Identifying new strategies for integrated person-centered care of older adults with dementia: from early signs to severe stages

Research problem and questions.

Even if dementia cannot be cured, older persons with this condition and their relatives can still have a long-lasting good quality of life if offered appropriate medical and social care.

As recently discussed in a FORTE-funded national symposium organized by the main applicant, the integrated person-centered model is recognized as a promising approach for improved health and service utilization outcomes, but questions remain about how to organize, provide, and assess such care.

This project intends to answer the following questions concerning older adults with dementia: 1) How can we ensure a person-centered and holistic assessment and follow up? 2) What are the predictors and clinical/care consequences of major acute events? and 3) How can we facilitate their seamless transfer across care settings?Data and methods.

Three studies will be implemented.

Study 1 will leverage on data from an existing, multi-center, population-based cohort (Swedish National Study on Aging and Care, SNAC) to examine the predictive capacity of the Health Assessment Tool (HAT) for detecting progression from cognitive impairment to dementia.

Study 2 will explore, based on data from the Swedish Dementia Registry, the predictors of common major acute events (i.e. falls, pneumonia, myocardial infarction) and how the latter impact dementia progression and health/social care use, including unplanned hospitalizations.

Finally, Study 3 will identify and map care transitions within and between medical and social care settings using an integrated national register dataset, with special emphasis on the rehabilitation and hospital discharge phases of care trajectories.Relevance and utilization.

The present project is a contribution to the long-awaited need for integrated person-centered care throughout the dementia continuum, which will add quality to the many years older persons may live with cognitive impairment and dementia by slowing down their progression.Plan for project realization.

We will draw on our team’s longstanding multidisciplinary expertise on aging and dementia research, already established collaborations, the involvement of key partners representing the councils of Elderly Research and Cognitive Disorders at the National Board of Health and Welfare, and the ease of access to the proposed longitudinal databases and register data.

This will facilitate, not only the feasibility of the project, but also the timely implementation of its findings.