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Aguilar BJ, Jasuja GK, Li X, Shishova E, Palacios N, Berlowitz D, Morin P, O'Connor MK, Nguyen A, Reisman J, Leng Y, Zhang R, Monfared AAT, Zhang Q, Xia W. Prevalence of Mild Cognitive Impairment and Alzheimer's Disease Identified in Veterans in the United States. J Alzheimers Dis 2024:JAD240027. [PMID: 38788073 DOI: 10.3233/jad-240027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/26/2024]
Abstract
Background Diagnostic codes can be instrumental for case identification in Alzheimer's disease (AD) research; however, this method has known limitations and cannot distinguish between disease stages. Clinical notes may offer more detailed information including AD severity and can complement diagnostic codes for case identification. Objective To estimate prevalence of mild cognitive impairment (MCI) and AD using diagnostics codes and clinical notes available in the electronic healthcare record (EHR). Methods This was a retrospective study in the Veterans Affairs Healthcare System (VAHS). Health records from Veterans aged 65 years or older were reviewed during Fiscal Years (FY) 2010-2019. Overall, 274,736 and 469,569 Veterans were identified based on a rule-based algorithm as having at least one clinical note for MCI and AD, respectively; 201,211 and 149,779 Veterans had a diagnostic code for MCI and AD, respectively. During FY 2011-2018, likely MCI or AD diagnosis was defined by≥2 qualifiers (i.e., notes and/or codes)≥30 days apart. Veterans with only 1 qualifier were considered as suspected MCI/AD. Results Over the 8-year study, 147,106 and 207,225 Veterans had likely MCI and AD, respectively. From 2011 to 2018, yearly MCI prevalence increased from 0.9% to 2.2%; yearly AD prevalence slightly decreased from 2.4% to 2.1%; mild AD changed from 22.9% to 26.8%, moderate AD changed from 26.5% to 29.1%, and severe AD changed from 24.6% to 30.7. Conclusions The relative distribution of AD severities was stable over time. Accurate prevalence estimation is critical for healthcare resource allocation and facilitating patients receiving innovative medicines.
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Affiliation(s)
- Byron J Aguilar
- Geriatric Research Education and Clinical Center, VA Bedford Healthcare System, Bedford, MA, USA
- The Bedford VA Research Corporation, Inc., Bedford, MA, USA
| | - Guneet K Jasuja
- Center for Healthcare Organization & Implementation Research, VA Bedford Healthcare System, Bedford, MA, USA
- Section of General Internal Medicine, Boston University Chobanian and Avedisian School of Medicine, Boston, MA, USA
- Department of Health Law, Policy and Management, Boston University School of Public Health, Boston, MA, USA
| | - Xuyang Li
- The Bedford VA Research Corporation, Inc., Bedford, MA, USA
- Department of Biomedical Engineering, Johns Hopkins University, Baltimore, MD, USA
| | - Ekaterina Shishova
- Department of Public Health, Zuckerberg College of Health Sciences, University of Massachusetts Lowell, Lowell, MA, USA
| | - Natalia Palacios
- Geriatric Research Education and Clinical Center, VA Bedford Healthcare System, Bedford, MA, USA
- Department of Public Health, Zuckerberg College of Health Sciences, University of Massachusetts Lowell, Lowell, MA, USA
| | - Dan Berlowitz
- Department of Public Health, Zuckerberg College of Health Sciences, University of Massachusetts Lowell, Lowell, MA, USA
| | - Peter Morin
- Department of Neurology, Boston University Chobanian & Avedisian School of Medicine, Boston, MA, USA
| | - Maureen K O'Connor
- Geriatric Research Education and Clinical Center, VA Bedford Healthcare System, Bedford, MA, USA
- Department of Neurology, Boston University Chobanian & Avedisian School of Medicine, Boston, MA, USA
| | - Andrew Nguyen
- Geriatric Research Education and Clinical Center, VA Bedford Healthcare System, Bedford, MA, USA
- The Bedford VA Research Corporation, Inc., Bedford, MA, USA
| | - Joel Reisman
- Department of Biological Science, Kennedy College of Sciences, University of Massachusetts Lowell, Lowell, MA, USA
| | - Yue Leng
- Department of Psychiatry, University of California San Francisco Weill Institute for Neurosciences, San Francisco, CA, USA
| | - Raymond Zhang
- Alzheimer's Disease and Brain Health, Eisai Inc., Nutley, NJ, USA
| | - Amir Abbas Tahami Monfared
- Alzheimer's Disease and Brain Health, Eisai Inc., Nutley, NJ, USA
- Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, QC, Canada
| | - Quanwu Zhang
- Alzheimer's Disease and Brain Health, Eisai Inc., Nutley, NJ, USA
| | - Weiming Xia
- Geriatric Research Education and Clinical Center, VA Bedford Healthcare System, Bedford, MA, USA
- Department of Biological Science, Kennedy College of Sciences, University of Massachusetts Lowell, Lowell, MA, USA
- Department of Pharmacology, Physiology and Biophysics, Boston University Chobanian & Avedisian School of Medicine, Boston, MA, USA
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Morin P, Aguilar BJ, Berlowitz D, Zhang R, Tahami Monfared AA, Zhang Q, Xia W. Clinical Characterization of Veterans With Alzheimer Disease by Disease Severity in the United States. Alzheimer Dis Assoc Disord 2024; 38:195-200. [PMID: 38755757 DOI: 10.1097/wad.0000000000000622] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2024] [Accepted: 04/07/2024] [Indexed: 05/18/2024]
Abstract
PURPOSE We aimed to examine the clinical characteristics of US veterans who underwent neurocognitive test score-based assessments of Alzheimer disease (AD) stage in the Veterans Affairs Healthcare System (VAHS). METHODS Test dates for specific stages of AD were referenced as index dates to study behavioral and psychological symptoms of dementia (BPSD) and other patient characteristics related to utilization/work-up and time to death. PATIENTS We identified veterans with AD and neurocognitive evaluations using the VAHS Electronic Health Record (EHR). RESULTS Anxiety and sleep disorders/disturbances were the most documented BPSDs across all AD severity stages. Magnetic resonance imaging, neurology and psychiatry consultations, and neuropsychiatric evaluations were slightly higher in veterans with mild AD than in those at later stages. The overall average time to death from the first AD severity record was 5 years for mild and 4 years for moderate/severe AD. CONCLUSION We found differences in clinical symptoms, healthcare utilization, and survival among the mild, moderate, and severe stages of AD. These differences are limited by the low documentation of BPSDs among veterans with test score-based AD stages. These data support the hypothesis that our cohorts represent coherent subgroups of patients with AD based on disease severity.
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Affiliation(s)
- Peter Morin
- Department of Neurology, Boston University Chobanian and Avedisian School of Medicine, Boston
| | - Byron J Aguilar
- Geriatric Research Education and Clinical Center, Bedford VA Healthcare System
- Department of Pharmacology, Physiology and Biophysics, Boston University Chobanian and Avedisian School of Medicine, Boston
| | - Dan Berlowitz
- Department of Public Health, Zuckerberg College of Health Sciences, University of Massachusetts Lowell, Lowell, MA
| | - Raymond Zhang
- Alzheimer's Disease and Brain Health, Eisai Inc., Nutley, NJ
| | - Amir Abbas Tahami Monfared
- Alzheimer's Disease and Brain Health, Eisai Inc., Nutley, NJ
- Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, QC, Canada
| | - Quanwu Zhang
- Alzheimer's Disease and Brain Health, Eisai Inc., Nutley, NJ
| | - Weiming Xia
- Geriatric Research Education and Clinical Center, Bedford VA Healthcare System
- Department of Pharmacology, Physiology and Biophysics, Boston University Chobanian and Avedisian School of Medicine, Boston
- Department of Biological Sciences, Kennedy College of Sciences, University of Massachusetts Lowell, Lowell, MA
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Morin P, Aguilar BJ, Li X, Chen J, Berlowitz D, Zhang R, Tahami Monfared AA, Zhang Q, Xia W. Alzheimer's Disease Stage Transitions Among United States Veterans. J Alzheimers Dis 2024; 97:687-695. [PMID: 38143359 DOI: 10.3233/jad-230850] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2023]
Abstract
BACKGROUND Alzheimer's disease (AD) and related dementias are progressive neurological disorders with stage-specific clinical features and challenges. An important knowledge gap is the "window of time" within which patients transition from mild cognitive impairment or mild AD to moderate or severe AD. Better characterization/establishment of transition times would help clinicians initiating treatments, including anti-amyloid therapy. OBJECTIVE To describe cognitive test score-based AD stage transitions in Veterans with AD in the US Veterans Affairs Healthcare System (VAHS). METHODS This retrospective analysis (2010-2019) identified Veterans with AD from the VAHS Electronic Health Record (EHR) notes. AD stage was based on Mini-Mental State Examination (MMSE), Montreal Cognitive Assessment (MoCA), or Saint Louis University Mental Status (SLUMS) Examination scores in the EHR. RESULTS We identified 296,519 Veterans with cognitive test-based AD staging. Over the 10-year study, the proportion of veterans with MMSE scores declined from 24.9% to 9.5% while those with SLUMS rose from 9.0% to 17.8%; and MoCA rose from 5.0% to 25.4%. The average forward transition times between each stage were approximately 2-4 years, whether assessed by MMSE, MoCA, or SLUMS. CONCLUSION The average transition time for cognitive test-based assessments of initial cognitive decline, early-stage AD, and moderate/severe AD in the VAHS is 2-4 years. In view of the short window for introducing disease-modifying therapy and the significant benefits of early treatment of AD, our data suggest a critical need for treatment guidelines in the management of AD.
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Affiliation(s)
- Peter Morin
- Department of Neurology, Boston University Chobanian & Avedisian School of Medicine, Boston, MA, USA
| | - Byron J Aguilar
- Geriatric Research Education and Clinical Center, Bedford VA Healthcare System, Bedford, MA, USA
| | - Xuyang Li
- Geriatric Research Education and Clinical Center, Bedford VA Healthcare System, Bedford, MA, USA
| | - Jinying Chen
- Department of Preventive Medicine and Epidemiology, Data Science Core, Boston University Chobanian & Avedisian School of Medicine, Boston, MA, USA
| | - Dan Berlowitz
- Department of Public Health, Zuckerberg College of Health Sciences, University of Massachusetts Lowell, Lowell, MA, USA
| | - Raymond Zhang
- Alzheimer's Disease and Brain Health, EisaiInc., Nutley, NJ, USA
| | - Amir Abbas Tahami Monfared
- Alzheimer's Disease and Brain Health, EisaiInc., Nutley, NJ, USA
- Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, QC, Canada
| | - Quanwu Zhang
- Alzheimer's Disease and Brain Health, EisaiInc., Nutley, NJ, USA
| | - Weiming Xia
- Geriatric Research Education and Clinical Center, Bedford VA Healthcare System, Bedford, MA, USA
- Department of Pharmacology, Physiology and Biophysics, Boston University Chobanian & Avedisian School of Medicine, Boston, MA, USA
- Department of Biological Sciences, Kennedy College of Science, University of Massachusetts Lowell, Lowell, MA, USA
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Tahami Monfared AA, Khachatryan A, Hummel N, Kopiec A, Martinez M, Zhang R, Zhang Q. Assessing Quality of Life, Economic Burden, and Independence Across the Alzheimer's Disease Continuum Using Patient-Caregiver Dyad Surveys. J Alzheimers Dis 2024; 99:191-206. [PMID: 38640156 DOI: 10.3233/jad-231259] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/21/2024]
Abstract
Background Alzheimer's disease (AD) and mild cognitive impairment (MCI) have negative quality of life (QoL) and economic impacts on patients and their caregivers and may increase along the disease continuum from MCI to mild, moderate, and severe AD. Objective To assess how patient and caregiver QoL, indirect and intangible costs are associated with MCI and AD severity. Methods An on-line survey of physician-identified patient-caregiver dyads living in the United States was conducted from June-October 2022 and included questions to both patients and their caregivers. Dementia Quality of Life Proxy, the Care-related Quality of Life, Work Productivity and Activity Impairment, and Dependence scale were incorporated into the survey. Regression analyses investigated the association between disease severity and QoL and cost outcomes with adjustment for baseline characteristics. Results One-hundred patient-caregiver dyads were assessed with the survey (MCI, n = 27; mild AD, n = 27; moderate AD, n = 25; severe AD, n = 21). Decreased QoL was found with worsening severity in patients (p < 0.01) and in unpaid (informal) caregivers (n = 79; p = 0.02). Dependence increased with disease severity (p < 0.01). Advanced disease severity was associated with higher costs to employers (p = 0.04), but not with indirect costs to caregivers. Patient and unpaid caregiver intangible costs increased with disease severity (p < 0.01). A significant trend of higher summed costs (indirect costs to caregivers, costs to employers, intangible costs to patients and caregivers) in more severe AD was observed (p < 0.01). Conclusions Patient QoL and functional independence and unpaid caregiver QoL decrease as AD severity increases. Intangible costs to patients and summed costs increase with disease severity and are highest in severe AD.
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Aguilar BJ, Miller D, Jasuja G, Li X, Shishova E, O'Connor MK, Nguyen A, Morin P, Berlowitz D, Zhang R, Monfared AAT, Zhang Q, Xia W. Rule-Based Identification of Individuals with Mild Cognitive Impairment or Alzheimer's Disease Using Clinical Notes from the United States Veterans Affairs Healthcare System. Neurol Ther 2023; 12:2067-2078. [PMID: 37747662 PMCID: PMC10630261 DOI: 10.1007/s40120-023-00540-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2023] [Accepted: 08/23/2023] [Indexed: 09/26/2023] Open
Abstract
BACKGROUND Early identification of individuals with mild cognitive impairment (MCI) and Alzheimer's disease (AD) is a clinical and research imperative. Use of diagnostic codes for MCI and AD identification has limitations. We used clinical notes to supplement diagnostic codes in the Veterans Affairs Healthcare System (VAHS) electronic health records (EHR) to identify and establish cohorts of Veterans recorded with MCI or AD. METHODS Targeted keyword searches for MCI ("Mild cognitive impairment;" "MCI") and AD ("Alz*") were used to extract clinical notes from the VAHS EHR from fiscal year (FY) 2010 through FY 2019. Iterative steps of inclusion and exclusion were applied until searches achieved a positive predictive value ≥ 80%. MCI and AD cohorts were identified via clinical notes and/or diagnostic codes (i.e., including Veterans recorded by "Notes Only," "Notes + Code," or "Codes Only"). RESULTS A total of 2,134,661 clinical notes from 339,007 Veterans met the iterative search criteria for MCI due to any cause and 4,231,933 notes from 572,063 Veterans met the iterative search criteria for AD. Over the 10-year study period, the number of clinical notes recording AD was generally stable, whereas the number for MCI more than doubled. More Veterans were identified for the MCI or AD cohorts via clinical notes than by diagnostic codes, particularly in the AD cohort. Among Veterans identified by having "Notes + Code" for MCI, the number first recorded by a code was lower than the number first recorded by a note until FY 2015 and then gradually became comparable after FY 2015. Among Veterans identified by having "Notes + Code" for AD, the number first recorded by a note was more than double the number first recorded by a code AD in each of the FYs. CONCLUSIONS Clinical note-based identification captured more Veterans recorded with MCI and AD than diagnostic code-based identification.
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Affiliation(s)
- Byron J Aguilar
- Geriatric Research Education and Clinical Center, VA Bedford Healthcare System, 200 Springs Road, Bedford, MA, USA
| | - Donald Miller
- Zuckerberg College of Health Sciences, University of Massachusetts Lowell, Lowell, MA, USA
| | - Guneet Jasuja
- Center for Healthcare Organization and Implementation, VA Bedford Healthcare System, Bedford, MA, USA
| | - Xuyang Li
- Geriatric Research Education and Clinical Center, VA Bedford Healthcare System, 200 Springs Road, Bedford, MA, USA
| | - Ekaterina Shishova
- Zuckerberg College of Health Sciences, University of Massachusetts Lowell, Lowell, MA, USA
| | - Maureen K O'Connor
- Geriatric Research Education and Clinical Center, VA Bedford Healthcare System, 200 Springs Road, Bedford, MA, USA
- Department of Neurology, Boston University Chobanian & Avedisian School of Medicine, Boston, MA, USA
| | - Andrew Nguyen
- Geriatric Research Education and Clinical Center, VA Bedford Healthcare System, 200 Springs Road, Bedford, MA, USA
| | - Peter Morin
- Department of Neurology, Boston University Chobanian & Avedisian School of Medicine, Boston, MA, USA
| | - Dan Berlowitz
- Zuckerberg College of Health Sciences, University of Massachusetts Lowell, Lowell, MA, USA
| | - Raymond Zhang
- Alzheimer's Disease and Brain Health, Eisai Inc., Nutley, NJ, USA
| | - Amir Abbas Tahami Monfared
- Alzheimer's Disease and Brain Health, Eisai Inc., Nutley, NJ, USA
- Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, QC, Canada
| | - Quanwu Zhang
- Alzheimer's Disease and Brain Health, Eisai Inc., Nutley, NJ, USA
| | - Weiming Xia
- Geriatric Research Education and Clinical Center, VA Bedford Healthcare System, 200 Springs Road, Bedford, MA, USA.
- Department of Pharmacology, Physiology and Biophysics, Boston University Chobanian & Avedisian School of Medicine, Boston, MA, USA.
- Department of Biological Sciences, Kennedy College of Sciences, University of Massachusetts Lowell, Lowell, MA, USA.
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Morin PJ, Zhang Q, Xia W, Miller D, Querfurth H, Tahami Monfared AA. Clinical and Scientific Challenges to Effectiveness Studies Under Coverage with Evidence Development in Alzheimer's Disease. Neurol Ther 2023; 12:721-726. [PMID: 36933140 DOI: 10.1007/s40120-023-00462-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2023] [Accepted: 03/09/2023] [Indexed: 03/19/2023] Open
Abstract
The Centers for Medicare and Medicaid Services (CMS) has recently issued a national coverage determination for US Food and Drug Administration (FDA)-approved anti-amyloid monoclonal antibodies (mAbs) for the treatment of Alzheimer's disease (AD) under coverage with evidence development (CED). CED schemes are complex, costly, and challenging, and often fail to achieve intended objectives because of administrative and implementation issues. AD is a heterogeneous, progressive neurodegenerative disorder with complex care pathway that additionally presents scientific challenges related to the choice of study design and methods used in evaluating CED schemes. These challenges are herein discussed. Clinical findings from the US Veterans Affairs healthcare system help inform our discussion of specific challenges to CED-required effectiveness studies in AD.
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Affiliation(s)
- Peter J Morin
- Department of Neurology, Boston University School of Medicine, Boston, MA, USA
| | - Quanwu Zhang
- Global Alzheimer's Disease and Brain Health, Eisai Inc., Nutley, NJ, USA
| | - Weiming Xia
- Department of Biological Science, Kennedy College of Sciences, University of Massachusetts Lowell, Lowell, MA, USA
- Department of Pharmacology and Experimental Therapeutics, Boston University School of Medicine, Boston, MA, USA
- Bedford VA Healthcare Systems, Bedford, MA, USA
| | - Donald Miller
- Department of Biological Science, Kennedy College of Sciences, University of Massachusetts Lowell, Lowell, MA, USA
- Department of Public Health, Zuckerberg College of Health Sciences, University of Massachusetts Lowell, Lowell, MA, USA
| | - Henry Querfurth
- Department of Neurology, Tufts Medical Center, Boston, MA, USA
| | - Amir Abbas Tahami Monfared
- Global Alzheimer's Disease and Brain Health, Eisai Inc., Nutley, NJ, USA.
- Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, QC, Canada.
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