575
University School of Medicine, Boston, MA, USA; 2University of Washington Medical School, Seattle, WA, USA. Background: Several genetic markers have been identified that confer risk for Alzheimer disease (AD) and related dementias. Some are rare genetic mutations (e.g., the presenilins) that almost inevitably result in AD, while the apolipoprotein E (APOE) ⑀4 allele is a common susceptibility polymorphism that increases risk but is neither necessary nor sufficient to cause AD. The psychological impact of genotype disclosure for these two types of genetic information has not been compared. Objective: To compare the psychological impact of susceptibility versus deterministic genetic testing among asymptomatic first-degree relatives of people with AD. Methods: Data were compared from two distinct protocols. The first was a multisite, randomized clinical trial in which 101 first-degree relatives of AD patients received APOE genotype disclosure. In a separate protocol, 22 individuals at risk for familial AD or frontotemporal dementia were disclosed presenilin 1, presenilin 2, or tau genotype. In both protocols, participants received genetic counseling and completed follow-up measures of testspecific distress (Impact of Event Scale, IES). Regression analyses assessed the effects of test result (positive vs. negative) and type of genetic testing (deterministic vs. susceptibility) on IES scores at one year (or closest timepoint), controlling for age and gender. Results: Participants who received gene-positive results from deterministic testing experienced similar levels of distress compared to those learning that they were APOE ⑀4⫹ (p⫽ 0.78). APOE ⑀4⫹ individuals experienced greater distress than those who tested ⑀4- (p⫽ 0.04); however, those who received positive results in the deterministic testing protocol did not experience significantly higher levels of distress as compared to those who received negative results (p⫽ 0.88). Clinically significant distress occurred in a minority of participants in both protocols (7% of those receiving susceptibility testing, 9% of those receiving deterministic testing). Conclusions: Results suggest that distress from a positive genetic testing result for AD is similar across susceptibility and deterministic testing contexts. In both protocols, the vast majority of participants appeared to cope adequately with test results. Future research should examine larger samples followed over longer time periods to further assess the safety of providing genotype information to individuals at risk for AD. P4-201
AGE GROUP DIFFERENCES IN RESPONSE TO GENETIC RISK ASSESSMENT: RESULTS FROM THE RISK EVALUATION & EDUCATION FOR ALZHEIMER’S DISEASE (REVEAL) STUDY
J. Scott Roberts1, Erin Linnenbringer1, L. Adrienne Cupples2, Charmaine Royal3, Grace Fasaye3, Thomas Obisesan3, Norman R. Relkin4, Elana Cox4, Peter J. Whitehouse5, Melissa Barber6, Robert C. Green1, 1Boston University School of Medicine, Boston, MA, USA; 2Boston University School of Public Health, Boston, MA, USA; 3 Howard University, Washington, DC, USA; 4Cornell University School of Medicine, New York, NY, USA; 5Case Western Reserve University School of Medicine, Cleveland, OH, USA; 6Case Western Reserve University School of Medicine, Cleveland, OH, USA. Contact e-mail: [email protected] Background: Given advances in treatment for Alzheimer’s disease (AD), it is important to understand the impact of genetic risk assessment on asymptomatic individuals. We report here on a randomized clinical trial (RCT) that examined the impact of risk assessment, including apolipoprotein E (APOE) genotype disclosure, on first-degree relatives of people with AD. Objectives: To assess age group differences in response to genetic risk assessment for AD. Methods: In this four-site RCT, asymptomatic adult children and siblings of AD patients (n ⫽ 280, mean age ⫽ 58 years, 70% female, 19% African American) were provided genetic risk assessment. Estimates of lifetime risk of disease (range: 13-77%) were derived from large-scale genetic epidemiology studies of AD and incorporated gender, ethnicity, family history, and APOE genotype information. We assessed participants’ response to risk assessment in the following do-
EVALUATING PROCESS OF CARE, QUALITY INDICATORS IN AMBULATORY DEMENTIA CARE
Daniel L. Murman1, Jennifer Elston Lafata2, Elizabeth Dobie2, George Divine2, 1Univ. of Nebraska Med. Center, Omaha, NE, USA; 2 Henry Ford Health System, Detroit, MI, USA. Contact e-mail: [email protected] Background: We derived 18 ambulatory care, process quality indicators using evidence-based recommendations from the American Academy of Neurology and the Assessing Care of Vulnerable Elders (ACOVE) project. Objective: To examine how often insured patients of an integrated delivery system received recommended dementia care, and to look for evidence of disparities in ambulatory dementia care quality based on age, gender, and race. Methods: All patients of the integrated delivery system were identified who had at least one encounter with an ICD-9 code for dementia, were age 50 and older, and who had continuous health plan coverage including prescription drugs for the two years ending January, 2005. We used automated administrative and clinical data, including pharmacy claims, combined with responses from a mailed caregiver’s survey to evaluate the 18 process quality indicators. We used generalized estimating equations (GEE) to adjust for clustering effects based upon the provider and to adjust for covariates in multivariable analyses. Results: 351 patients were identified as study eligible, 180 (51%) of which had completed caregiver surveys returned. Patients with surveys differed significantly (p⬍0.05) from those without on demographic variables, but not on recommended care processes. Recommended care related to dementia diagnosis and psychosocial support occurred in 53% to 80% of patients. Seventy-eight percent of patients had filled a prescription for a cholinesterase inhibitor, but only 34% had evidence of persistent treatment. We did not find significant disparities in ambulatory dementia care quality based upon age or race in multivariable models that adjusted for education, marital status, income, Charleston Co-morbidity Index score, and Dementia Severity Rating Scale score. However, in multivariable models women were significantly (p⬍0.05) more likely to be dispensed an antidepressant medication, more likely to be dispensed an anti-cholinergic medication, and significantly less likely to have evidence of persistent cholinesterase inhibitor use. Conclusion: There is substantial room for improvement in providing recommended dementia care in the ambulatory care setting. The results of this study, including the disparities identified, can be used to better understand barriers to delivering quality dementia care and to target quality improvement efforts in healthcare systems. P4-200
THE PSYCHOLOGICAL IMPACT OF SUSCEPTIBILITY VERSUS DETERMINISTIC GENETIC TESTING FOR ALZHEIMER’S DISEASE
J. Scott Roberts1, Michael Cassidy1, Thomas D. Bird2, Ellen J. Steinbart2, Erin Linnenbringer1, Robert C. Green1, 1Boston
S575
University School of Medicine, Boston, MA, USA; 2University of Washington Medical School, Seattle, WA, USA. Background: Several genetic markers have been identified that confer risk for Alzheimer disease (AD) and related dementias. Some are rare genetic mutations (e.g., the presenilins) that almost inevitably result in AD, while the apolipoprotein E (APOE) ⑀4 allele is a common susceptibility polymorphism that increases risk but is neither necessary nor sufficient to cause AD. The psychological impact of genotype disclosure for these two types of genetic information has not been compared. Objective: To compare the psychological impact of susceptibility versus deterministic genetic testing among asymptomatic first-degree relatives of people with AD. Methods: Data were compared from two distinct protocols. The first was a multisite, randomized clinical trial in which 101 first-degree relatives of AD patients received APOE genotype disclosure. In a separate protocol, 22 individuals at risk for familial AD or frontotemporal dementia were disclosed presenilin 1, presenilin 2, or tau genotype. In both protocols, participants received genetic counseling and completed follow-up measures of testspecific distress (Impact of Event Scale, IES). Regression analyses assessed the effects of test result (positive vs. negative) and type of genetic testing (deterministic vs. susceptibility) on IES scores at one year (or closest timepoint), controlling for age and gender. Results: Participants who received gene-positive results from deterministic testing experienced similar levels of distress compared to those learning that they were APOE ⑀4⫹ (p⫽ 0.78). APOE ⑀4⫹ individuals experienced greater distress than those who tested ⑀4- (p⫽ 0.04); however, those who received positive results in the deterministic testing protocol did not experience significantly higher levels of distress as compared to those who received negative results (p⫽ 0.88). Clinically significant distress occurred in a minority of participants in both protocols (7% of those receiving susceptibility testing, 9% of those receiving deterministic testing). Conclusions: Results suggest that distress from a positive genetic testing result for AD is similar across susceptibility and deterministic testing contexts. In both protocols, the vast majority of participants appeared to cope adequately with test results. Future research should examine larger samples followed over longer time periods to further assess the safety of providing genotype information to individuals at risk for AD. P4-201
AGE GROUP DIFFERENCES IN RESPONSE TO GENETIC RISK ASSESSMENT: RESULTS FROM THE RISK EVALUATION & EDUCATION FOR ALZHEIMER’S DISEASE (REVEAL) STUDY
J. Scott Roberts1, Erin Linnenbringer1, L. Adrienne Cupples2, Charmaine Royal3, Grace Fasaye3, Thomas Obisesan3, Norman R. Relkin4, Elana Cox4, Peter J. Whitehouse5, Melissa Barber6, Robert C. Green1, 1Boston University School of Medicine, Boston, MA, USA; 2Boston University School of Public Health, Boston, MA, USA; 3 Howard University, Washington, DC, USA; 4Cornell University School of Medicine, New York, NY, USA; 5Case Western Reserve University School of Medicine, Cleveland, OH, USA; 6Case Western Reserve University School of Medicine, Cleveland, OH, USA. Contact e-mail: [email protected] Background: Given advances in treatment for Alzheimer’s disease (AD), it is important to understand the impact of genetic risk assessment on asymptomatic individuals. We report here on a randomized clinical trial (RCT) that examined the impact of risk assessment, including apolipoprotein E (APOE) genotype disclosure, on first-degree relatives of people with AD. Objectives: To assess age group differences in response to genetic risk assessment for AD. Methods: In this four-site RCT, asymptomatic adult children and siblings of AD patients (n ⫽ 280, mean age ⫽ 58 years, 70% female, 19% African American) were provided genetic risk assessment. Estimates of lifetime risk of disease (range: 13-77%) were derived from large-scale genetic epidemiology studies of AD and incorporated gender, ethnicity, family history, and APOE genotype information. We assessed participants’ response to risk assessment in the following do-