The Costs of Dementia in Europe: An Updated Review and Meta-analysis

The costs of dementia care by US state: Medical spending and the cost of unpaid caregiving

BackgroundThere are 5.5 million people living with dementia in the United States (US), with the cost of unpaid care making up a significant portion of the care costs.ObjectiveSummarize variation in the cost of dementia care across the US and examine the association between medical spending and costs of unpaid care at the state level.MethodsWe estimated total cost for dementia by combining recent medical spending estimates from the Disease Expenditure project and unpaid care cost estimates from Lastuka and colleagues. Hours of unpaid care were valued as the hourly wage of a home health aide. We used linear regression to measure the association between the cost of unpaid care and medical spending. The spending that would have occurred if unpaid care had been provided by professional home health care workers was used to measure the cost of unpaid care.ResultsThe annual cost of care attributable to dementia in 2019 was $53,502 (95% uncertainty interval [UI] 46,135-60,594) per case. The contribution of unpaid care to total costs varied by state, ranging from 70.2% (95% UI 64.3-75.4) in the District of Columbia to 89.9% (95% UI 87.8-91.5) in Arizona. We found that higher costs of unpaid care were associated with lower medical spending on nursing facility care.ConclusionsThe large variation in total costs of dementia shows that the economic burden of dementia care is distributed unevenly throughout the US.

Brain health services for the secondary prevention of cognitive impairment and dementia: Opportunities, challenges, and the business case for existing and future facilities

A European Task Force has recently developed and published the concept and protocols for the setup of the innovative health offer of Brain Health Services for the secondary prevention of dementia and cognitive impairment (dBHS). dBHS are outpatient health care facilities where adult persons can find an assessment of their risk of developing cognitive impairment and dementia, have their risk level and contributing factors communicated using appropriate language supported by adequate communication tools, can decide to participate to programs for personalized risk reduction if at higher risk, and benefit from cognitive enhancement interventions. This health offer is distinct from that of currently active memory clinics. The ultimate aim of dBHS is to extend healthy life, free from cognitive impairment. Here, we (i) discuss the pertinent opportunities and challenges for those persons who want to benefit from dBHS, professionals, and wider society, (ii) describe the concepts, protocols, organizational features, and patient journeys of some currently active dBHS in Europe, and (iii) argue in favor of the business case for dBHS in Europe.

Explaining the unmet information needs of family carers of people with dementia: a theoretical model of information behaviour

BACKGROUND

Family carers of people with dementia often report unmet information needs, despite policy emphasis on the provision of information as key to enabling good care and empowering carers in their role. Although the consequences of unmet information needs are detrimental to both the person being cared for and the carer, a systematic understanding of the causes of unmet information needs is lacking. To address this gap, this article presents a theoretical framework centred on the concept of information behaviour and integrating the information seeking and communication model, candidacy theory, and discrepancy theory. The framework maps information behaviour across six phases (from the identification of an information need to its satisfaction) and three levels (individual, service, system) at which explanatory factors may be observed.

METHODS

The framework was tested on data collected from 24 in-depth interviews and two focus groups with people with dementia and family carers of someone living with dementia in the North-East of England (UK). Data were analysed thematically to map the factors at play at each phase of the framework that might explain whether needs were met.

RESULTS

Unmet information needs are not always the result of a lack of information. Issues such as inadequate support for the user in identifying the need, problems in finding information, the timing of information provision, the amount of information provided, the credibility of the information source, and the relevance of the information (given care needs, preferences, personal, and family circumstances) can all contribute to unmet information needs. This work shows that meeting an information need ultimately requires progress through the different stages of information behaviour, each of which is influenced by the interplay of individual-, service-, and system-level factors, and depends on both users and providers.

CONCLUSIONS

This work challenges the rational paradigm in health and care information, which assumes that more information will lead to better care, and contributes to a critical perspective on health and care information that reframes successful information behaviour as a set of complex activities that are relational, emotionally charged, contextually embedded, and require (and produce) situated knowledge.

TRIAL REGISTRATION

Not applicable.

The Excess Direct Social Costs of Dementia-Related Neuropsychiatric Symptoms: A Regionwide Cohort Study Beyond Silos

OBJECTIVES

To estimate the excess formal social costs or direct non-healthcare costs of dementia-related neuropsychiatric symptoms (NPS).

METHODS

The presence of dementia, NPS, antipsychotic and antidepressant use, somatic and psychiatric comorbidities, and formal social benefits were studied in a regionwide cohort of all 60-year-old and older individuals. A random forest-based algorithm identified NPS, and 2-part regression models and entropy balance were used.

RESULTS

Of the 215 859 individuals, 7553 (3.50%) had dementia, 74 845 (34.7%) had some NPS, and 20 787 (9.63%) received long-term care benefits. Notably, nearly two-thirds (63.9%) of people with dementia received benefits. The probability of having social costs varied markedly with age (odds ratio [OR] 12.28 [10.17-14.82] for >90-year-olds category), and the presence of dementia (OR 7.36 [6.13-8.84]) or NPS (OR 3.23 [2.69-3.88]). NPS (relative change [RC] 1.39 [1.31-1.49]) and dementia (RC 1.32 [1.24-1.41]) were associated with higher average benefit costs. Low socioeconomic status was significantly associated with both a higher probability of receiving benefits (OR 1.52 [1.38-1.68]) and higher costs of their provision (RC 1.18 [1.15-1.21]).

CONCLUSIONS

The burden of caring for NPS is greater than that indicated by the literature as these symptoms multiply the social costs of dementia by more than 3, owing to the greater use of residential care and formal coverage reaching more patients than that indicated by the literature. The greater presence of dementia and NPS in the population of lower socioeconomic status indicates an inequality in health attenuated by greater use of social benefits.

Patient management pathways in dementia - Resource utilisation, diagnosis and drug treatment in the Stockholm region, Sweden

BACKGROUND

New diagnostic and therapeutic options for Alzheimer's disease are beginning to be introduced and expected igto become more widely available in the coming years. Improved understanding of current pathways in diagnosis and initial care of patients with dementia can help inform choices around how best to integrate new technologies in existing care structures.

OBJECTIVES

The aim of this study is to describe the care management pathways defined by the involvement of specialist and primary care for individuals with newly diagnosed dementia. It also seeks to characterise individuals in different management pathways based on resource use prior to diagnosis, the type of dementia diagnosis received, and the proportion who receive symptomatic anti-dementia drug treatment.

DESIGN

Observational cohort study SETTING: Stockholm region, Sweden.

PARTICIPANTS

All newly diagnosed dementia cases between 1st January 2018 to 30th June 2020 (n = 9,781). Dementia diagnoses in primary care were based on Regional Stockholm health care database and diagnoses in specialist care were based on the National Patient Register in Sweden.

MEASUREMENTS

Care management pathways were categorized into three groups: primary care only (diagnosed and followed up in primary care), specialist, no follow-up (diagnosed in specialist care but not followed up in specialist care), and specialist with follow-up (diagnosed and followed up in specialist care). These classifications were based on patients' care episodes from the date of diagnosis and the subsequent 18 months. age at diagnosis, resource utilisation one-year prior diagnosis and diagnosis given and symptomatic anti-dementia treatment 18 months after initial diagnosis.

RESULTS

A total of 9,781 newly diagnosed dementia cases were identified. In the 18 months following diagnosis, 63 % of patients were diagnosed either partly or fully in specialist care, while 37 % were diagnosed solely in primary care. Patients diagnosed and managed only in primary care were older, spent more days in hospital, and received more social care in the year preceding their diagnosis. Their total care costs were also the highest. Alzheimer's disease was the most common diagnosis (48 %), while 27 % had an unspecified dementia diagnosis, varying by care setting (61 % for patients managed in primary care only and 6 % for patients diagnosed and followed up in specialist care). Overall, 47 % of patients received symptomatic anti-dementia treatment, with the highest share for patients diagnosed and followed up in specialist care (73 %) and the lowest in primary care only (19 %). Diagnosis varied by age and care setting Alzheimer's was most common in settings involving specialist care, whereas unspecified dementia was more common in primary care only regardless of age.

CONCLUSION

The findings that patients managed exclusively in primary care were older, had higher pre-diagnosis resource utilisation, and were less likely to receive specific diagnoses or anti-dementia treatments highlight the crucial role of primary care in diagnosing and managing dementia among older individuals with complex needs. Further research is needed to explore primary care's role in diagnosis and treatment across diverse healthcare systems. Future research is needed to explore whether and how new diagnostic tools and treatment for AD could facilitate timely diagnosis and care for older individuals with dementia in primary care.

Urban-rural differences in the health care of people living with dementia and mild cognitive impairment in shared-housing arrangements in Germany - have inequities in urban vs. rural locations been overcome?

BACKGROUND

Previous studies have identified inequities in the diagnostic and therapeutic procedures used with community-dwelling people living with dementia (PlwDs) or people living with mild cognitive impairment (PlwMCIs) depending on the urban vs. rural location of their residence. Whether those differences in health care and health services utilization still exist for people residing in shared-housing arrangements (SHAs) remains unclear at this point.

METHODS

In a prospective, multicenter, mixed-methods, cluster-randomized controlled trial, the "DemWG study," 341 PlwDs or PlwMCIs living in a total of 97 SHAs across Germany were recruited. 31 of the participating SHAs were rural (133 participants), 66 were urban (208 participants). As a secondary analysis we evaluated health care data (e.g. vaccinations, medication), utilization of inpatient/outpatient medical services, non-pharmacological therapies according to the German Remedies Directive, provision of health and medical aids and structural data of the SHAs. Variables were assessed at baseline by trained staff from the SHAs using validated instruments (e.g. FIMA - questionnaire for health-related resource use in an elderly population). Descriptive and inferential statistical methods were applied. P-values were corrected with the Benjamini-Hochberg procedure.

RESULTS

The majority of the assessed health care data did not show significant differences between urban and rural SHA inhabitants. After the p-values were corrected, only two variables remained different: inhabitants of rural SHAs were prescribed a significantly larger number of total drugs, while urban inhabitants had significantly more appointments with neurologists/psychiatrists in the last 6 months. There were no significant differences in the use of all other type of inpatient/outpatient services, non-pharmacological therapies, use of health and medical aids. Also, the structural data of the SHAs like staffing did not significantly differ between urban and rural place of living.

DISCUSSION

While it seems that most inequities in the care of PlwDs/PlwMCIs living in SHAs between rural and urban areas have been overcome, there is still the one crucial difference in this non-representative sample of SHAs: the contact with neurologic/psychiatric specialists who offer elaborated diagnostic procedures is less frequent in rural areas.

TRIAL REGISTRATION

ISRCTN89825211 (Registered prospectively, 16 July 2019).

Towards the automatic detection of activities of daily living using eye-movement and accelerometer data with neural networks

Early diagnosis of neurodegenerative diseases, such as Alzheimer's disease, improves treatment and care outcomes for patients. Early signs of cognitive decline can be detected using functional scales, which are written records completed by a clinician or carer, detailing a patient's capability to perform routine activities of daily living. For example, tasks requiring planning, such as meal preparation, are some of the earliest affected by early mild cognitive impairment. In this article, we describe work towards the development of a system to automatically discriminate and objectively quantify activities of daily living. We train a selection of neural networks to discriminate a novel list of 14 activities, specially selected to overlap with those measured by existing functional scales. Our dataset consists of eight hours of development data captured from four individuals wearing the Continuous Ambulatory Vestibular Assessment (CAVA) device, which was originally developed to aid the diagnosis of vertigo. Using frequency domain recognition features derived from eye-movement and accelerometer data, we compare several classification approaches, including three bespoke neural networks, and two established network architectures commonly applied to time-series classification problems. In 10-fold cross-validation experiments, a peak mean accuracy of 64.1% is obtained. The highest accuracy across all folds is 75.3%, produced by networks comprising Gated Recurrent Units. The addition of eye-movement data is shown to improve discrimination compared to using accelerometer data alone, by close to 9%. Classification accuracy is shown to degrade if the system is trained such that test subjects are excluded from the training data, with the small size of the dataset given as a likely explanation. Our findings demonstrate that the addition of eye-movement data can significantly improve the discrimination of daily activities, and that neural networks are well suited to this task.

Informal caregivers' perspectives on participation in a dementia rehabilitation programme

BACKGROUND

There is limited experience in combining interdisciplinary rehabilitation for persons with dementia and caregiver support.

AIM

To explore how informal caregivers perceive participation in a person-centred, multidimensional, interdisciplinary rehabilitation programme targeting community-dwelling older adults with dementia and their informal caregivers, and how the programme has influenced their everyday life.

MATERIAL AND METHODS

Fourteen informal caregivers, aged 45-84 years, participated in a qualitative interview following a randomised controlled pilot study. Transcribed interviews were analysed using qualitative content analysis.

RESULTS

The analysis resulted in seven categories and three themes: feeling challenged and boosted to face an uncertain future, perceiving supportive activities as sources of both joy and frustration in everyday life and finding relief in recognising their relative's former self.

CONCLUSIONS AND SIGNIFICANCE

Combining interdisciplinary rehabilitation for adults with dementia with education and support for caregivers was perceived as viable and valuable for the informal caregivers. They felt strengthened by the rehabilitation and better prepared for their uncertain future. However, participation also challenged everyday routines, but the benefits appeared to outweigh the strain.

Costs of Care in Relation to Alzheimer's Disease Severity in Sweden: A National Registry-Based Cohort Study

BACKGROUND

The advancement of diagnostic and therapeutic interventions in early Alzheimer's disease (AD) has demanded the economic evaluation of such interventions. Resource utilization and cost estimates in early AD and, more specifically, the amyloid-positive population are still lacking. We aimed to provide cost estimates in AD in relation to disease severity and compare these with the control population. We also aimed to provide cost estimates for a subset of the AD population with both clinical diagnosis and amyloid-positive confirmation.

MATERIALS AND METHODS

This was a retrospective longitudinal analysis of resource utilization using data from national registries. A cohort from the national Swedish registry for cognitive/dementia disorders (SveDem) includes all clinically diagnosed AD between 2013 and 2020. The study population included 31,951 people with AD and 63,902 age- and sex-matched controls (1:2). The population was followed until death, the end of December 2020, or 2 years from the last clinic visit. Direct medical and social costs were estimated from other national registries. Direct medical costs include costs for medications and inpatient and outpatient clinical visits. Direct social costs include costs for institutionalization, home care, short-term care, support for daytime activities, and housing support. Mean annual costs and 95% confidence intervals were obtained by bootstrapping, presented in 2021 Swedish Krona (SEK) (1 SEK = 0.117 USD, 1 SEK = 0.0985 EUR in 2021), and disaggregated by AD severity, cost component, sex, age group, and care setting.

RESULTS

Mean annual costs for individuals with clinically diagnosed AD were SEK 99,906, SEK 290,972, SEK 479,524, and SEK 795,617 in mild cognitive impairment (MCI), mild, moderate, and severe AD. The mean annual costs for the population with both clinical diagnosis and amyloid-positive AD confirmation (N = 5610) were SEK 57,625, SEK 179,153, SEK 333,095, and SEK 668,073 in MCI, mild, moderate, and severe AD, respectively. The mean annual costs were higher in institutionalized than non-institutionalized patients, females than males, and older than younger age groups. Inpatient and drug costs were similar in all AD severity stages, but outpatient costs decreased with AD severity. Costs for institutionalization, home care, support for daytime activities, and short-term care increased with AD severity, whereas the cost of housing support decreased with AD severity.

CONCLUSIONS

This is the first study estimating annual costs in people with AD from MCI to severe AD, including those for the amyloid-positive population. The study provides cost estimates by AD severity, cost components, care settings, sex, and age groups, allowing health economic modelers to apply the costs based on different model structures and populations.

Chronic pain in older adults with disabilities is associated with cognitive impairment-a prospective cohort study

BACKGROUND

Chronic pain may be an important factor influencing cognitive impairment; however, there is limited research on that link in older adults with disabilities. We aimed to determine the association between chronic pain and cognitive impairment in older adults with disabilities.

METHODS

This 24-month prospective cohort study involved 143 Japanese older adults (≥65 years of age) with long-term care insurance. Chronic pain was defined as pain persisting for ≥3 months, and cognitive impairment was defined as a Mini-Mental State Examination score ≤ 23. We employed logistic regression analysis with chronic pain as the independent variable and cognitive impairment as the dependent variable after propensity score matching (PSM).

RESULTS

Sixty-six participants were selected using PSM, and logistic regression analysis showed that chronic pain was significantly associated with cognitive impairment (odds ratio: 4.103, 95% confidence interval: 1.455-11.567, P = 0.008).

CONCLUSION

To prevent cognitive impairment in older adults with disabilities, the management of chronic pain should be considered, as they are related.

Cognitive decline and diabetes in the clinical setting

Objective

The aim of our study was to evaluate the prevalence of cognitive decline in patients with diabetes in the clinical setting and to identify patient characteristics directly associated with this condition.

Methods

In our cross-sectional study, we applied the Mini Mental State Examination (MMSE) and the Montreal Cognitive Assessment (MoCA) to determine cognitive function in 172 diabetic patients, in the clinical setting. We included 120 patients with type 2 diabetes (T2DM), 42 cases with type 1 diabetes (T1DM) and 10 patients with confirmed secondary diabetes (SDM). The mean age of the participants was 62.4 years (±1.01, min: 26 years, Max: 87 years), with median diabetes duration of 15±11.8 years.

Results

More than half (55.23%) of the subjects presented cognitive deterioration, which was diabetes type-specific (p<0.05). Mild forms affected mostly T1DM and SDM cases (31.5% and 30% vs. T2DM: 14.5%, p=0.00), whereas moderate cognitive decline was more predominant in T2DM (21.9% vs. T1DM: 7.1%, p=0.1). A higher prevalence of severe cognitive impairment was present in T1DM (14.5% vs. T2DM: 8.7%, p=0.1).The middle-aged category (40-64 years) was characterized by a more significant reduction of cognitive function in comparison with other age groups (p=0.02).No gender-related difference in the prevalence of cognitive decline was found (female: 45.83% vs male: 45.71%, p=0.98), although severe forms were significantly more suggestive for men (15.27% vs. 4.18%, p=0.04).Diabetic ketoacidosis (DKA) at admission was more frequently associated with cognitive deterioration, in comparison with hypoglycemic events (p=0.03).In T2DM, cognitive decline (p=0.006, r=-0.342) was associated with the presence of anemia.In T2DM women, treatment with calcium-channel blockers facilitated cognitive decrement (p=0.01, r=-0.339), whereas in men, therapy for distal symmetric polyneuropathy resulted in higher MMSE/MoCA test scores (p=0.00, r=0.72).In T1DM, a higher glycemic burden evidenced by increased HbA1c (p=0.03, r=-0.364) and glycemia at admission (p=0.01, r=-0.389) was suggestive to a more severe form of cognitive impairment. Distal symmetrical polyneuropathy (p=0.05, r=-0.305) and diabetic retinopathy (p=0.03, r=-0.102) was often co-occurring with cognitive decline.Cognitive deterioration was associated with insulin therapy (p=0.05, r=-0.232).

Conclusion

The prevalence of cognitive decline is high in the diabetic population. Risk stratification must start at diagnosis and physicians should follow disease progression periodically, with special attention attributed to T1DM and the middle-aged population.

Informal care for people with dementia in Europe

INTRODUCTION

Informal care estimates for use in health-economic models are lacking. We aimed to estimate the association between informal care time and dementia symptoms across Europe.

METHODS

A secondary analysis was performed on 13,529 observations in 5,369 persons from 9 European pooled cohort or trial studies in community-dwelling persons with dementia. A mixed regression model was fitted to time spent on instrumental or basic activities of daily living using disease severity and demographic characteristics.

RESULTS

Daily informal care time was 0.5 hours higher in moderate compared to mild and 1.3h higher in severe compared to mild cognitive impairment. Likewise, this was 1.2h and 2.7h for functional disability and 0.3h and 0.6h for behavioral symptoms in the same directions.

DISCUSSION

Estimates can be used in both single- and multi-domain health-economic models for dementia in European settings.

Hearing and vision rehabilitation for people with dementia in five European countries (SENSE-Cog): a randomised controlled trial

BACKGROUND

The effect of hearing and vision difficulties on the risk of developing dementia and worsening outcomes in people already living with dementia is well established. We evaluated the clinical impact of a hearing and vision rehabilitation and support programme on quality of life in people with mild-to-moderate dementia and concurrent sensory difficulties.

METHODS

We conducted a parallel-group, multicentre, observer-blind, superiority randomised controlled trial in seven older adult clinics in five European countries (Cyprus, France, Greece, Ireland, and the UK). People with mild-to-moderate dementia with adult-acquired hearing difficulties, vision difficulties, or both were randomly assigned (1:1) along with their care partner to an 18-week home-basedsensory support intervention (SSI) of tailored hearing and vision rehabilitation and support, or to care as usual. Randomisation was blocked (block size of four, six, or eight) and stratified by country, with allocation assigned via a remote web-based system. The SSI included: full hearing assessment, vision assessment, or both; fitting of hearing aids, glasses, or other sensory aids; and home-based support from a sensory support therapist to assist adherence and uptake of sensory aids, foster social networking, and optimise the home sensory environment. Care as usual involved no additional intervention beyond services normally available to people with dementia at the respective sites. The primary outcome was health-related quality of life (Dementia Quality of Life Instrument [DEMQoL]) score at 36 weeks, reported as an adjusted mean difference. Analyses were done according to the intention-to-treat principle. This trial is registered with the ISRCTN Registry, ISRCTN17056211.

FINDINGS

Between May 4, 2018, and May 6, 2021, 252 people with mild-to-moderate dementia were randomly assigned, of whom 251 (n=126 in the SSI group and n=125 in the care as usual group) were included in the analysis. The mean age of participants was 79·6 years (SD 5·8), and 132 (53%) were women. After a median follow-up time of 37·7 weeks (IQR 36·2-39·0), the mean DEMQoL score was 92·8 (SD 15·2) in the SSI group and 92·8 (14·0) in the care as usual group (adjusted difference 0·18, 95% CI -2·13 to 2·30, p=0·87). Among 114 adverse events reported for 56 (44%) participants in the SSI group, ten events in nine participants were related or possibly related to the intervention (medical device pain or discomfort n=6, ear pain n=1, scratch to the ear n=1, sore eye n=1, redness n=1; all of grade 1). Serious adverse events were reported for 25 (20%) participants in the SSI group and 16 (13%) in the care as usual group. Six (5%) participants in the SSI group and five (4%) in the care as usual group died. None of the serious adverse events or deaths were related to the study intervention or procedures.

INTERPRETATION

This study showed no improvement in quality in life in participants who received the intervention in the longer term. Sensory difficulties are common in people with dementia and interventions aimed at improving sensory-cognitive health should be explored further.

FUNDING

EU Horizon 2020.

Trends in Global Burden of Alzheimer's Disease and Other Dementias Attributable to High Fasting Plasma Glucose, 1990-2021

Background and Objectives: Alzheimer's disease and other dementias represent some of the leading public health concerns worldwide. This study aimed to assess the global burden of Alzheimer's disease and other dementias attributable to high fasting plasma glucose in the last decades. Materials and Methods: A descriptive epidemiological study was conducted. The Global Burden of Disease (GBD) study data about deaths and Disability-Adjusted Life Years (DALYs) were used. All figures were presented as age-standardized rates (ASRs). The average annual percent change (AAPC) was computed using the Joinpoint regression analysis. Also, age-period-cohort analysis was performed. Results: A total of 2 million deaths from Alzheimer's disease and other dementias were reported worldwide in 2021, whereby the total number deaths from Alzheimer's disease and other dementias attributable to high fasting plasma glucose was 290,032 (98,900 males and 191,132 females) in 2021. The highest ASRs of burden of Alzheimer's disease and other dementias attributable to high fasting plasma glucose were found in Afghanistan, Iraq, Morocco, Qatar, and the United States of America, while the lowest ASRs were in Belarus and Mongolia. From 1990 to 2021, a significant increase (p < 0.001) was noted in ASRs of deaths and DALYs for Alzheimer's disease and other dementias attributable to high fasting plasma glucose. Looking at the GBD regions, the trends in ASRs for mortality and for DALYs of Alzheimer's disease and other dementias attributable to high fasting plasma glucose between 1990 and 2021 showed a growth 10-fold faster in High-income North America (AAPC = 2.0%, for both equally) and Central Asia (AAPC = 2.4% and AAPC = 2.5%, respectively) than in the region of High-income Asia Pacific (AAPC = 0.1% and AAPC = 0.2%, respectively). The relative risk of mortality and DALYs for Alzheimer's disease and other dementias attributable to high fasting plasma glucose demonstrated statistically significant (p < 0.0001) period and cohort effects, and net drift and local drifts. Conclusions: This study showed an increase in the global burden of Alzheimer's disease and other dementias attributable to high fasting plasma glucose in the last decades. Future successful entire-population strategies targeting high fasting plasma glucose may reduce the burden of a wide range of these diseases.

Participation in everyday activities among young adult relatives of parents with dementia - A qualitative study

Previous research has shown that young adult relatives of parents with dementia experience strain through increased responsibility and changed relationships in the family with potential consequences for their emotional, mental and physical well-being. Less is known about how young adult relatives experience their participation in everyday activities typically associated with young adulthood and how their participation is affected by the parent´s dementia. This study explores young adult relatives' experiences of participation in everyday activities and how their participation was affected by having a parent with dementia. The study followed a qualitative, descriptive approach. Semi-structured individual interviews with 11 young adult relatives (aged 21 - 31) of parents with dementia were conducted. The interviews were analysed using Kirsti Malterud's iterative cross case analysis method 'Systematic text condensation'. The analysis identified three categories: Dilemmas of choosing, Not having a choice and Reversal of roles. The young adult relatives experienced dilemmas and constraints regarding participation in everyday activities usually related to young adulthood. They navigated situations where they were to choose between the parent with dementia and their own everyday activities and they often downgraded or cancelled participation in own activities related to leisure time, school, job and career. Moreover, their participation seemed affected by chores and responsibilities resulting in a lack of energy leading them to forego social activities in particular or change their choice of activities. The young adult relatives need help and support in their everyday lives. Health care professionals are encouraged to focus on relieving them from some of the responsibilities and practical tasks enabling them to live their own lives as young adults, while being part of the family and contributing towards the responsibilities and tasks with which they can cope.

Inequalities in the Prevention and Treatment of Alzheimer Disease

Incidence of Alzheimer disease (AD) is going to rise in the next years and to become a health and social emergency. The prevention and the therapeutic management of AD still present unmet needs worldwide. The recent approval of monoclonal antibodies against amyloid β (anti-Aβ mAbs) for AD has increased the level of uncertainty regarding on how such drugs should be administered, to whom, and for how long. Concerns about cost-effectiveness ratios of anti-Aβ mAbs and the need for actual strategies of risk prevention have further dug barriers of inequalities between the national health care systems. Planning research to address questions on the real feasibility of the correct therapeutic management, improving international cooperation on surveillance of risk factors, implementing pathways for timely diagnosis, and effective medical and social support for patients with AD worldwide would be extremely valuable to fight against this upcoming pandemic.

Needs for Care, Service Use and Quality of Life in Dementia: 12-Month Follow-Up of the Actifcare Study in Portugal

INTRODUCTION

The intermediate stages of dementia are relatively under-researched, including in Portugal. The Actifcare (ACcess to TImely Formal Care) EU-JPND project studied people with mild-moderate dementia, namely their needs, access to and use of community services (e.g., day centers, home support). In our baseline assessment of the Portuguese Actifcare cohort, the unmet needs of some participants would call for formal support, which was not always accessible or used. We now report the main results of the 12-month follow-up, analyzing changes in needs, service (non)use, quality of life and related variables.

METHODS

This was a longitudinal, observational study using a convenience sample of 54 dyads of people with dementia and their family carers. Our main outcomes were the Camberwell Assessment of Need for the Elderly (CANE) and the Resources Utilization in Dementia. Clinical-functional, quality of life, psychological distress and caregiving-related assessments were also used.

RESULTS

At follow-up, the cognitive and functional status of people with dementia declined (p < 0.001), and their neuropsychiatric symptoms increased (p = 0.033). Considering CANE interviewers' ratings, the total needs of people with dementia increased at follow-up (p < 0.001) but not the unmet needs. Quality of life was overall stable. The use of formal care did not increase significantly, but informal care did in some domains. Carers' depressive symptoms increased (p = 0.030) and perseverance time decreased (p = 0.045). However, carers' psychological distress unmet needs were lower (p = 0.007), and their stress and quality of life remained stable.

CONCLUSION

People with dementia displayed complex biopsychosocial unmet needs. Their cognitive-functional decline over one year was not accompanied by a corresponding increase in any pattern of unmet need, nor of service use. Reliance on informal care (namely supervision) may have contributed to this. Caregiving-related outcomes evolved according to different trends, although stability was almost the rule. Primary carers were even more present at follow-up, without an apparently heavier toll on their own needs, burden, and quality of life. Overall, this longitudinal study comprehensively assessed Portuguese community-dwelling people with dementia. Despite the lack of generalizability, participants' needs remained overall stable and partly unmet over one year. Longer follow-up periods are needed to understand such complex processes.

North Macedonia interprofessional dementia care (NOMAD) - personalized care plans for people with dementia and caregiver psychoeducation delivered at home by interprofessional teams

Introduction

The increasing number of people living with dementia and its burden on families and systems particularly in low- and middle-income countries require comprehensive and efficient post-diagnostic management. This study aimed to explore the acceptability and efficacy of a multi-professional case management and psychoeducation model (North Macedonia Interprofessional Dementia Care, or NOMAD) delivered by mobile teams for people with dementia and their caregivers in North Macedonia.

Method

We conducted a two-arm randomized controlled trial comparing the intervention with treatment as usual. Participants were recruited from 12 general practitioner (GP) offices in the Skopje region. The NOMAD intervention included the delivery of a personalized care plan over four home visits to dyads of people with dementia and their caregivers by a team including a dementia nurse and a social worker, in collaboration with GPs and dementia experts, and the introduction of a caregiver manual. We assessed caregivers' depressive symptoms, burden, and quality of life and the neuropsychiatric symptoms, daily living activities, and service utilization of people with dementia at baseline and follow-up; we also assessed the acceptability of the intervention by analyzing case notes and attendance rates.

Results

One hundred and twenty dyads were recruited and randomized to either the control (n = 60) or the intervention group (n = 60). At follow-up, caregivers in the intervention group had, on average, scores that were 2.69 lower for depressive symptoms (95% CI [-4.75, -0.62], p = 0.012), and people with dementia had, on average, 11.32 fewer neuropsychiatric symptoms (95% CI [-19.74, -2.90], p = 0.009) and used, on average, 1.81 fewer healthcare services (95% CI [-2.61, -1.00], p < 0.001) compared to the control group. The completion of the home visits was 100%, but the intervention's acceptability was underpinned by relationship building, GP competencies, and resources to support families with dementia. There were no differences in the caregivers' quality of life and burden levels or daily living activities in people with dementia. NOMAD is the first case management, non-pharmacological, and multi-professional intervention tested in North Macedonia.

Discussion

The trial showed that it is effective in reducing caregivers' depressive symptoms and neuropsychiatric symptoms in people with dementia and the burden on health and social care services, and it is acceptable for families. Implementing NOMAD in practice will require building primary care capacity and recognizing dementia as a national priority.

Impact of major osteoporotic fractures on the use of healthcare resources in Catalonia, Spain

OBJECTIVES

To estimate the impact of first major osteoporotic fractures (MOF) on health resource use and healthcare expenditures in people aged ≥50 years in Catalonia, Spain.

DESIGN

Observational, retrospective study. The Catalan Health Surveillance System (CHSS) registry was used to obtain sociodemographic, clinical and expenditure data from all public centres in Catalonia (Spain).

SETTING AND PARTICIPANTS

Males and females aged ≥50 years who sustained a first major osteoporotic fracture between January 1, 2018, and December 31, 2020.

METHODS

Data on admissions to the emergency department, hospitalization and skilled nursing facilities, primary and specialized care visits, nonemergency medical transport, outpatient rehabilitation and pharmacy prescriptions were retrieved for each patient. Monthly and yearly mean usage rates, expenditure in euros (€) and incremental costs one and two years after fracture were calculated.

RESULTS

There were 64,403 patients with first MOF: 47,555 females and 16,848 males with a mean age (standard deviation) of 76.5 (12.0) years. The average annual expenditure increased from €4564 in the year before to €12,331 in the year following a hip fracture. For forearm fractures, the expenditure increased from €2511 to €4251, for vertebral fractures from €4146 to €6659, for pelvic fractures from €4442 to €7124, for humerus fractures from €3058 to €5992, and for multiple fractures from €4598 to €12,028. The average cost for overall fractures experienced a 110.3 % increase. The leading cause of health expenditure in the year following MOF was hospital admission. Expenditure in the second year post-fracture returned to pre-fracture levels. The use of some healthcare resources, especially visits to emergency services, increased in the prefracture month. Male sex, older age and high previous comorbidities were associated with a higher expenditure.

CONCLUSIONS

In people with a first MOF, healthcare expenditure doubled during the first-year post-facture, mostly in relation to inpatient care. The healthcare resource use increased during the previous month. This increase could potentially be attributed to the worsening of pre-existing comorbidities.

Predicting sojourn times across dementia disease stages, institutionalization, and mortality

INTRODUCTION

Inferring the timeline from mild cognitive impairment (MCI) to severe dementia is pivotal for patients, clinicians, and researchers. Literature is sparse and often contains few patients. We aim to determine the time spent in MCI, mild-, moderate-, severe dementia, and institutionalization until death.

METHODS

Multistate modeling with Cox regression was used to obtain the sojourn time. Covariates were age at baseline, sex, amyloid status, and Alzheimer's disease (AD) or other dementia diagnosis. The sample included a register (SveDem) and memory clinics (Amsterdam Dementia Cohort and Memento).

RESULTS

Using 80,543 patients, the sojourn time from clinically identified MCI to death across all patient groups ranged from 6.20 (95% confidence interval [CI]: 5.57-6.98) to 10.08 (8.94-12.18) years.

DISCUSSION

Generally, sojourn time was inversely associated with older age at baseline, males, and AD diagnosis. The results provide key estimates for researchers and clinicians to estimate prognosis.

Cost-Effectiveness of Prevention for People at Risk for Dementia: A Scoping Review and Qualitative Synthesis

Dementia is from an economic perspective a main challenge for economies worldwide because of increasing costs. Since there is no cure in sight, prevention seems the most promising approach for reducing health care cost due to Dementia. On the contrary, approximately 40% of dementias is attributable to modifiable risk factors and first studies showed that multidomain interventions may be effective for preventing dementia. Considering the increasing economic burden, for many health administrations worldwide, cost-effectiveness plays a mayor role. This scoping review wants to bring evidence to the question if prevention for people at risk may be cost-effective. Therefore, the four databases Medline (via Pubmed), CINHAL (via EBSCO), Business Source Complete (via EBSCO), and the Health Economic Evaluation database (HEED) were used to conduct a scoping review using PICO and a systematic search string. 3,629 studies were identified and seven met all inclusion criteria. The included studies showed clear cost-effectiveness for most multidomain interventions. The gained QALYs at mean were 0.08 (SD=0.08) and the intervention average costs 472.20 EUR per Person (SD=74.06 EUR). The Incremental Cost-Effectiveness Ratios varied between -80,427.97 and 104,189.82 EUR per QALY. The three core results are (i) prevention programs focusing on people at risk may be cost-effective and cost-efficient, (ii) multimodal prevention reveal cost saving potential, when the people at risk are defined well, (iii prevention in middle-aged cohorts may be also cost-effective if life-style related risk factors are addressed.

Optimising Alzheimer's Disease Diagnosis and Treatment: Assessing Cost-Utility of Integrating Blood Biomarkers in Clinical Practice for Disease-Modifying Treatment

BACKGROUND

Recent developments in blood biomarkers (BBM) have shown promising results in diagnosing amyloid pathology in Alzheimer's Disease (AD). However, information on how these BBMs can best be used in clinical settings to optimise clinical decision-making and long-term health outcomes for individuals with AD is still lacking.

OBJECTIVES

We aim to assess the potential value of BBM in AD diagnosis within the context of disease-modifying treatment (DMT).

DESIGN

We developed a decision analytic model to evaluate the long-term health outcomes using BBM in AD diagnosis. We compared standard of care (SOC) diagnosis workflow to the integration of BBM as a (1) referral decision tool in primary health center (PHC) and (2) triaging tool for invasive CSF examination in specialist memory clinic (MC). We combined a decision tree and a Markov model to simulate the patient's diagnostic journey, treatment decisions following diagnosis and long-term health outcomes. Input parameters for the model were identified from published literature and registry data analysis. We conducted a cost-utility analysis from the societal perspective using a one-year cycle length and a 30-year (lifetime) horizon.

MEASUREMENTS

We reported the simulated outcomes in the percentage of correct diagnosis, costs (in 2022 Euros), quality-adjusted life year (QALY), and incremental cost-effectiveness ratios (ICER) associated with each diagnosis strategy.

RESULTS

Compared to SOC, integrating BBM in PHC increased patient referrals by 8% and true positive AD diagnoses by 10.4%. The lifetime costs for individuals diagnosed with AD were € 249,685 and €250,287, and QALYs were 9.5 and 9.52 in SOC and PHC pathways, respectively. The cost increments were €603, and QALYs gained were 0.01, resulting in an ICER of €48,296. Using BBM in MC reduced the exposure to invasive CSF procedures and costs but also reduced true positive AD diagnoses and QALYs.

CONCLUSIONS

Using BBM at PHC to make referral decisions might increase initial diagnostic costs but can prevent high costs associated with disease progression, providing a cost-effective DMT is available, whereas using BBM in MC could reduce the initial evaluation cost but incur high costs associated with disease progression.

Progress in the Treatment of Alzheimer's Disease Is Needed - Position Statement of European Alzheimer's Disease Consortium (EADC) Investigators

β-amyloid-targeting antibodies represent the first generation of effective causal treatment of Alzheimer's disease (AD) and can be considered historical research milestones. Their effect sizes, side effects, implementation challenges and costs, however, have stimulated debates about their overall value. In this position statement academic clinicians of the European Alzheimer's Disease Consortium (EADC) discuss the critical relevance of introducing these new treatments in clinical care now. Given the complexity of AD it is unlikely that molecular single-target treatments will achieve substantially larger effects than those seen with current β-amyloid-targeting antibodies. Larger effects will most likely only be achieved incrementally by continuous optimization of molecular approaches, patient selection and combinations therapies. To be successful in this regard, drug development must be informed by the use of innovative treatments in real world practice, because full understanding of all facets of novel treatments requires experience and data of real-world care beyond those of clinical trials. Regarding the antibodies under discussion we consider their effects meaningful and potential side effects manageable. We assume that the number of eventually treated patient will only be a fraction of all early AD patients due to narrow eligibility criteria and barriers of access. We strongly endorse the use of these new compound in clinical practice in selected patients with treatment documentation in registries. We understand this as a critical step in advancing the field of AD treatment, and in shaping the health care systems for the new area of molecular-targeted treatment of neurodegenerative diseases.

Clinical outcomes up to 9 years after [18F]flutemetamol amyloid-PET in a symptomatic memory clinic population

BACKGROUND

Previous studies demonstrated increases in diagnostic confidence and change in patient management after amyloid-PET. However, studies investigating longitudinal outcomes over an extended period of time are limited. Therefore, we aimed to investigate clinical outcomes up to 9 years after amyloid-PET to support the clinical validity of the imaging technique.

METHODS

We analyzed longitudinal data from 200 patients (Mage = 61.8, 45.5% female, MMMSE = 23.3) suspected of early-onset dementia that underwent [18F]flutemetamol-PET. Baseline amyloid status was determined through visual read (VR). Information on mortality was available with a mean follow-up of 6.7 years (range = 1.1-9.3). In a subset of 108 patients, longitudinal cognitive scores and clinical etiological diagnosis (eDx) at least 1 year after amyloid-PET acquisition were available (M = 3.06 years, range = 1.00-7.02). VR - and VR + patients were compared on mortality rates with Cox Hazard's model, prevalence of stable eDx using chi-square test, and longitudinal cognition with linear mixed models. Neuropathological data was available for 4 patients (mean delay = 3.59 ± 1.82 years, range = 1.2-6.3).

RESULTS

At baseline, 184 (92.0%) patients were considered to have dementia. The majority of VR + patients had a primary etiological diagnosis of AD (122/128, 95.3%), while the VR - group consisted mostly of non-AD etiologies, most commonly frontotemporal lobar degeneration (30/72, 40.2%). Overall mortality rate was 48.5% and did not differ between VR - and VR + patients. eDx at follow-up was consistent with baseline diagnosis for 92/108 (85.2%) patients, with most changes observed in VR - cases (VR -  = 14/35, 40% vs VR +  = 2/73, 2.7%, χ2 = 26.03, p < 0.001), who at no time received an AD diagnosis. VR + patients declined faster than VR - patients based on MMSE (β =  - 1.17, p = 0.004), episodic memory (β =  - 0.78, p = 0.003), fluency (β =  - 1.44, p < 0.001), and attention scores (β = 16.76, p = 0.03). Amyloid-PET assessment was in line with post-mortem confirmation in all cases; two cases were VR + and showed widespread AD pathology, while the other two cases were VR - and showed limited amyloid pathology.

CONCLUSION

In a symptomatic population, we observed that amyloid-status did not impact mortality rates, but is predictive of cognitive functioning over time across several domains. Also, we show particular validity for a negative amyloid-PET assessment, as these patients did not receive an AD diagnosis at follow-up.

Assessing frailty at the centers for dementia and cognitive decline in Italy: potential implications for improving care of older people living with dementia

INTRODUCTION

Frailty is strongly associated with the clinical course of cognitive impairment and dementia, thus arguing for the need of its assessment in individuals affected by cognitive deficits. This study aimed to retrospectively evaluate frailty in patients aged 65 years and older referred to two Centers for Cognitive Decline and Dementia (CCDDs).

METHODS

A total of 1256 patients consecutively referred for a first visit to two CCDDs in Lombardy (Italy) between January 2021 to July 2022 were included. All patients were evaluated by an expert physician in diagnosis and care of dementia according to a standardized clinical protocol. Frailty was assessed using a 24-items Frailty Index (FI) based on routinely collected health records, excluding cognitive decline or dementia, and categorized as mild, moderate, and severe.

RESULTS

Overall, 40% of patients were affected by mild frailty and 25% of the sample has moderate to severe frailty. The prevalence and severity of frailty increased with decreasing Mini Mental State Examination (MMSE) score and advancing age. Frailty was also detected in 60% of patients with mild cognitive impairment.

CONCLUSION

Frailty is common in patients referring to CCDDs for cognitive deficits. Its systematic assessment using a FI generated with readily available medical information could help develop appropriate models of assistance and guide personalization of care.

Effectiveness of creative story therapy for dementia: a systematic review and meta-analysis

OBJECTIVE

To conduct a meta-analysis of the effectiveness of creative story therapy versus routine nursing alone for the treatment of dementia.

METHODS

We manually searched PubMed, Embase, Cochrane Library, Web of Science, China National Knowledge Infrastructure (CNKI), China VIP Database (VIP), China Biomedical Literature Database (CBM), and Wanfang Data up to May 2023. Randomized controlled trials (RCTs) of creative story therapy combined with routine nursing versus routine nursing for the treatment of dementia were included.

RESULTS

A total of 597 participants were enrolled in the 9 RCTs. Among them, 296 were in the creative story therapy group, and 301 were in the routine nursing group. We found statistically significant effects of creative story therapy combined with routine nursing on cognitive function [standardized mean difference (SMD) = 0.99, 95% CI 0.57, 1.41, P < 0.00001], CSDD score [mean difference (MD) =  - 1.71, 95% CI - 3.27, - 0.14, P < 0.00001], quality of life [SMD = 0.97, 95% CI 0.04, 1.90, P = 0.04], and social communication [MD = 0.46, 95% CI 0.17, 0.74, P < 0.00001] between the creative story therapy group and routine nursing groups; no significant difference in change in basic needs communication [MD = 0.09, 95% CI - 0.58, 0.76, P < 0.00001].

CONCLUSION

This meta-analysis shows that creative story therapy combined with routine nursing has significant effectiveness in improving cognitive function and depression in people with dementia. More high-quality RCTs are required to validate these results.

The affordability of lecanemab, an amyloid-targeting therapy for Alzheimer's disease: an EADC-EC viewpoint

Lecanemab, an anti-amyloid antibody with effects on biomarker and clinical endpoints in early Alzheimer's Disease (AD), was granted accelerated approval by the FDA in 2023 and regulatory review in Europe is ongoing. We estimate the population potentially eligible for treatment with lecanemab in the 27 EU countries to 5.4 million individuals. Treatment costs would exceed 133 billion EUR per year if the drug is priced similarly as in the United States, amounting to over half of the total pharmaceutical expenditures in the EU. This pricing would be unsustainable; the ability to pay for high-priced therapies varies substantially across countries. Pricing similarly to what has been announced for the United States may place the drug out of reach for patients in some European countries. Disparities in access to novel amyloid-targeting agents may further deepen the inequalities across Europe in health outcomes. As representatives of the European Alzheimer's Disease Consortium Executive Committee, we call for pricing policies that allow eligible patients across Europe to access important innovations, but also continued investments in research and development. Infrastructure to follow up the usage of new therapies in routine care and new payment models may be needed to address affordability and inequalities in patient access.

Association Between Neuroticism and Dementia on Healthcare Use: A Multi-Level Analysis Across 27 Countries from The Survey of Health, Ageing and Retirement in Europe (SHARE)

BACKGROUND

People with high levels of neuroticism are greater users of health services. Similarly, people with dementia have a higher risk of hospitalization and medical visits. As a result, dementia and a high level of neuroticism increase healthcare use (HCU). However, how these joint factors impact the HCU at the population level is unknown. Similarly, no previous study has assessed the degree of generalization of such impacts, considering relevant variables including age, gender, socioeconomic, and country-level variability.

OBJECTIVE

To examine how neuroticism and dementia interact in the HCU.

METHODS

A cross-sectional study was performed on a sample of 76,561 people (2.4% with dementia) from 27 European countries and Israel. Data were analyzed with six steps multilevel non-binomial regression modeling, a statistical method that accounts for correlation in the data taken within the same participant.

RESULTS

Both dementia (Incidence Rate Ratio (IRR): 1.537; α= 0.000) and neuroticism (IRR: 1.122; α= 0.000) increased the HCU. The effect of having dementia and the level of neuroticism increased the HCU: around 53.67% for the case of having dementia, and 12.05% for each increment in the level of neuroticism. Conversely, high levels of neuroticism in dementia decreased HCU (IRR: 0.962; α= 0.073). These results remained robust when controlling for age, gender, socioeconomic, and country-levels effects.

CONCLUSION

Contrary to previous findings, neuroticism trait in people with dementia decreases the HCU across sociodemographic, socioeconomic, and country heterogeneity. These results, which take into account this personality trait among people with dementia, are relevant for the planning of health and social services.

A Literature Review on the Burden of Alzheimer's Disease on Care Partners

BACKGROUND

Many individuals with Alzheimer's disease (AD) are dependent on nonprofessional care partners. Providing informal care can result in emotional, physical, and financial burdens; however, there is a need for a better understanding of the impact of AD on care partners to support the clinical and economic assessment of potential new treatments.

OBJECTIVE

We conducted a literature review to evaluate the burden experienced by care partners of individuals with AD.

METHODS

Electronic screening and supplementary searches identified studies published from 2011 to 2022 describing the association between AD and the quality of life (QoL) and physical health of care partners, and the economic or financial burden of AD.

RESULTS

Following electronic screening, 62, 25, and 39 studies were included on care partner burden, cost, and healthcare resource use in AD, respectively. Supplementary searches identified an additional 32 studies, resulting in 149 unique studies. These studies showed that care partners of individuals with AD report moderate to severe burden. Higher burden and lower QoL were observed in those caring for individuals with more severe AD. Care partners of individuals with AD experience higher burden, lower QoL, and higher levels of stress, depression, and anxiety than those without caring responsibilities. Informal care costs increased with AD severity and accounted for the greatest proportion of overall societal cost.

CONCLUSIONS

Care partners of individuals with AD experience emotional and economic burden, which increases with AD severity. These impacts should be quantified comprehensively in future studies and captured in economic evaluations of AD interventions.