The Effectiveness of Community Aging Care Centers on Global Function for People Living with Dementia

Abstract

Background:

The global population with dementia is growing rapidly. Dementia patients have been included in the services of the long-term care Act 2.0, supported by Taiwan’s government since 2017. Community aging care centers are extensively established, which are places providing social connections and group physical and cognitive training programs for elderly people.

Objective:

To elucidate the efficacy of community aging care centers on cognitive function in people with dementia.

Methods:

A total of 1,277 patients with dementia diagnosed at the Changhua Christian Hospital outpatient departments were enrolled. A total of 113 patients who used community aging care centers and 452 subjects matched for age, education, and initial score of clinical dementia rating scale sum of boxes (CDR-SOB) control group were analyzed. The primary outcome was the change in CDR-SOB scores before and after utilization of community aging care centers.

Results:

The mean annual change of CDR-SOB scores were 1.72±2.97, 1.08±2.36, and 1.04±3.64 in control, Community Service Centers for Dementia, and community elderly stations, respectively, after about 1.5 years follow-up. Patients with dementia using community aging care centers had significantly less progression in CDR-SOB scores than those in the control group (–0.65; 95% CI: –1.27, –0.03; p = 0.041). Using one more day of community aging care centers per week significantly promotes 0.16 points of CDR-SOB decline (–0.16, 95% CI: –0.31; –0.00; p = 0.045).

Conclusion:

Community aging care centers, based on the long-term care Act 2.0 in Taiwan, were effective in delaying the decline in global function in people living with dementia.

Keywords

Cognitive dysfunction community care dementia long-term care

INTRODUCTION

The number of people with dementia has increased worldwide. According to the World Alzheimer Report 2015, 46.8 million people were living with dementia in 2015, and the number will double in the coming 20 years. The total estimated worldwide cost of dementia in 2015 was US$ 818 billion, which may increase to US$ 2 trillion by 2030 [1].

According to the Ministry of Health and Welfare and Taiwan Alzheimer Disease Association, in 2011, the prevalence of dementia was 3.40% in the 65–69-year-old group, followed by 3.46%, 7.19%, 13.03%, 21.92%, and 36.88% in the 70–74, 75–79, 80–84, 85–89, and over 90-year-old groups, respectively [2]. Today, Taiwan is an aged society and is predicted to become a super-aged society by 2025. The population with dementia will also increase in recent decades.

The long-term care system was established in Taiwan in 2007 as a response to an aging society. Community-aging care centers were encouraged to settle in each town. Community elderly stations (CES) were set up extensively in nearly every village and offered a place that provided congregate meals, general medical information, and exercise programs for healthy, pre-frail, and frail elderly people who still live in the community. To further help families with dementia, Taiwan’s government established the Long-term Care Act 2.0 since 2017, which included people with dementia over the age of 50 in its coverage [3]. The new policy provides home and community-based services and a three-layer service network within towns and districts. As part of this reform, the government implemented innovative programs including “Dementia Integrated Care Centers” and “Community Service Centers for Dementia” (CSCD). The former are hospitals or sites that diagnose, provide patient and caregiver education, introduce social resources, promote health literacy of dementia, and educate healthcare providers. The latter are community care sites that offer cognitive training or stimulation programs and respite services, specifically for people living with dementia. As of September 2021, Taiwan had 103 dementia integrated care centers, 506 CSCD, and3,621 CES.

Most older people prefer to age at home. Community-based support helps delay the utilization of residential care, which is usually stated as an avoidable option for people living with dementia [4]. Several observational studies have suggested that social participation and connectedness protect against cognitive decline [5]. Being connected to one’s familiar environment, community, and nature is an important motivation for engagement in daily activities among patients with dementia [6]. A few studies in Taiwan have reported cognitive improvements using community care sites. Chen et al. found that daycare services improved cognitive performance, physical independence, mood status, and reduced unexpected hospitalization in elderly patients with dementia compared with residential care [7]. A small sample study found that elderly people with dementia using day care services had improved physical and mental functions [8]. However, the efficacy of new community services based on the Long-term Care Act 2.0 in patients with dementia in Taiwan is still not clear.

The present study aimed to elucidate the effectiveness of community aging care centers, including CSCD and CES, on cognitive functions in patients with dementia.

METHODS

Participants

The Changhua Christian Hospital (CCH), a medical center in central Taiwan, established a dementia collaborative care model in October 2015. The model comprised multidisciplinary healthcare professionals supporting community residential patients with dementia and their care partners. CCH is also the largest dementia integrated care center in Changhua. The care team performed face-to-face interviews every six months, including patients’ living status, etiology of dementia, past medical history, and caregivers’ preference and care burden. Individualized care plans tailored to their needs, such as transferring suitable social resources, were arranged after each interview [9, 10]. Cognitive function was assessed by the Clinical Dementia Rating scale (CDR) annually by a clinical psychologist [11]. All the data were recorded in electronic charts. Using this model, 2,509 newly diagnosed dementia patients and caregiver dyads were included, between October 2015 and July 2021. Exclusion criteria were refused intervention by care team, loss of out-patient follow-up, death, transfer to residential care, or no complete CDR evaluation (Fig. 1). Finally, 1,277 patients were included into analysis.

Fig. 1

Flowchart presenting the selected study population.

People living with dementia who utilized community aging care centers (including CSCD and CES) were the main study population. Community aging care centers were supported by the Long-term Care Act 2.0 and provided congregate meals and physical or cognitive promoting programs for elderly participants. CSCD provide cognitive training or stimulation lessons as well as caregiver support and training lessons specifically for dementia patients and their care partners. Only subjects with confirmed dementia diagnosis can join CSCD. Most CSCD arrange daytime small group (usually 6–20 individuals) cognitive training or stimulation programs 3 to 5 days per week. The cognitive program was organized by multidisciplinary professionals trained in dementia care. The care providers at CSCD were trained for basic dementia care and the training programs in CSCD were specially designed for dementia patients. CES provided congregate meals, general medical information, and physical training lessons for healthy, pre-frail, and frail elderly people with or without cognitive dysfunction who still live in the community. Physical training lessons were arranged as a median group (20–30 participants), 2 hours in the morning on weekdays, and a congregate lunch meal.

The care team provided information of closest CSCD and CES to every patient when the diagnosis of dementia was made and encouraged them to utilize the resources. The patients and their caregivers can choose freely after realizing the contents of both care models.

The control group was selected by matching their age, education, and initial score of the Clinical Dementia Rating Scale Sum of Boxes (CDR-SOB) with a 1:4 ratio. Participants in the control group did not receive any community services despite the recommendation by the collaborative team. The pharmacological management of dementia or other general medical care (including health education and control of other chronic diseases) was same in both groups.

This clinical study was approved by the Institutional Review Board (IRB) of Changhua Christian Hospital (CCH IRB 210912). As all data needed in the present study were extracted from the electronic chart after deleting personalized information, informed consent was waived by the IRB of the hospital.

Measurements

Basic characteristics, including age, sex, and educational level, were obtained. Systemic disorders, including hypertension, diabetes mellitus, hyperlipidemia, cerebral vascular accident, cardiovascular disease, and the etiology of dementia, were recorded by a neurologist or psychiatrist. For the diagnosis of Alzheimer’s disease dementia (AD), vascular cognitive impairment, Parkinson’s disease dementia (PDD), dementia with Lewy bodies (DLB), frontotemporal dementia (FTD), the National Institute on Aging-Alzheimer’s Association (NIA-AA) [12, 13], the International Society for Vascular Behavioral and Cognitive disorders (VASCOG) [14], the Movement Disorder Society-Task force criteria [15], the Fourth Consensus Report of DLB Consortium [16], and the International Consensus Criteria for Behavioral Variant FTD [17] were used. Patients who met both the NIA-AA criteria for AD and the VASCOG criteria for possible major vascular cognitive disorders were classified as having mixed dementias. Lewy body disease included patients diagnosed with PDD or DLB.

In the study group, the closet CDR scores before utilizing community aging care centers were defined as initial CDR scores. The next CDR evaluations after the initial CDR scores were used to calculate change of global function. Changes in CDR-SOB scores before and after the utilization of community aging care centers were used as the primary outcome in the study group. In the control group, the initial CDR-SOB score was matched and the next CDR scores were collected. The CDR-SOB is a score calculated by the sum of the six aspects of the CDR score, which can be viewed as a composed cognitive and functional assessment. All CDR evaluations were randomly assigned to one of the three clinical psychologists in our hospital who were blinded from the participant’s group.

Statistical analysis

All statistical analyses were performed using R Statistical Software (version 4.1.0; R Foundation for Statistical Computing, Vienna, Austria) [18]. For baseline characteristics, we used Pearson’s chi-square test for nominal variables, while continuous variables were analyzed using one-way ANOVA. We also used one-way ANOVA to analyze the first and second time CDR-SOB, delta CDR-SOB, and interval between the first and second time. A multivariate linear regression model was applied to analyze the association between delta CDR-SOB and other factors of interest. A p-value <0.05 was considered statistically significant.

RESULTS

Figure 1 shows the flowchart of selected study population. A total of 565 patients were included in our study: 113 participants used community aging care centers (including 61 patients in CSCD and 52 in CES) and 452 matched participants in the control group.

Table 1 shows the basic characteristics of the participants. Age, sex, education level, dementia etiology, underlying diseases, baseline CDR-SOB and CDR subitem scores, and intervals between CDR evaluations were comparable between the groups. Supplementary Table 1 lists the information of how the patients accessed to health care system, their income level and if they utilized other social resources covering by long term care act 2.0. There was also no significant difference between study groups.

Table 1

Baseline characteristics between the control and the intervention group

	Control	CSCD	CES	p
Number	452	61	52
Age (mean (SD))	79.69 (7.72)	79.10 (7.58)	79.55 (9.05)	0.859
Gender (male)	174 (38.5%)	17 (27.9%)	14 (26.9%)	0.091
Education (mean (SD))	5.67 (4.64)	6.66 (4.59)	5.00 (4.84)	0.153
Underlying disease (n)
Hypertension	274(61.0%)	34 (55.7%)	31 (59.6%)	0.727
Diabetes mellitus	150(33.4%)	18 (29.5%)	11 (21.2%)	0.183
Hyperlipidemia	159(35.4%)	23 (37.7%)	17 (32.7%)	0.857
CVA	59 (13.2%)	5 (8.2%)	6 (11.5%)	0.528
CVD	38 (8.5%)	3 (4.9%)	1 (1.9%)	0.171
Diagnosis				0.597
AD	269 (59.5%)	40 (65.6%)	33 (63.5%)
Non-AD	183 (40.5%)	21 (34.4%)	19 (36.5%)
Baseline CDR-SOB (mean (SD))	5.07 (3.50)	4.98 (3.37)	5.17 (3.87)	0.960
Baseline CDR subitem (mean (SD))
Memory	1.04 (0.51)	1.04 (0.47)	1.06 (0.56)	0.977
Orientation	0.81 (0.64)	0.80 (0.62)	0.85 (0.74)	0.928
Judgment	0.87 (0.62)	0.88 (0.64)	0.90 (0.65)	0.916
Community affairs	0.89 (0.68)	0.84 (0.59)	0.89 (0.69)	0.865
Home and hobbies	0.91 (0.71)	0.89 (0.66)	0.89 (0.75)	0.961
Personal care	0.53 (0.75)	0.53 (0.78)	0.56 (0.87)	0.976
CDR-SOB interval (mean (SD))	514.54 (270.85)	495.23 (226.10)	484.10 (213.10)	0.658

CSCD, Community Service Center for Dementia; CES, Community elderly stations; CDR-SOB, Clinical Dementia Rating scale sum of boxes; SD, standard deviation; CVA, cerebral vascular accident; CVD, cardiovascular disease; AD, Alzheimer’s disease; CDR-SOB interval, the time we evaluating the patient between first and second CDR-SOB.

Table 2 shows the average score of CDR-SOB stratified by service type and usage frequencies before and after utilizing community aging care centers. The baseline CDR-SOB scores were 5.07±3.50, 4.98±3.37, and 5.17±3.87 in control, CSCD, and CES, respectively. The follow-up CDR-SOB scores were 7.26±4.76, 6.43±4.12, and 6.76±4.90 in each group. Because the time intervals between baseline and follow-up CDR-SOB scores were variable, the observation time interval was adjusted. Mean annual CDR-SOB (delta CDR-SOB) scores were 1.72±2.97, 1.08±2.36, and 1.04±3.64 in control, CSCD, and CES, respectively. Delta CDR-SOB scores were 1.32±2.59, 0.56±4.42, and 1.16±2.32 in participants with using frequency of 1–2 days, 3–4 days, and more than 5 days per week, respectively.

Table 2

CDR-SOB by community aging care centers and

	control	Community centers		p	Using Frequency			p
		CSCD	CES		1–2	3–4	≥5
N	452	61	52		30	27	56
Baseline CDR-SOB (mean (SD))	5.07 (3.50)	4.98 (3.37)	5.17 (3.87)	0.960	4.47 (2.60)	4.74 (3.41)	5.55 (4.09)	0.538
Followed CDR-SOB (mean (SD))	7.26 (4.76)	6.43 (4.12)	6.76 (4.90)	0.361	6.47 (4.03)	5.80 (4.54)	7.02 (4.69)	0.370
Delta CDR-SOB (mean (SD))^¶	1.72 (2.97)	1.08 (2.36)	1.04 (3.64)	0.108	1.32 (2.59)	0.56 (4.42)	1.16 (2.32)	0.140
CDR-SOB interval (days, mean (SD))	514.54 (270.85)	495.23 (226.10)	484.10 (213.10)	0.658	527.20 (233.18)	440.07 (165.88)	494.36 (232.95)	0.495

CSCD, Community Service Center for Dementia; CES, community elderly stations; CDR-SOB, Clinical Dementia Rating scale sum of boxes; SD, standard deviation. ^¶Delta CDR-SOB score means change of CDR-SOB score after adjusting observation time = [(followed CDR-SOB score) –(baseline CDR-SOB score)]/observation time(year).

Table 3 reveals multivariate linear regression analysis to predict factors associated with delta CDR-SOB scores. Community aging care centers had significantly lower delta CDR-SOB scores than the control group (–0.65; 95% CI: –1.27, –0.03; p = 0.041).

Table 3

Multivariate linear regression to determine factors associated with change of CDR-SOB

	Coefficient	95% confidence interval	p
Intercept	1.81	1.31; 2.32	<0.001
Gender (ref: female)	–0.10	–0.62; 0.42	0.698
Use community aging care centers	–0.65	–1.27; –0.03	0.041
Diagnosis			0.279
AD	Ref	Ref
non-AD	–0.30	–0.85; 0.24
Underlying disease
Hypertension	–0.13	–0.66; 0.40	0.629
Diabetes mellitus	0.01	–0.55; 0.58	0.961
Hyperlipidemia	0.05	–0.50; 0.59	0.870
CVA	0.74	–0.06; 1.55	0.070
CVD	0.78	–0.17; 1.74	0.109

AD, Alzheimer’s disease; CVA, cerebral vascular accident; CVD, cardiovascular disease.

Table 4 displays the association between delta CDR-SOB scores and center types or frequency. Although not statistically significant, CSCD and CES both tended to have lower delta CDR-SOB scores than the control group (delta CDR-SOB = –0.62 and –0.66, respectively). Participants who visited care centers with a frequency of 3–4 days per week tended to have lower CDR-SOB scores during follow-up (–1.09, 95% CI: –2.25;0.08; p = 0.067).

Table 4

Multivariate linear regression model to predict change of CDR-SOB scores by care center types or using frequencies

	Coefficient	95% confidence interval	p
Intercept	2.09	1.48; 2.70	<0.001
Care center type
(Ref: control)
CSCD	–0.62	–1.42; 0.18	0.127
CES	–0.66	–1.52; 0.20	0.132
Using frequency^¶(times per week) (Ref: 0)
1–2	–0.46	–1.57; 0.64	0.411
3–4	–1.09	–2.25; 0.08	0.067
≥5	–0.52	–1.35; 0.31	0.222

CSCD, Community Service Center for Dementia; CES, community elderly stations. Both model adjusted gender, underlying disease, dementia diagnosis, and baseline CDR-SOB.

Figure 2 shows delta CDR-SOB scores in different using days (0–5 days). Using one more day of community aging care centers per week significantly decreased 0.16 delta CDR-SOB scores (–0.16, 95% CI: –0.31; –0.00; p = 0.045).

Fig. 2

Scatter plot of delta CDR-SOB by using days per week. ^*Model adjusted gender, underlying disease, dementia diagnosis, and baseline CDR-SOB.

DISCUSSION

The present study showed that community aging care centers slow the rate of global function decline in people living with dementia. The effectiveness was substantial with 0.65 points lower of CDR-SOB score increase per year when compared with matched control populations. Both CSCD and CES were effective. Using one more day of community aging care centers per week promotes 0.16 points of CDR-SOB decline. Community aging care centers are usually connected to the patient’s familiar environment, which promotes social participation and interpersonal interaction. Social contact and community-based care are effective remedies for preventing cognitive and functional decline in patients with dementia [4 –6].

Physical and cognitive training programs in community aging care centers may also play an important role. Cognitive stimulation and training play important roles in the management of dementia. A meta-analysis of 11 studies found that cognitive training had a significant but small effect on overall cognition in older adults with mild cognitive impairment or dementia [19]. However, the result mostly driven by two studies using virtual reality and new software technology. Without these two studies, the results did not reach statistical significance. In another review, cognitive training also showed small to moderate positive effects on global cognition in patients with mild to moderate dementia [20]. Cognitive training slowed the clinical progression in a medium follow-up analysis. However, the evidence was of low quality and could not draw a certain conclusion.

The effect of physical activity on cognition is also discussed. A systemic review concluded that only low-strength evidence supports multi-domain intervention (physical activity, diet, and cognitive training) to improve cognitive function in patients without cognitive impairment, but physical activity alone did not [21]. In patients with AD, a meta-analysis suggested that physical activity slows down the decline of cognition, although high-quality randomized controlled trials (RCTs) are scanty [22, 23]. One RCT reported surprisingly deteriorated cognitive scores in the exercise group [24]. However, the difference was small and of uncertain clinical relevance.

Because a single component of therapy had only a small effect, the efficacy of multi-domain interventions including cognitive stimulation/training, motor activity, diet, or practices in activities of daily living (ADL) for patients with dementia was evaluated. Some trials showed a positive effect on cognition [25, 26], ADL or instrumental ADL [26 –28], and behavior and quality of life [25]. One study showed significantly better cognition and ADL function 10 months after multi-domain interventions [28]. The small size of the current RCTs and heterogeneous design limited positive interpretations. Healthy education, cognitive and exercise programs arranged in community aging care centers may be viewed as a type of multi-domain intervention, although its design was not as rigorous as in previous trials.

Increased using frequency was associated with significantly delayed decline of global function in people living with dementia. The present study showed that 3–4 times per week may have trends to be the most promising frequency. However, although not significant, participants using 5 days of community aging care centers had highest baseline CDR-SOB scores, which might influence the main outcome. Baseline CDR-SOB scores were added into adjustment in Table 4 to minimize the effect. The small case number in each frequency group also made the conclusion more blurred. The optimal frequency of multi-domain interventions for patients with dementia is still not clear. A previous systematic review found better global cognition, immediate memory, verbal letter fluency, and executive function in more intense cognitive training (more than 3 formal sessions of cognitive training per week) than in the less intense group for patients with mild to moderate dementia [20]. Meta-analysis also found that time and frequency of physical activity interventions also influence the effect on cognition in patients with dementia [23, 29]. Physical interventions conducted less than 3 times, including 3 times per week, showed a greater effect on improving cognition of patients compared to those conducted more than 3 times per week [23]. Better cognitive function was observed in the low-frequency group (<150 min/week) than in the high-frequency group (≥150 min) [29]. Further studies are needed to clarify the optimal frequency of multi-domain interventions for patients with dementia.

Previous literature showed the efficacy of community participation prevent dementia onset in non-demented elderly [30, 31]. A study conducted in England found community engagement may reduce risk of dementia onset, particularly when relating to cultural activities [30]. Social non-participant increased 22% of dementia risk in community-dwelling elderly in Japan [31]. Studies focusing on cognitive or functional effect of community group engagement in dementia population are scarce, however, being connected to one’s familiar environment and community is an important motivation for the engagements in daily activities among patients with dementia [6]. According to previous and the present studies, community group caring model may be a suitable choice for mild dementia populations to delay the decline of global function. Community group engagement may be considered a national policy for dementia care.

Recently, the outbreak of COVID-19 has had a serious impact on patients with dementia and their caregivers. Social distancing may separate patients from beloved ones, which can cause anxiety or other mood disorders. There is some evidence that COVID-19 could affect brain and cognition [32, 33]. Miners et al. concluded that COVID-19 and dementia share several comorbidities and risk factors. The underlying mechanism of shared comorbidities may contribute to higher incidence and mortality rates among patients with dementia [32]. Community services were paused during the COVID-19 pandemic. Even though it is a big challenge for both dementia patients and caregivers, virtual technology provides an option to visit and keeps communicating [34] Information and communication technology for fostering social health and social participation in people with dementia will be an important issue in every community aging care center.

This is the first study to show that community-based long-term care sites are effective in enhancing global function in people living with dementia in Taiwan. However, the present study has some limitations. First, the relatively small number of participants in community aging care centers limits the interpretation of the subgroup analysis. Second, the complexity of the activities provided by every care center blurred the conclusion of which component was the most effective. Third, the retrospective case-control study design may have led to a selection bias. We attempted to minimize this bias by matching baseline characteristics, including age, education, and initial CDR-SOB scores in the control and case groups. However, the database did not record care center’s accessibility, patient’s family support system and detail socio-economic status such as average family income, which may also lead to potential selection bias. Fourth, only the mean of 1.5 year followed cognition was evaluated in the present study. The long-term effects of community services require further investigation. Fifth, the unbalance of exclusive causes and incomplete CDR rates between groups might also cause selective drop-out bias. The excluded rate was 22.1% in control group and 17.3% in using community center group. Patient ratios had not completed two CDR-SOB evaluations (except patients join our model less than 1 year) were 21.6% in control and 3.7% in study group. The higher proportion of incomplete CDR evaluation in participants not using community aging care centers might be due to the worse cognitive and functional status, which made in-hospital CDR evaluations difficult. In final analysis, initial CDR-SOB were matched between groups to minimize this bias. Refused interventions by care team as well as less complete CDR evaluations may also reflect more passive attitude toward medical advisors. The degree of cooperation between patients and care team might influence cognitive outcomes. Sixth, the functional decline is not supposed to be liner but more tends to be exponential [35]. The present study used observation time interval adjusted CDR-SOB scores may not reflect the true decline speed.

Conclusion

Community aging care centers, based on the Long-term Care Act 2.0 in Taiwan, were effective in delaying the decline in global function in people living with dementia. Dementia care team members should provide, refer, and encourage dementia patients and caregivers to utilize these community aging care centers.

Footnotes

ACKNOWLEDGMENTS

This study was supported by CCH Grants 111-CCH-IRP-009.

Authors’ disclosures available online ().

The supplementary material is available in the electronic version of this article: .

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