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Utilization of occupational therapy services and relation to survival in people taking dementia‐specific medication in Austria—A retrospective population‐based study with a 13‐year observation period

Abstract Objectives Evidence‐based treatment of dementia includes pharmacological and non‐pharmacological methods of which psycho‐social interventions are an important component, commonly administered by occupational therapists. The aim of this study was to investigate the utilization of occupational therapy (OT) services and its association with survival in people taking dementia‐specific medication in a population‐based Austrian dataset compared to a two times as large control group without dementia‐specific medication. Methods/Design A retrospective study with a 13‐year observation period (2003–2016) was conducted on real‐world data. Two stratifications were done and we used descriptive statistics, Chi‐squared/Fisher's Exact Tests and survival analyses including three Cox models. Results Data from 286,553 participants were analysed. Only 4.5% (n = 12,950) received OT services. In the dementia‐medication group (n = 111,033), participants who received OT services (3.6%; n = 4032) had significantly more comorbidities (4.7%) compared to those without OT (3.5%; p < 0.001) and were also more likely to be male (4 vs. 3.5%; p < 0.001). While persons taking dementia‐specific medication showed a slightly reduced survival with OT (p < 0.001) compared to those without, the result in the control group without dementia‐specific medication showed a slightly better result of the participants who received OT (p < 0.001). The reduced survival in the dementia‐medication group with OT is likely to be related to the higher number of comorbidities in this group. Conclusion People receiving dementia‐specific medication were more likely to receive OT if they had additional comorbidities, however our analysis showed that utilization of OT services in Austria was very low indicating an overall insufficient accessibility of OT services for patients who needed it.


| INTRODUCTION
Dementia affects approximately 50 million people worldwide and is the seventh leading cause of death. 1 The most common form, contributing to 60%-70% of cases, is Alzheimer's disease. 2 Dementia is a serious and growing public health problem with almost ten million new cases are diagnosed annually. 1 Since incidence and prevalence increase with age, it is expected that the number of people affected by dementia worldwide will rise to 74.7 million by 2030 and to 131.5 million people by 2050. 3,4 In 2018 there were more than 146,000 people living with dementia in Austria, representing 1.66% of the total population, 5 and that number is anticipated to more than double by 2050. 6,7 Moreover, dementia has a destructive impact on the daily life of not only the affected person, but also their families, caregivers and society at large. The global costs of dementia have increased substantially, 8 requiring urgent action from governments, policy makers and authorities, as well as health care and services providers. 9 According to the Austrian Alzheimer Association, yearly costs for the care of people with dementia are approximately one billion euros. 7,10 Evidence-based treatment of dementia includes pharmacological and non-pharmacological methods. 3,8,9,11 Several consensus statements recommend non-pharmacological methods as the initial treatment for people with dementia. 12,13 An important component of non-pharmacological treatment are psycho-social interventions, 14 which are commonly administered by occupational therapists. 3,15 National 16 and international guidelines 11 for people with dementia as well as various studies, [17][18][19][20][21][22][23][24][25][26][27][28][29][30]  preferences. 32 In the early stages of dementia, in order to promote participation in activities of everyday living (ADLs), some of the interventions include setting up the physical environment (such as installing visual cues for daily routine schedules, calendars, medication and appointment reminders) as well as maintaining relationship and social participation. In the middle stages of dementia, facilitating engagement and enhancing function in ADLs is paramount. Retraining basic ADLs (such as self-feeding, dressing, toileting, taking a shower and other) through demonstration, physical-, verbal-and visual guidance, at the same time and place and through the same sequence is critical in order to increase memory retention. 32 In the late stages, people with dementia will have difficulties performing basic ADLs such as feeding, drinking, dressing, washing, brushing teeth along with other activities. Thus, the focus will be on educating caregivers on proper body positioning of people with dementia and avoiding contractures, skin protection, increasing comfort and providing enjoyable sensory stimulation. Providing support groups for family members and caregivers is also crucial. 32 People with early-or mild stage of dementia could benefit even more from OT interventions to potentially delay and/or prolong functional decline. 33,34 While OT interventions were found to show effects in clinical studies, there is a lack of observational, real world data on a national level that could show how many people with dementia need and/or receive non-pharmacological interventions such as OT. Information such as regional or socio-economic differences could show areas where underutilization exist and thus provide important insights for future health care planning. Such population-based datasets could provide information whether OT is equally implemented in daily routine health care and accessible to all people with dementia, or if specific characteristics such as presence of comorbidities, age, sex or other influence participation in OT.

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The purpose of this study was to investigate the utilization of OT services in a population-based Austrian dataset of all people taking dementia-specific medication in relation to age, sex, comorbidities and region of residence. We compared people in the dementia medication group to a control group of older adults without dementia-specific medication. We also explored the overall survival of participants taking dementia-specific medications in relation to whether they received OT services or not. We used OT services as an indicator for psychosocial interventions because OT services are commonly prescribed and also reimbursed by Austrian health insurances, thus population-based data are available.

| Design
A retrospective cohort study with a 13-year observation period from 2003 to 2016 was conducted on real world data of the Austrian health insurance funds covering 98% of all insured Austrians.

| Participants
Two stratifications were done. First, we extracted population-based health services data from persons who had received dementia-specific medication including donepezil, rivastigmine, galantamine and memantine at least once between 2003 and 2016. In addition, we obtained data from an age-stratified twice as large control group without dementia-specific medication. In a second stratification we divided the participants into a group who received OT services at least once in the observation period (starting from January 2009 until July 2016) and another group without. Since our main aim was to investigate the utilization of OT services in a population-based Austrian dataset of all people taking dementia-specific medication, we analysed sociodemographic characteristics (sex, age, date of birth/death), a set of comorbidities (non-traumatic subarachnoid, intracerebral and other cranial haemorrhage; cerebral infarction and sequelae of cerebrovascular disease; fracture of the femur), other relevant pharmacological treatment (ginkgo, antipsychotic drugs, antidepressants and Parkinson's disease medication) and the use of OT services per quarter as represented by OT appointments reimbursed by social insurance companies. Comorbidities were extracted from hospital discharge diagnoses and by using medications as surrogate parameters, where appropriate. As no dementia-specific, clinician-reported data were available in population-based health services in Austria, we considered participants taking memantine according to treatment guidelines 11,16,35 to be more likely to have more severe cognitive decline. The study was approved by the ethical committee of the Medical University of Vienna (EK 2029/ 2016).

| Statistical analysis
Descriptive statistics were calculated for persons with and without dementia-specific medication regarding age, sex, comorbidities and region of residence. We used histograms and Kolmogorov-Smirnov tests to determine data distribution. Measures for central tendency and dispersion, as well as absolute and relative frequencies were reported where appropriate. We applied non-parametric methods to non-normally distributed data. Differences in frequency of categorical variables were determined by the Chi 2 -test for independence together with the Fisher's Exact Test and Bonferroni correction, which was calculated using categorical, dichotomized and continuous variables where appropriate. The Chi 2 -and Fishers's Exact Test were employed for comparing sex, age groups, different comorbidities, comedications and people from various Austrian regions. Since we did multiple analysis on the same dependent variable (OT: yes/no), we applied Bonferroni corrections for those covariates in order to avoid type I error. Kaplan-Meier (KM) estimates for survival time were fitted separately for persons who received OT and those who did not and tested for statistically significant differences with the Log-Rank test. 36 In order to estimate hazard ratios for risk of death, we used Cox proportional hazards regression model. 37 Three Cox proportional ratio models were done with the main outcome variable being dichotomized OT attendance (yes/no). The full model was adjusted for sex, comorbidities and medications as these parameters were likely to have a significant effect on death in our dataset. Hazard ratios with 95% confidence intervals were calculated. All p-values below 0.05 were considered statistically significant. The statistical analyses were performed using R (https://www.r-project.org/) and SPSS 26.0 statistical software.

| Participant characteristics
We identified 111,033 participants who received dementia-specific medication at least once in the observation period and 175,520 agematched controls (286,553 persons in total). Because of the high prevalence of dementia in very old age groups, the two times as large control group was not available for all birth cohorts. Women were represented at a higher rate (61.5%; n = 176,215) as compared to men (Table 1). In the group with dementia-specific medication, the most frequent comorbidity was fracture of the femur with 6.5%   (Table 1). In the dementia medication group, 3.6% (n = 4032) participants attended OT and had significantly more coexisting conditions (4.7%) compared to those without comorbidities (3.5%; p < 0.001) and were also more likely to be male (4%) versus female (3.5%; p < 0.001). Additional information is presented in Table 2.
Regarding the frequency of OT across different Austrian regions, the federal state of Styria had the highest number of participants who attended OT (28.9%; n = 10,486), while in T A B L E 1 Sociodemographic characteristics of the study population stratified by those who received and did not receive occupational therapy (OT) services Medication include 1 : dementia specific medication (memantine, donepezil, rivastigmine, galantamine) and 2 not-dementia-specific medication (ginkgo, antipsychotic drugs, antidepressants and Parkinson disease medication). c Over regional includes four social-insurance companies that cover more than one Austrian region.

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T A B L E 2 Sociodemographic characteristics of the study population with and without dementia-specific medication, stratified by those who received and did not receive occupational therapy (OT) services -1183 Vorarlberg, no instances of OT services were recorded (Table 1).
In the dementia-medication group, without Styria and Vorarlberg which were likely to be 'outliers' for different reasons, Salzburg had the highest frequency of individuals who received OT (2.2%), whereas Upper Austria showed the lowest percentage (0.1%, Table 2).

| Survival
Participants who received OT interventions were more likely to die at an earlier age than people without OT (Log-Rank Test; p < 0.001).
Moreover, the majority of people who died while attending OT were 65 years old or older (98%; n = 1521; p < 0.001). Participants took memantine and at least one other dementia specific medication (donepezil, rivastigmine, galantamine) and/or not-dementia-specific medication (ginkgo, antipsychotic drugs, antidepressants or Parkinson disease medication). c Participants did not take memantine medicine, but they took at least one dementia-specific medication (donepezil, rivastigmine, galantamine) and/or at least one not-dementia-specific medication (ginkgo, antipsychotic drugs, antidepressants or Parkinson disease medication). d Participants took both-Parkinson disease medicine and antidepressants.

T A B L E 3
Crude and adjusted hazard ratio models stratified by those who received and did not receive occupational therapy services  Abbreviations: CI, confidence intervals; HR, hazard ratio.
participants taking dementia-specific medication received OT services in Austria. This proportion is surprisingly low, as national 16 and international guidelines 11 together with numerous reports and studies 17-34 emphasize the importance of receiving non-pharmacological bio-psycho-social interventions, including OT services, in order to promote optimal functioning for people with dementia, their families and care providers. The reasons for not receiving OT services cannot be clearly interpreted from this dataset analysis, however they are most likely multifactorial. One reason for the low level of OT services for people taking dementia-specific medication could be that there is a substantial reduction of occupational therapists in the longterm care geriatric institutions in Austria. Moreover, the fact that OT services are not fully covered by insurance companies for people with dementia compels end-users to rely on private funding for OT treatment.
Our analysis showed that the majority of OT services were recorded in the federal state of Styria. One potential reason for this very high frequency of OT treatment in Styria could be that the local insurance companies in that federal state provide and reimburse the costs for OT treatment more than in other parts of Austria. Another reason may be that a larger percentage of occupational therapists working in Styria are specialized in working with adults with dementia.
Interestingly, Vorarlberg was the only federal state in Austria where no OT services were reimbursed for people who were taking both dementia/non-dementia specific medications, with or without comorbidities. Some of the reasons for that could be the relatively low number of occupational therapists working in Vorarlberg (28 officially registered in 2016) 38 as well as the fact that the local insurance institutions mostly work on the reimbursement basis for OT. 38,39 Participants who received OT services in our study and who were taking dementia-specific medication died earlier than people without OT. This could be related to the fact that OT attenders had significantly more comorbidities and were more likely to be male, as described in the results section. Without a doubt, this was a most unexpected finding and we had actually assumed the opposite would be the case. We had drawn these conclusions from existing studies reporting the positive effects of OT interventions on people with dementia. [17][18][19][20][21][22][23][24][25][26][27][28][29][30] To explain this unexpected finding of our study, we first hypothesized that people with dementia would receive OT services later in the course of their disease and we therefore took memantine as a surrogate parameter for more severe disease.
However, persons taking only memantine were less likely to receive OT service compared to people taking other dementia-specific medication, which actually showed that people with more severe disease might even receive fewer OT services than people in the earlier disease course. We then explored the frequencies of comorbidities. As participants with more comorbidities were more likely to receive OT services, this might be an explanation for the reduced survival in the OT services group. It might also show that people need to have more comorbidities to receive OT services and that dementia alone might not be reason enough to prescribe/pay OT services in Austria. Moreover, in a group of those who were taking dementia-specific medication and had received OT services, the majority of those who died were 65 years old or older (98%) and the observed differences in survival time between the groups were small

| Strengths and limitations
Limitations include the higher number of women compared to men; however, this representation is in accordance with previously published studies in people with dementia as well as with the Austrian dementia report. Moreover, the subtype of dementia as well as the STEFANAC ET AL.
-1185 frequency and type of OT services for people with dementia were not recorded, precluding any further cause-effect relationship analysis.
Additionally, another significant limitation with regard to the survival analysis is that the majority of those who died while receiving OT services were 65 years old or older, where 'old age' might be the reason for dying, rather than OT itself. Furthermore, no official reports have been published on a national level about the incidence of OT services in persons taking dementia-specific medication, so reflections presented in the discussion were based on unpublished reports and websites.
One of the major strengths is that these results are reported for the first time, thus providing a first look into incidence of OT services in people taking dementia-specific medication across all Austrian federal states with regard to age, sex, medication use and comorbidities.
Moreover, a large sample size allowed more precise results depicting current trends of OT services in Austria for persons taking dementiaspecific medication. A lack of prior research studies on the national/ international level concerning utilization of OT services and survival rate of people taking dementia-specific medication might show the importance of studies of this kind. We therefore recommend that further studies should be done in this area and build upon our findings.

| CONCLUSION
As the human lifespan as well as the number of people affected by dementia worldwide increase, there is a growing need for OT services in people with dementia. As shown in this paper, OT services in Austria may not be accessible to all people with dementia who need them, which is a substantial public health problem. Since the benefits of OT services for people with dementia are well known, consistent OT services should be provided to all people with any form of dementia, starting from the earliest stage of the disease.
Considering a lack of data on OT services and their effect on the overall survival of people with dementia, further longitudinal studies in this area are warranted.