The effect of dementia on acute care in a geriatric medical unit

Understanding health-care outcomes of older people with cognitive impairment and/or dementia admitted to hospital: a mixed-methods study

Background

Cognitive impairment is common in older people admitted to hospital, but previous research has focused on single conditions.

Objective

This project sits in phase 0/1 of the Medical Research Council Framework for the Development and Evaluation of Complex Interventions. It aims to develop an understanding of current health-care outcomes. This will be used in the future development of a multidomain intervention for people with confusion (dementia and cognitive impairment) in general hospitals. The research was conducted from January 2015 to June 2018 and used data from people admitted between 2012 and 2013.

Design

For the review of outcomes, the systematic review identified peer-reviewed quantitative epidemiology measuring prevalence and associations with outcomes. Screening for duplication and relevance was followed by full-text review, quality assessment and a narrative review (141 papers). A survey sought opinion on the key outcomes for people with dementia and/or confusion and their carers in the acute hospital (n = 78). For the analysis of outcomes including cost, the prospective cohort study was in a medical admissions unit in an acute hospital in one Scottish health board covering 10% of the Scottish population. The participants (n = 6724) were older people (aged ≥ 65 years) with or without a cognitive spectrum disorder who were admitted as medical emergencies between January 2012 and December 2013 and who underwent a structured nurse assessment. ‘Cognitive spectrum disorder’ was defined as any combination of delirium, known dementia or an Abbreviated Mental Test score of < 8 out of 10 points. The main outcome measures were living at home 30 days after discharge, mortality within 2 years of admission, length of stay, re-admission within 2 years of admission and cost.

Data sources

Scottish Morbidity Records 01 was linked to the Older Persons Routine Acute Assessment data set.

Results

In the systematic review, methodological heterogeneity, especially concerning diagnostic criteria, means that there is significant overlap in conditions of patients presenting to general hospitals with confusion. Patients and their families expect that patients are discharged in the same or a better condition than they were in on admission or, failing that, that they have a satisfactory experience of their admission. Cognitive spectrum disorders were present in more than one-third of patients aged ≥ 65 years, and in over half of those aged ≥ 85 years. Outcomes were worse in those patients with cognitive spectrum disorders than in those without: length of stay 25.0 vs. 11.8 days, 30-day mortality 13.6% vs. 9.0%, 1-year mortality 40.0% vs. 26.0%, 1-year mortality or re-admission 62.4% vs. 51.5%, respectively (all p < 0.01). There was relatively little difference by cognitive spectrum disorder type; for example, the presence of any cognitive spectrum disorder was associated with an increased mortality over the entire period of follow-up, but with different temporal patterns depending on the type of cognitive spectrum disorder. The cost of admission was higher for those with cognitive spectrum disorders, but the average daily cost was lower.

Limitations

A lack of diagnosis and/or standardisation of diagnosis for dementia and/or delirium was a limitation for the systematic review, the quantitative study and the economic study. The economic study was limited to in-hospital costs as data for social or informal care costs were unavailable. The survey was conducted online, limiting its reach to older carers and those people with cognitive spectrum disorders.

Conclusions

Cognitive spectrum disorders are common in older inpatients and are associated with considerably worse health-care outcomes, with significant overlap between individual cognitive spectrum disorders. This suggests the need for health-care systems to systematically identify and develop care pathways for older people with cognitive spectrum disorders, and avoid focusing on only condition-specific pathways.

Future work

Development and evaluation of a multidomain intervention for the management of patients with cognitive spectrum disorders in hospital.

Study registration

This study is registered as PROSPERO CRD42015024492.

Funding

This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research; Vol. 9, No. 8. See the NIHR Journals Library website for further project information.

Comorbidity in Dementia Diseases and Associated Health Care Resources Utilization and Cost

BACKGROUND

People with dementia (PwD) suffer from coexisting medical conditions, creating complex clinical challenges and increasing the risk of poor outcomes, which could be associated with high healthcare cost.

OBJECTIVE

To describe the prevalence of comorbidity in PwD and to analyze the association between comorbidity in dementia diseases and healthcare costs from a payer's perspective.

METHODS

This cross-sectional analysis was based on n = 362 PwD of the DelpHi-MV trial (Dementia: Life-and person-centered help in Mecklenburg-Western Pomerania). Comorbidity was assessed using the Charlson comorbidity index (CCI) and was categorized into low, high, and very high comorbidity. Healthcare resource utilization and unit costs were used to calculate costs. Multivariable regression models were applied to analyze the association between comorbidity and costs.

RESULTS

Comorbidity was highly prevalent in the sample. 47% of PwD had a very high, 37% a high, and 16% a low comorbidity in addition to dementia. The most prevalent co-existing comorbidity were diabetes mellitus (42%), peripheral vascular disease (28%) and cerebrovascular disease (25%). Total costs significantly increased by 528€ (SE = 214, CI95 = 109-947, p = 0.014) with each further comorbidity, especially due to higher cost for medication and medical aids. Compared with a low comorbidity, a very high comorbidity was significantly associated with 818€ (SE = 168, CI95 = 489-1147, p < 0.001) higher medication costs and 336€ (SE = 161, CI95 = 20-652, p = 0.037) higher cost for medical aids. There were no significant association between a higher comorbidity and cost for formal care services.

CONCLUSIONS

Comorbidity in PwD represents a substantial financial burden on healthcare payers and is a challenge for patients, healthcare providers, and the health systems. Innovative approaches are needed to achieve a patient-oriented management of treatment and care in comorbid PwD to reduce long-term costs.

The impact of dementia on hospital outcomes for elderly patients with sepsis: A population-based study

BACKGROUND

Prior studies have suggested that dementia adversely influences clinical outcomes and increases resource utilization in patients hospitalized for acute diseases. However, there is limited population-data information on the impact of dementia among elderly hospitalized patients with sepsis.

METHODS

From the 2009-2011 National Hospital Discharge Database we identified hospitalizations in adults aged ≥65 years. Using ICD9-CM codes, we selected sepsis cases, divided them into two cohorts (with and without dementia) and compared both groups with respect to organ dysfunction, in-hospital mortality and the use of hospital resources. We estimated the impact of dementia on these primary endpoints through multivariate regression models.

RESULTS

Of the 148 293 episodes of sepsis identified, 16 829 (11.3%) had diagnoses of dementia. Compared to their dementia-free counterparts, they were more predominantly female and older, had a lower burden of comorbidities and were more frequently admitted due to a principal diagnosis of sepsis. The dementia cohort showed a lower risk of organ dysfunction (adjusted OR: 0.84, 95% Confidence Interval [CI]: 0.81, 0.87) but higher in-hospital mortality (adjusted OR: 1.32, 95% [CI]: 1.27, 1.37). The impact of dementia on mortality was higher in the cases of younger age, without comorbidities and without organ dysfunction. The cases with dementia also had a lower length of stay (-3.87 days, 95% [CI]: -4.21, -3.54) and lower mean hospital costs (-3040€, 95% [CI]: -3279, -2800).

CONCLUSIONS

This nationwide population-based study shows that dementia is present in a substantial proportion of adults ≥65s hospitalized with sepsis, and while the condition does seem to come with a lower risk of organ dysfunction, it exerts a negative influence on in-hospital mortality and acts as an independent mortality predictor. Furthermore, it is significantly associated with shorter length of stay and lower hospital costs.

Length of hospital stay and dementia: A systematic review of observational studies

OBJECTIVE

Hospitalizations of people with dementia (PWD) are often accompanied by complications or functional loss and can lead to adverse outcomes. Unsystematic findings suggest an influence of comorbidities on the extent of differences in the length of hospital stay (LOS). This systematic review aimed to identify and evaluate all studies reporting LOS in PWD as compared to PwoD in general hospitals.

METHODS

A systematic review of observational studies using PubMed and ISI Web of Knowledge. Inclusion criteria comprised original studies written in English or German, assessment of diagnosis of dementia, measurement of LOS, and comparison of people with and without dementia.

RESULTS

Fifty-two of 60 studies reported a longer hospitalization time for PWD compared to PwoD. The extent of the difference in LOS varied between and within countries as well as by type of primary morbidity (eg, injuries, cardiovascular diseases). The range of the LOS difference for studies without restriction to a primary morbidity was -2 to +22 days after matching or adjustment for a variable number and selection of potentially relevant covariates. For studies with injuries/fractures/medical procedures and infectious/vascular disease as the primary morbidity, the range was -2.9 to +12.4 and -11.2 to +21.8 days, respectively.

CONCLUSIONS

The majority of studies reported a longer hospitalization of PWD compared to PwoD. Length of hospital stay seems to be influenced by a variety of medical, social, organizational factors, including reasons for hospital admission, whose role should be explored in detail in further research.

Dementia in older people admitted to hospital: An analysis of length of stay and associated costs

OBJECTIVES

Patients with dementia in the acute setting are generally considered to impose higher costs on the health system compared to those without the disease largely due to longer length of stay (LOS). Many studies exploring the economic impact of the disease extrapolate estimates based on the costs of patients diagnosed using routinely collected hospital discharge data only. However, much dementia is undiagnosed, and therefore in limiting the analysis to this cohort, we believe that LOS and the associated costs of dementia may be overestimated. We examined LOS and associated costs in a cohort of patients specifically screened for dementia in the hospital setting.

METHODS

Using primary data collected from a prospective observational study of patients aged ≥70 years, we conducted a comparative analysis of LOS and associated hospital costs for patients with and without a diagnosis of dementia.

RESULTS

There was no significant difference in overall length of stay and total costs between those with (μ = 9.9 days, μ = € 8246) and without (μ = 8.25 days, μ = € 6855) dementia. Categorical data analysis of LOS and costs between the two groups provided mixed results.

CONCLUSIONS

The results challenge the basis for estimating the costs of dementia in the acute setting using LOS data from only those patients with a formal dementia diagnosis identified by routinely collected hospital discharge data. Accurate disease prevalence data, encompassing all stages of disease severity, are required to enable an estimation of the true costs of dementia in the acute setting based on LOS.

Analysis of Episodes of Care in Medicare Beneficiaries Newly Diagnosed with Alzheimer's Disease

OBJECTIVES

To study transitions between healthcare settings and quantify the cost burdens associated with different combinations of transitions during a 6-month period before initial Alzheimer's disease (AD) diagnosis so as to investigate how using an episode-of-care approach to payment for specific disease states might apply in AD.

DESIGN

A retrospective observational cohort study.

SETTING

United States.

PARTICIPANTS

A random sample of 8,995 individuals aged 65 to 100 with a diagnosis of AD (International Classification of Diseases, Ninth Revision, Clinical Modification code 331.0) were identified from the Medicare database between January 1, 2011, and June 30, 2014. This analysis identified individuals with AD diagnosed in inpatient (18%), skilled nursing facility (SNF) (1%), hospice (4%), and home and outpatient (77%) settings and analyzed episodes that began in the index setting (defined as the care setting in which the individual was first diagnosed with AD).

MEASUREMENTS

Study outcomes included number of transitions between settings, primary discharge diagnoses, and total all-cause healthcare costs during the 6 months after the AD diagnosis.

RESULTS

The average numbers of transitions between care settings were 2.8 originating from an inpatient setting, 2.4 from a SNF, 0.3 from a hospice setting and 0.7 from a home or outpatient setting during 6 months post-AD diagnosis. The overall cost burden during the 6 months after AD diagnosis (including costs incurred at the index setting) was high for individuals diagnosed in a nonambulatory setting (mean $41,468). Individuals diagnosed in an ambulatory setting incurred only $12,597 in costs during the same period.

CONCLUSION

Episodes of care can be defined and studied in individuals with AD. An episode-of-care approach to payment could encourage providers to use the continuum of care needed for quality medical management in AD more efficiently.

Frequency of dementia among elderly admitted to a Geriatrics Inpatients Sector of a Brazilian public hospital

Patients with dementia are commonly admitted to inpatient sectors. The aim of this study was to describe the frequency of dementia among elderly inpatients admitted to the Geriatrics Sector of a Brazilian Tertiary University Hospital, and to identify associations between dementia and clinical and sociodemographic factors.

METHODS

All patients admitted to the Geriatrics Sector of a public Brazilian university-hospital from March 1st 2014 to January 31st 2015 were assessed by geriatricians. The patients were divided into groups "with or without diagnosis of dementia". Univariate analysis was performed between these two groups using the Chi-Square Test, Student's t-test or the Mann-Whitney Test.

RESULTS

One hundred and three elderly inpatients, with a mean age of 82 (±7.9) years, were assessed. Overall, 74.7% had low educational level (<4 years), 66% used polypharmacy, 57.2% developed delirium during hospitalization and 59% were totally dependent for basic activities of daily living. The diagnosis of dementia was observed in 59 (57%) subjects.

CONCLUSION

The frequency of dementia was high among the elderly inpatients evaluated. The association between dementia and certain clinical conditions, such as incontinence, delirium and use of psychoactive drugs, was in line with the medical literature.

Epidemiology and outcomes of people with dementia, delirium, and unspecified cognitive impairment in the general hospital: prospective cohort study of 10,014 admissions

BACKGROUND

Cognitive impairment of various kinds is common in older people admitted to hospital, but previous research has usually focused on single conditions in highly-selected groups and has rarely examined associations with outcomes. This study examined prevalence and outcomes of cognitive impairment in a large unselected cohort of people aged 65+ with an emergency medical admission.

METHODS

Between January 1, 2012, and June 30, 2013, admissions to a single general hospital acute medical unit aged 65+ underwent a structured specialist nurse assessment (n = 10,014). We defined 'cognitive spectrum disorder' (CSD) as any combination of delirium, known dementia, or Abbreviated Mental Test (AMT) score < 8/10. Routine data for length of stay (LOS), mortality, and readmission were linked to examine associations with outcomes.

RESULTS

A CSD was present in 38.5% of all patients admitted aged over 65, and in more than half of those aged over 85. Overall, 16.7% of older people admitted had delirium alone, 7.9% delirium superimposed on known dementia, 9.4% known dementia alone, and 4.5% unspecified cognitive impairment (AMT score < 8/10, no delirium, no known dementia). Of those with known dementia, 45.8% had delirium superimposed. Outcomes were worse in those with CSD compared to those without - LOS 25.0 vs. 11.8 days, 30-day mortality 13.6% vs. 9.0%, 1-year mortality 40.0% vs. 26.0%, 1-year death or readmission 62.4% vs. 51.5% (all P < 0.01). There was relatively little difference by CSD type, although people with delirium superimposed on dementia had the longest LOS, and people with dementia the worst mortality at 1 year.

CONCLUSIONS

CSD is common in older inpatients and associated with considerably worse outcomes, with little variation between different types of CSD. Healthcare systems should systematically identify and develop care pathways for older people with CSD admitted as medical emergencies, and avoid only focusing on condition-specific pathways such as those for dementia or delirium alone.

Prevalence of dementia in elderly patients with hip fracture

Hip fractures occur commonly and are a cause of disability for older adults and lead to increased dependence and requirements for social support. Dementia is one of the possible risk factors for falling and hip fracture, a potential source for complications during surgery and during the postoperative period, difficulties in rehabilitation and a risk factor for hip fracture reccurence. However, in previous studies of hip fracture patients, cognitive status has not been formally assessed during the inpatient stay and diagnosis was based only on previous history. Additionally, no previous studies have compared prevalence of dementia between elderly patients with hip fracture and patients with other surgical pathology. Our aim was to define whether dementia was more prevalent in older subjects with hip fracture than in other elderly patients undergoing surgery. In this study, we prospectively assessed all patients aged 68 and older admitted to our hospital for hip fracture surgery during a one year period and compared them with age and gender matched patients attending other surgical departments. 80 hip fracture patients and 80 controls were assessed for dementia. Dementia was common in both groups, presumably reflecting the advanced mean age of both groups and cognitive deterioration due to hospitalization-status. Dementia was significantly higher in the hip fracture group (85%) compared to the control group (61.5%; p=0.002). Dementia is very common in older patients admitted for surgery to a general hospital and extremely common in those with hip fracture. It seems that dementia is under diagnosed in elderly hospitalised patients. Our data confirm that dementia is a major risk factor for hip fracture in the elderly.

Improving care of older adults with dementia: description of 6299 hospitalizations over 11 years in a special acute care unit

OBJECTIVE

To describe hospitalizations in a Special Acute Care inpatient Unit for older adults with Alzheimer's disease (AD) and other related disorders.

DESIGN

An 11-year observational study of consecutive hospitalizations from 1996 to 2006.

SETTING

The Alzheimer Special Acute Care inpatient Unit in the Geriatrics Department of the Toulouse University Hospital, France.

PARTICIPANTS

A total of 4708 patients with dementia accounting for 6299 consecutive hospitalizations.

MEASUREMENTS

Data regarding admission causes, cognition, physical disability, nutritional assessment, behavioral and psychological symptoms of dementia, and sociodemographics were recorded.

RESULTS

Data from 6299 hospitalizations are presented: 4708 (74.7%) hospitalizations accounted for first-time admissions and 1591 (25.3%) were rehospitalizations. Among the first-time admissions, complications of dementia and cognitive diagnosis experienced a significant switch in frequency. Whereas until 2001, the main cause of admission was for a diagnosis (51%), complications became the primary cause from 2003 onward with a significant increasing trend (56%) (P < .001). The most frequent cause of complications was behavioral and psychological symptoms of dementia, with a significant trend for an increased frequency (P < .001). Agitation-aggressiveness represented 60% of behavioral and psychological symptoms of dementia. Between 1996 and 2006, the age of patients at first-time admission gradually increased over time, as did the severity of cognitive impairment and the prevalence of unsatisfactory nutritional status (P for trend < .001 for each variable).

CONCLUSIONS

The evolving patient characteristics and the causes of first-time admissions changed over the course of 11 years. Behavioral and psychological symptoms of dementia, especially agitation-aggressiveness, have progressively become the key drivers of Special Acute Care inpatient Unit hospitalizations. These findings suggest that the role, mission, and functioning of the Special Acute Care inpatient Unit within the Alzheimer care system has been modified over time.

The Hospital Dementia Services Project: age differences in hospital stays for older people with and without dementia

BACKGROUND

People with dementia may have adverse outcomes following periods of acute hospitalization. This study aimed to explore the effects of age upon hospitalization outcomes for patients with dementia in comparison to patients without dementia.

METHODS

Data extracted from the New South Wales Admitted Patient Care Database for people aged 50 years and over for the period July 2006 to June 2007 were linked to create person-based records relating to both single and multiple periods of hospitalization. This yielded nearly 409,000 multi-day periods of hospitalization relating to almost 253,000 persons. Using ICD-10-AM codes for dementia and other principal diagnoses, the relationship between age and hospitalization characteristics were examined for people with and without dementia.

RESULTS

Dementia was age-related, with 25% of patients aged 85 years and over having dementia compared with 0.9% of patients aged 50-54 years. People with dementia were more likely to be admitted for fractured femurs, lower respiratory tract infections, urinary tract infections and head injuries than people without dementia. Mean length of stay for admissions for people with dementia was 16.4 days and 8.9 days for those without dementia. People with dementia were more likely than those without to be re-admitted within three months for another multi-day stay. Mortality rates and transfers to nursing home care were higher for people with dementia than for people without dementia. These outcomes were more pronounced in younger people with dementia.

CONCLUSION

Outcomes of hospitalization vary substantially for patients with dementia compared with patients without dementia and these differences are frequently most marked among patients aged under 65 years.

A systematic review of the prevalence, associations and outcomes of dementia in older general hospital inpatients

BACKGROUND

Older people are commonly admitted to the acute hospital and increasing numbers will have dementia. In this study we systematically reviewed the prevalence, associations and outcomes of dementia in older people in the general hospital, to examine the range of diagnostic tools used and highlight gaps in the literature.

METHODS

We searched the English language literature using Embase, PsychInfo and Medline. Studies were included if they used validated criteria for diagnosing dementia, involved subjects over the age of 55 years and were set in the general hospital.

RESULTS

Fourteen papers were identified. Prevalence estimates for dementia in studies with robust methodology were 12.9-63.0%. Less than a third of studies screened for delirium or depression and therefore some subjects may have been misclassified as having dementia. The data were highly heterogeneous and prevalence estimates varied widely, influenced by study setting and demographic features of the cohorts. Patients with dementia in the acute hospital are older, require more hours of nursing care, have longer hospital stays, and are more at risk of delayed discharge and functional decline during admission.

CONCLUSIONS

When planning liaison services, the setting and demographic features of the population need to be taken into account. Most study cohorts were recruited from medical wards. More work is required on the prevalence of dementia in surgical and other specialties. A wider range of associations (particularly medical and psychiatric comorbidity) and outcomes should be studied so that care can be improved.

Novel approaches to incorporating pharmacoeconomic studies into phase III clinical trials for Alzheimer's disease

The societal and individual costs of Alzheimer's disease are significant, worldwide. As the world ages, these costs are increasing rapidly, while health systems face finite budgets. As a result, many regulators and payers will require or at least consider phase III cost-effectiveness data (in addition to safety and efficacy data) for drug approval and reimbursement, increasing the risks and costs of drug development. Incorporating pharmacoeconomic studies in phase III clinical trials for Alzheimer's disease presents a number of challenges. We propose several specific suggestions to improve the design of pharmacoeconomic studies in phase III clinical trials. We propose that acute episodes of care are key outcome measures for pharmacoeconomic studies. To improve the possibility of detecting a pharmacoeconomic impact in phase III, we suggest several strategies including; study designs for enrichment of pharmacoeconomic outcomes that include co-morbidity of patients; reducing variability of care that can affect pharmacoeconomic outcomes through standardized care management; employing administrative claims data to better capture meaningful pharmacoeconomic data; and extending clinical trials in open label follow-up periods in which pharmacoeconomic data are captured electronically by administrative claims. Specific aspects of power analysis for pharmacoeconomic studies are presented. The particular pharmacoeconomic challenges caused by the use of biomarkers in clinical trials, the increasing use of multinational studies, and the pharmacoeconomic challenges presented by biologicals in development for Alzheimer's disease are discussed. In summary, since we are entering an era in which pharmacoeconomic studies will be essential in drug development for supporting regulatory approval, payor reimbursement and integration of new therapies into clinical care, we must consider the design and incorporation of pharmacoeconomic studies in phase III clinical trials more seriously and more creatively.

Impact and recognition of cognitive impairment among hospitalized elders

BACKGROUND

Older adults are predisposed to developing cognitive deficits. This increases their vulnerability for adverse health outcomes when hospitalized.

OBJECTIVE

To determine the prevalence and impact of cognitive impairment (CI) among hospitalized elders based on recognition by lCD-coding versus screening done on admission.

DESIGN

Observational cohort study.

SETTING

Urban public hospital in Indianapolis.

PATIENTS

997 patients age 65 and older admitted to medical services between July 2006 and March 2008.

MEASUREMENTS

Impact of CI in terms of length of stay, survival, quality of care and prescribing practices. Cognition was assessed by the Short Portable Mental Status Questionnaire (SPMSQ).

RESULTS

424 patients (43%) were cognitively impaired. Of those 424 patients with CI, 61% had not been recognized by ICD-9 coding. Those unrecognized were younger (mean age 76.1 vs. 79.1, P <0.001); had more comorbidity (mean Charlson index of 2.3 vs.1.9, P = 0.03), had less cognitive deficit (mean SPMSQ 6.3 vs. 3.4, P < 0.001). Among elders with CI, 163 (38%) had at least one day of delirium during their hospital course. Patients with delirium stayed longer in the hospital (9.2 days vs. 5.9, P < 0.001); were more likely to be discharged into institutional settings (75% vs. 31%, P < 0.001) and more likely to receive tethers during their care (89% vs. 69%, P < 0.001), and had higher mortality (9% vs. 4%, P = 0.09).

CONCLUSION

Cognitive impairment, while common in hospitalized elders, is under-recognized, impacts care, and increases risk for adverse health outcomes.

Follow-up for Alzheimer patients: European Alzheimer Disease Consortium position paper

BACKGROUND AND PURPOSE

Alzheimer disease (AD) is one of the leading causes of dependence in the elderly. Providing care for patients with AD is complex and the type of care required depends on the stage of the disease and varies over time. The aim of this article is to discuss available care strategies once the AD diagnosis has been made and to propose a follow-up plan as standard of care at a European level.

METHODS

The proposals developed in this article stem from the collaborative work of a panel of multidisciplinary experts involved in the care of AD patients (European Alzheimer Disease Consortium) based on the results of published scientific studies and on their experience from clinical practice.

CONCLUSION

Suggestions for follow-up frequency and easily administered and scored assessment tools are provided, thereby increasing efficiency and quality of care for patients with Alzheimer disease.

Health economics and the value of therapy in Alzheimer's disease

In increasingly aging societies throughout the developed and developing world, Alzheimer's disease and related dementias are fast becoming a critical public health issue, exacting an enormous toll on individuals and healthcare systems. Over the past 10 years, five drugs have been developed and approved for the symptomatic treatment of Alzheimer's dementia, and several disease-modifying drugs are in various stages of clinical development. While symptomatic medications were consistently shown to have clinical benefit in numerous efficacy studies, the cost effectiveness of antidementia therapies and their value to healthcare systems remain unclear. The pharmacoeconomics of antidementia therapies is an evolving field, with several unanswered questions. This poses many challenges for biopharmaceutical companies developing these therapies, regulatory agencies responsible for their approval, and payers responsible for ensuring their availability to patients. The challenge partly relates to the unique nature of dementia as a disease of impaired cognition, behavior, and function. Thus, the selection of appropriate outcome measures that directly relate to healthcare utilization, quality of life, caregiver burden, and pharmacoeconomic analysis has been difficult. The development of meaningful and widely acceptable outcome measures, as well as novel clinical-study designs, is needed to better evaluate cost effectiveness and to demonstrate the value of therapeutics for Alzheimer's disease. Providing the decision-makers in healthcare systems with a body of evidence that demonstrates a positive relationship between clinical outcomes and the economic and humanistic benefits of antidementia therapeutics will improve patient access to novel drugs as they become available.

Special acute care unit for older adults with Alzheimer's disease

OBJECTIVE

To describe the cognitive, functional, and nutritional features of patients admitted to a Special Acute Care Unit (SACU) for elderly patients with Alzheimer's disease (AD).

METHODS

One-year observational study of patients with AD and other related disorders hospitalized in the SACU, Department of Geriatrics, Toulouse university Hospital during 2005. A comprehensive neurocognitive and non-cognitive geriatric assessment was performed. Data on full clinical evaluation, nutritional status, activities of daily living (ADL), gait and balance disturbance, behavioural and psychological symptoms (BPSD), and sociodemographics were recorded.

RESULTS

Four-hundred and ninety-two patients were assessed. Their mean age was 81.1+/-7.7, the mean length of stay was 10.7+/-6.3 days, 62% were female, 63.9% were admitted from their own home and 30.4% from a nursing home. Eighty percent of patients had probable Alzheimer's disease or mixed dementia, less than 20% had other causes of dementia. Results of their comprehensive assessment showed a mean mini-mental state examination of 14.5+/-7.4; a mean total ADL score of 3.7+/-1.7. Seventy-seven percent had gait or balance disturbances; 90% of patients presented an unsatisfactory nutritional status. The most common reason for admission was BPSD.

CONCLUSION

AD complications are responsible for many acute admissions. Elderly patients suffering from dementia represent a population with unique clinical characteristics. Further randomised clinical trials are needed to evaluate the effectiveness of Special Acute Care Units for patients with AD and other related disorders.

Indicateurs précoces de durée de séjour prolongée chez les sujets âgés

OBJECTIVES

The aim of this study was to identify early indicators of prolonged hospital stays by elderly patients.

METHODS

This prospective pilot study, conducted at Strasbourg University Hospital, included patients aged 75 years or older who were hospitalized via the emergency department (SAFES cohort: Sujet Agé Fragile: Evaluation et suivi, that is, Frail Elderly Subjects: Evaluation and Follow-up). A gerontologic evaluation of these patients during the first week of their hospitalization furnished the data for an exact logistic regression. Two definitions were used for prolonged hospitalization: 30 days and a composite number adjusted for diagnosis-related group according to the French classification (f-DRG).

RESULTS

The analysis examined 137 hospitalizations. More than two thirds of the patients were women (73%), with a mean age of 84 years. Twenty-four hospitalizations (17%) lasted more than 30 days, but only 6 (4%) lasted beyond the DRG-adjusted limit. No social or demographic variables appeared to affect the length of stay, regardless of the definition of prolonged stay. No indicator was associated with the 30-day limit, but clinical markers were linked to prolongation assessed by f-DRG adjustment. A "risk of malnutrition" (OR=14.07) and "mood disorders" (OR=2,5) were both early markers for prolonged hospitalization. Although not statistically significant, "walking difficulties" (OR=2.72) and "cognitive impairment" (OR=5.03) appeared to be associated with prolonged stays. No association was seen with either the variables measured by Katz's Activities of Daily Living Index or its course during hospitalization.

CONCLUSION

Our study shows that when generally recognized indicators of frailty are taken into account, a set of simple items enables a predictive approach to the prolongation of emergency hospitalizations of the elderly.

The economic costs of dementia in Korea, 2002

OBJECTIVE

To estimate the economic costs of dementia in 2002 using an economic evaluation model for dementia care.

METHODS

Data were from the Korea National Survey of the Long-Term Care Need (LTC survey) (n = 5058), two prospective 1-year studies [one clinical trial (n = 234), one naturalistic community cohort study (n = 107)], and two epidemiologic community studies for prevalence of dementia (n = 1037 + 1481). Daily costs and proportions of different levels of institutional service provided were collected from the LTC survey. Resource use in the community included health care services, social care services, out-of-pocket purchase for self-support, caregiver time and missed work of caregiver. Costs in community were calculated based on resource utilization multiplied by the unit costs for each resource.

RESULTS

Total annual costs of dementia were estimated to be over 2.4 billion US dollars for 272,000 dementia sufferers. Costs in community represent 96% of the total annual costs, while costs of informal care and missed work of caregivers were 1.3 billion US dollars, or 55% of total annual cost. Average annual costs of full time care (FTC) and pre-FTC in community LTC were 44 121 US dollars and 13 273 US dollars per person, whereas cost per patient who did not need community LTC was 3,986 US dollars.

CONCLUSION

Given that the number of dementia sufferers is projected to increase in the near future and that larger part of the costs are subsidized by the government, the economic and social costs of dementia is significant not only for dementia sufferers and their caregivers, but also for society.

Early Markers of Prolonged Hospital Stays in Older People: A Prospective, Multicenter Study of 908 Inpatients in French Acute Hospitals

OBJECTIVES

To identify early markers of prolonged hospital stays in older people in acute hospitals.

DESIGN

A prospective, multicenter study.

SETTING

Nine hospitals in France.

PARTICIPANTS

One thousand three hundred six patients aged 75 and older were hospitalized through an emergency department (Sujet Agé Fragile: Evaluation et suivi (SAFEs)--Frail Elderly Subjects: Evaluation and follow-up).

MEASUREMENTS

Data used in a logistic regression were obtained through a gerontological evaluation of inpatients, conducted in the first week of hospitalization. The center effect was considered in two models as a random and fixed effect. Two limits were used to define a prolonged hospital stay. The first was fixed at 30 days. The second was adjusted for Diagnosis Related Groups according to the French classification (f-DRG).

RESULTS

Nine hundred eight of the 1,306 hospital stays that made up the cohort were analyzed. Two centers (n=298) were excluded because of a large volume of missing f-DRGs. Two-thirds of subjects in the cohort analyzed were women (64%), with a mean age of 84. One hundred thirty-eight stays (15%) lasted more than 30 days; 46 (5%) were prolonged beyond the f-DRG-adjusted limit. No sociodemographic variables seemed to influence the length of stay, regardless of the limit used. For the 30-day limit, only cognitive impairment (odds ratio (OR)=2.2, 95% confidence interval (CI)=1.2-4.0) was identified as a marker for prolongation. f-DRG adjustment revealed other clinical markers. Walking difficulties (OR=2.6, 95% CI=1.2-16.7), fall risk (OR=2.5, 95% CI=1.7-5.3), cognitive impairment (OR=7.1, 95% CI=2.3-49.9), and malnutrition risk (OR=2.5, 95% CI=1.7-19.6) were found to be early markers for prolonged stays, although dependence level and its evolution, estimated using the Katz activity of daily living (ADL) index, were not identified as risk factors.

CONCLUSION

When the generally recognized parameters of frailty are taken into account, a set of simple items (walking difficulties, risk of fall, risk of malnutrition, and cognitive impairment) enables a predictive approach to the length of stay of elderly patients hospitalized under emergency circumstances. Katz ADLs were not among the early markers identified.

Functional impairment, healthcare costs and the prevalence of institutionalisation in patients with Alzheimer's disease and other dementias

INTRODUCTION

The progressive decline in functional status for patients with Alzheimer's disease and other dementias (ADOD) is well documented. However, there is limited information on the economic benefits of interventions improving functional status in an ADOD population. This study estimated the relationship between the degree of functional impairment in patients with ADOD and their healthcare costs and prevalence of institutionalisation.

METHODS

Retrospective cross-sectional analyses of the Medicare Current Beneficiary Survey (MCBS) were performed. A nationally representative sample of Medicare beneficiaries with ADOD was identified from the 1995-8 waves of the MCBS (n = 3138): 34% in the community, 57% institutionalised and 9% residing in both settings during the year. Three measures of functioning were used: the number of activities of daily living (ADLs) and independent ADLs (IADLs) impaired; an index summarising number and severity of ADL and IADL impairments; and the Katz Index of ADLs. Healthcare costs included costs for all healthcare services received in all settings, regardless of whether they were covered by insurance or paid out of pocket. The relationships between each measure of impairment and healthcare costs and prevalence of institutionalisation were estimated using linear and logistic regression.

RESULTS

Healthcare costs (1995-8 values) for all ADOD patients increased by 1,958 US dollars (p < 0.001) for each additional ADL impairment and 549 US dollars (p = 0.073) for each additional IADL impairment. For community-dwelling ADOD patients, healthcare costs increased by 1,541 US dollars (p < 0.001) for each additional ADL and 714 US dollars (p = 0.022) for each additional IADL. Costs also increased by severity on the summary index and the Katz Index. Odds of institutionalisation also increased by the three measures of functional impairment.

CONCLUSION

Although relationships between function and costs have been described previously, the exact nature of these relationships has not been investigated solely in patients with dementia. The data from this study suggest a strong relationship between functional impairment and healthcare costs, specifically in patients with dementia. Even IADL impairments, which are common in mild to moderate dementia, may significantly raise costs. The results suggest that therapies and care management that improve functioning may possibly reduce other healthcare costs.

Impact of donepezil use in routine clinical practice on health care costs in patients with Alzheimer's disease and related dementias enrolled in a large medicare managed care plan: A case-control study

BACKGROUND

Clinical studies have shown efficacy of cholinesterase inhibitors (eg, donepezil) in mild to moderate Alzheimer's disease (AD). However, there are limited studies examining the impact on health care costs of cholinesterase inhibitors prescribed in routine clinical practice.

OBJECTIVE

The purpose of this study was to estimate the impact of donepezil use on health care costs and utilization in patients with mild to moderate AD and related dementias.

METHODS

This case-control study was conducted using data from the Health Insurance Plan of Greater New York (New York, New York). Data from patients with predominantly mild to moderate AD and related dementias who were enrolled in this Medicare managed care plan from January 1, 1999, to December 31, 2002, were included. The health care costs and utilization of patients who had received donepezil prescribed in routine clinical practice were compared with those of patients who had never received donepezil or other cholinesterase inhibitors (control group). The 2 study groups were matched for age, sex, number of comorbid conditions, and presence of complications of late-stage dementia. Regression analysis was used to estimate the impact of donepezil use on health care costs and utilization during a 12-month follow-up period, controlling for characteristics associated with the outcomes. The analyses did not use a direct measure of disease severity but instead used proxy measures of severity based on medical conditions associated with late-stage dementia.

RESULTS

Data from 687 patients were included in the study. The donepezil group comprised 229 patients (140 women, 89 men; mean age, 79.6 years); the control group, 458 patients (280 women, 178 men; mean age, 80.0 years). The mean costs of medical services per year in the donepezil group were US $2500 (95% CI, $300-$4671) less than those in the control group (P = 0.024). Lower medical costs in the donepezil group ($3325; 95% CI, $1163-$5486; P < 0.003 vs controls) were largely attributable to the lower costs of services performed in the hospital ($2594; 95% CI, $846-$4341; P < 0.004 vs controls) and postacute skilled nursing facility (SNF) ($1012; 95% CI, $444-$1579; P < 0.001 vs controls), which were partially offset by $1241 in higher prescription, physician's office, and outpatient hospital costs. Patients receiving donepezil had shorter mean lengths of stay in the hospital (3.00 vs 5.43 days; 95% CI, 0.66-4.19; P < 0.008) and postacute SNF (0.42 vs 3.40 days; 95% CI, 1.28-4.69; P < 0.001) but a higher mean number of physician's office visits (10.91 vs 7.91 visits; 95% CI, 1.63-4.36; P < 0.001) compared with controls.

CONCLUSIONS

In this case-control study in patients with predominantly mild to moderate AD and related dementias, donepezil therapy prescribed in routine clinical practice was associated with reduced health care costs to the Medicare managed care plan studied. The findings support previous pharmacoeconomic studies with larger sample sizes obtained over a longer period of time, and with improved case-matching criteria.

Usefulness of a single item in a mail survey to identify persons with possible dementia: a new strategy for finding high-risk elders

The objective of this study was to examine the characteristics of elderly persons who responded positively to a question about "severe memory problems" on a mailed health questionnaire yet were missed by the existing health risk algorithm to identify vulnerable elderly persons. A total of 324,471 respondents aged 65 and older completed a primary care health status questionnaire that gathered clinical information to quickly identify members with functional impairment, multiple chronic diseases, and higher medical care needs. The respondents were part of a large, integrated, not-for-profit managed care organization that implemented a model of care for elders using a uniform risk identification method across eight regions. Respondents with severe memory problems were compared to general respondents by morbidity, geriatric syndromes, functional impairments, service utilization, sensory impairments, sociodemographic characteristics, and activities of daily living. Of the respondents, 13,902 persons (4.3%) reported severe memory problems; the existing health risk algorithm missed 47.1% of these. When severe memory problems were included in the risk algorithm, identification increased from 11% to 13%, and risk prevalence by age groups ranged from 4.4% to 40.5%; one third had severe memory problems, a finding that was fairly consistent within age groups (28.4% to 36.5%). A question about severe memory problems should be incorporated into population risk-identification techniques. While false-negative rates are unknown, the false-positive rate of a self-report mail survey appears to be minimal. Persons reporting severe memory problems clearly have multiple comorbidities, higher prevalence of geriatric syndromes, and greater functional and sensory impairments.

Evaluating hospital care for individuals with Alzheimer's disease using inpatient quality indicators

The purpose of this study was to determine whether persons with Alzheimer's disease (AD) were at greater risk for in-hospital mortality than non-AD patients as a result of poor quality of care. The study focused on six common medical conditions that result in hospital mortality. Using 1995 to 2000 data from New York state (n = 7,021,065), analysts compared mortality risk for individuals with and without AD. Among men, adjusted odds of death were greater for those with AD for gastrointestinal (GI) hemorrhage (+52 percent), congestive heart failure (CHF) (+42 percent), hip fracture (+35 percent), and acute myocardial infarction (AMI) (+30 percent) (all p < .0001). Among women, AD did not affect risks for most conditions. The results of the study show that men with AD are at higher risk of hospital mortality for common medical conditions, which may indicate poor quality of care. Their risk of hospital death was greater than that of men without AD for AMI, CHF, hip fracture, and GI hemorrhage. Their risk was also greater than that of women with AD for CHF, pneumonia, hip fracture, and GI hemorrhage. With the exception of pneumonia, this risk difference notably exceeded the analogous difference between women and men without AD. Hospital staff should be alerted to greater mortality risk for men with AD, as this risk may indicate lower quality of care.

Dementia and serious coexisting medical conditions: a double whammy

Research-based information about the prevalence of other serious medical conditions in people with dementia has become available only recently, and the true prevalence is not known, primarily because many people with dementia do not have a diagnosis. The existing information is sufficient, however, to show that these other conditions are common in people with dementia. It is also clear that coexisting medical conditions increase the use and cost of health care services for people with dementia, and conversely, dementia increases the use and cost of health care services for people with other serious medical conditions. Nurses and other healthcare professionals should expect to see these relationships in their elderly patients. They should know how to recognize possible dementia and assess, or obtain an assessment of, the patient's cognitive status. They should expect the worsening of cognitive and related symptoms in acutely ill people with dementia and try to eliminate factors that cause this worsening, to the extent possible, while assuring the family that the symptoms are likely to improve once the acute phase of illness or treatment is over. Families, nurses, and other health care professionals are challenged by the complex issues involved in caring for a person with both dementia and other serious medical conditions. Greater attention to these issues by informed and thoughtful clinicians will improve outcomes for the people and their family and professional caregivers.

The economic benefits of acetylcholinesterase inhibitors for patients with Alzheimer disease and associated dementias

Most cost-effectiveness studies using simulation modeling have demonstrated that donepezil, rivastigmine, and galantamine are cost effective for the treatment of mild-to-moderate Alzheimer disease (AD). These conclusions are in large part based on the assumption that improvement in cognitive status, or prevention of cognitive and functional decline, reduces the amount of time patients spend institutionalized or receiving other full-time care. However, as discussed in this article, outcomes besides delay to institutionalization affect the costs of AD. In reviews of utilization data from Medicare and managed care organizations, it was noted that hospitalization and post acute care in skilled nursing facilities accounted for the largest amount of excess direct costs, even among patients with mild or moderate AD. These utilization reviews also suggest that many patients with AD and related dementias require inpatient care because they are not able to self-manage comorbid conditions. The improvements in cognitive status and daily functioning associated with acetylcholinesterase inhibitor (AChEI) therapy are expected to translate into improved management of comorbidities and reduced caregiver burden, thus reducing the total cost of care. To confirm these and other economic benefits of AChEIs, pharmacoeconomic outcomes should be evaluated routinely as part of randomized, controlled trials and through well-controlled observational studies of AD patients in community and institutional settings.

Using a Nursing Minimum Data Set with older patients with dementia in an acute care setting

BACKGROUND

Many older people with dementia are admitted to acute care settings suffering from comorbidities. These and their treatments can lead to confusion in these patients, adding to their existing cognitive deficits, and this may not be recognized by care staff. The care of such patients is complex and requires multidisciplinary team input. The purposes of the Nursing Minimum Data Set are to describe the nursing care of patients in a variety of settings and to establish comparability of nursing data across clinical populations, settings and time.

AIMS

This paper reports a study to describe the characteristics of hospitalized older patients with dementia and nursing diagnoses and nursing interventions for these patients, and to identify trends in the nursing care provided over a 3-year period using a Nursing Minimum Data Set from a community hospital in the United States of America.

METHODS

Secondary data analysis was conducted in 2000 on a large clinical discharge data set containing Nursing Minimum Data Set elements. The sample included 597 elders with dementia among a total of 7772 older patients who were discharged between 1996 and 1998.

RESULTS

The most common comorbidity was hypertension (n = 123, 21%), followed by cardiac dysrhythmias (n = 80, 13%). The most frequent nursing diagnoses were altered health maintenance (n = 419, 84%), knowledge deficit (n = 357, 71%), potential for injury (n = 242, 48%), potential for infection (n = 230, 46%), pain (n = 184, 37%), impaired physical mobility (n = 169, 34%), and altered thought process (n = 144, 29%). The most frequent interventions were discharge planning (n = 340, 68%), surveillance safety (n = 195, 39%), fall prevention (n = 175, 35%), teaching: disease process (n = 166, 33%), learning facilitation (n = 148, 30%), and infection protection (n = 147, 29%).

CONCLUSIONS

The results provide a description of nursing diagnoses and interventions for elders with dementia in an acute care setting using the Nursing Minimum Data Set framework. They identify the need to develop staff education programmes for individualized care of older patients with dementia. In addition, they support the need for continued work on linkage of the nursing care elements of the Nursing Minimum Data Set, including nursing diagnoses, nursing interventions, and nursing-sensitive outcomes.

Outcomes for patients with dementia from the Cleveland Alzheimer's Managed Care Demonstration

This investigation evaluates effects of care consultation delivered within a partnership between a managed health care system and Alzheimer's Association chapter. Care consultation is a multi-component telephone intervention in which Association staff work with patients and caregivers to identify personal strengths and resources within the family, health plan, and community. The primary hypothesis is that care consultation will decrease utilization of managed care services and improve psychosocial outcomes. A secondary modifying-effects hypothesis posits benefits will be greater for patients with more severe memory impairment. The sample is composed of managed care patients whose medical records indicate a diagnosis of dementia or memory loss. Patients were randomly assigned to an intervention group, which was offered care consultation in addition to usual managed care services, or to a control group, which was offered only usual managed care services. Data come from two in-person interviews with patients, and medical and administrative records. Results supporting the primary hypothesis show intervention group patients feel less embarrassed and isolated because of their memory problems and report less difficulty coping. Findings consistent with the modifying-effects hypothesis show intervention group patients with more severe impairment have fewer physician visits, are less likely to have an emergency department visit or hospital admission, are more satisfied with managed care services, and have decreased depression and strain.

Current concepts in the prevention of Alzheimer's disease

Alzheimer's disease represents a significant challenge to the aging population. Since most estimates suggest that AD has a multifactorial etiology, the challenge to find preventative approaches is particularly great. With the aging of the population and the very high incidence from the eighth decade on, the challenge is further enhanced by the need to think of relatively safe interventions given the relative frailty of this elderly population. The need to find safe treatments, or ones with well-understood safety profiles, has led to the examination of known agents for potential dementia-preventing properties. Data supporting these interventions comes from observational studies, laboratory analyses, and clinical trials. Potential mechanisms for prevention of AD include anti-inflammatory and antioxidant approaches. Modulation of risk factors associated with cardiac disease may also reduce the risk of AD. Known agents have been examined for their potential to modify amyloid pathology. Trial designs to address prevention of AD include both primary and secondary prevention studies as well designs to assess slowing disease progression. Information can also be gathered when dementia evaluation is added to ongoing studies. As results from these studies becoming available, we will be able to refine our approach to managing this disease.

The Cleveland Alzheimer's managed care demonstration: outcomes after 12 months of implementation

PURPOSE

This demonstration evaluates the effects of integrating Alzheimer's Association care consultation service with health care services offered by a large managed care system. The primary hypothesis is that Association care consultation will decrease service utilization, increase satisfaction with managed care, and decrease caregiver depression and care-related strain. Secondary modifying-effects hypotheses posit that the effects of the intervention will be intensified when patients have not received a firm dementia diagnosis, patients have more severe memory problems, caregivers use other Association services in tandem with care consultation, and caregivers are not patients' spouses.

DESIGN AND METHODS

The demonstration is a randomized trial that examines outcomes after a 12-month study period. Interview data from 157 primary family caregivers are combined with data abstracted from medical/administrative records.

RESULTS

Support for the primary hypothesis is found for selected, but not all, service utilization outcomes and for caregiver depression. Support for secondary modifying-effects hypotheses is found for satisfaction outcomes and care-related strain outcomes.

IMPLICATIONS

Care consultation delivered within a partnership between a managed care health system and an Alzheimer's Association is a promising strategy for improving selected outcomes for patients with dementia and their caregivers.

The costs of vascular dementia: a comparison with Alzheimer's disease

OBJECTIVES

To estimate the costs of Medicare patients with vascular dementia (VaD). To compare the costs of VaD to Alzheimer's disease (AD) and controls without dementia.

METHODS

The study samples were drawn from community-dwelling patients in a large Medicare managed care organization (MCO) operating in the Northeast region of the USA. Costs for three study groups were contrasted in the study: 240 cases with vascular dementia (VaD), 1,366 cases with Alzheimer's disease (AD), and 19,300 controls without dementia. Costs were estimated from medical and pharmacy claims data. Estimated cost differences are controlled for age, gender, and comorbid conditions using regression analysis.

RESULTS

VaD patients accounted for 6% of all dementia patients identified in the health plan. VaD patients had substantially higher prevalence rates for 10 cardiovascular conditions compared with AD patients and controls. Annual costs for VaD patients were US$6,797 greater than AD patients. Compared with controls, costs were US$10,545 higher for VaD patients and US$3,748 higher for AD patients. Higher costs for VaD and AD patients relative to controls were largely attributable to higher inpatient costs.

CONCLUSIONS

Annual medical costs for VaD patients were substantially higher than costs for patients with AD and control patients without dementia. The high cost of VaD patients suggests a need to improve medical management and treatment of these patients to optimize patient outcomes and medical costs.

Optimizing coding and reimbursement to improve management of Alzheimer's disease and related dementias

The objectives of this study were to review the diagnostic, International Classification of Disease, 9th Revision, Clinical Modification (ICD-9-CM), diagnosis related groups (DRGs), and common procedural terminology (CPT) coding and reimbursement issues (including Medicare Part B reimbursement for physicians) encountered in caring for patients with Alzheimer's disease and related dementias (ADRD); to review the implications of these policies for the long-term clinical management of the patient with ADRD; and to provide recommendations for promoting appropriate recognition and reimbursement for clinical services provided to ADRD patients. Relevant English-language articles identified from MEDLINE about ADRD prevalence estimates; disease morbidity and mortality; diagnostic coding practices for ADRD; and Medicare, Medicaid, and managed care organization data on diagnostic coding and reimbursement were reviewed. Alzheimer's disease (AD) is grossly undercoded. Few AD cases are recognized at an early stage. Only 13% of a group of patients receiving the AD therapy donepezil had AD as the primary diagnosis, and AD is rarely included as a primary or secondary DRG diagnosis when the condition precipitating admission to the hospital is caused by AD. In addition, AD is often not mentioned on death certificates, although it may be the proximate cause of death. There is only one ICD-9-CM code for AD-331.0-and no clinical modification codes, despite numerous complications that can be directly attributed to AD. Medicare carriers consider ICD-9 codes for senile dementia (290 series) to be mental health codes and pay them at a lower rate than medical codes. DRG coding is biased against recognition of ADRD as an acute, admitting diagnosis. The CPT code system is an impediment to quality of care for ADRD patients because the complex, time-intensive services ADRD patients require are not adequately, if at all, reimbursed. Also, physicians treating significant numbers of AD patients are at greater risk of audit if they submit a high frequency of complex codes. AD is grossly undercoded in acute hospital and outpatient care settings because of failure to diagnose, limitations of the coding system, and reimbursement issues. Such undercoding leads to a lack of recognition of the effect of AD and its complications on clinical care and impedes the development of better care management. We recommend continuing physician education on the importance of early diagnosis and care management of AD and its documentation through appropriate coding, expansion of the current ICD-9-CM codes for AD, more appropriate use of DRG coding for ADRD, recognition of the need for time-intensive services by ADRD patients that result in a higher frequency of use of complex CPT codes, and reimbursement for CPT codes that cover ADRD care management services.

Donepezil use in managed Medicare: effect on health care costs and utilization

Donepezil is one of the first effective and well-tolerated medications approved for the treatment of Alzheimer's disease (AD). This study examined the impact of donepezil on the costs of AD in a multisite managed care organization between January 1, 1996, and March 31, 1998. A pretreatment/posttreatment study was conducted using retrospective medical and prescription claims data for 70 individuals with AD and related dementias who were prescribed donepezil. The outcomes of interest were costs during the pretreatment and posttreatment phases, which were categorized as medical, prescription, and combined costs. Per diem costs were adjusted for differences in the duration of follow-up. We found that median per diem medical costs were $1.22 lower in the posttreatment phase than in the pretreatment phase (P = 0.02). Moreover, posttreatment costs were reduced in 6 of 7 service settings, with median per diem savings of $0.77 in outpatient care (P = 0.002) and $0.65 in office visits (P < 0.001). In the posttreatment phase, the median per diem costs for prescriptions and all claims combined were higher by $2.59 (P < 0.001) and $2.11 (P = 0.04), respectively. Donepezil treatment was associated with a decrease in medical costs, particularly in the outpatient components of health care. However, overall costs were increased due to the higher costs of medication. Further pharmacoeconomic studies are needed to determine the exact impact of acetylcholinesterase-inhibitor therapy on the overall costs of care for individuals with dementia.

Cost of Alzheimer's disease and related dementia in managed-medicare

BACKGROUND

Managed care organizations (MCOs) will have increased responsibility for the care of large numbers of persons with dementia. There are, however, few studies that inform about decisions of healthcare utilization and expenditures for individuals with dementia in managed care.

OBJECTIVES

To examine in a large MCO whether people diagnosed with dementia have higher healthcare utilization and costs than enrollees without dementia.

DESIGN

A retrospective study of medical and prescription claims.

SETTING

An MCO covering more than 80,000 Medicare enrollees in four geographical locales between January 1, 1996, and March 31, 1998.

SUBJECTS

There were 677 paired cases with and without dementia. Controls were selected randomly and matched to cases on age, gender, and region.

MEASUREMENTS

Summed total costs and number of claims accrued during the study period, as well as a breakdown of costs and claims with respect to place of service, were annualized and adjusted for age, gender, and comorbid conditions. Costs and claims were broken down by place of service.

RESULTS

Dementia prevalence was 0.83%. Mean total costs were 1.5 times higher for patients with dementia relative to controls ($13,487 vs $9,276, P < .001) when annualized and adjusted for level of comorbidity. Almost 75% of the higher costs among cases were linked to inpatient expenses.

CONCLUSIONS

Higher costs for individuals with dementia and disproportionate inpatient costs in this MCO parallel patterns among Medicare enrollees in fee-for-service. The high prevalence of dementia among the oldest old coupled with the high costs of dementia care create very significant clinical and financial incentives for managed care plans to improve the care of members suffering from dementia.

The economic consequences of Alzheimer's disease in the context of new drug developments

The first national symptomatic treatment for Alzheimer's disease has received a very mixed and perhaps ageist reception from purchasers of health care in the UK. This is largely because detailed information on the long-term effects of this class of drugs is scarce. However, by looking at the published evidence on the economic burden of Alzheimer's disease, some observations and assumptions can be made as to the influence of the new drug treatments. The drug therapies available and those most likely to become licensed are reviewed and the potential economic impact is discussed. Long-term outcome studies would properly address this, but as these drugs have now demonstrated efficacy, particularly in non-cognitive behaviours, it will be ethically more difficult to maintain patients on placebo for long periods. Some assumptions therefore have to be made from long-term open-label studies. Those drugs currently available, and those in development, may offer effective treatment for some of the core symptoms of Alzheimer's disease, slowing the rate of cognitive decline and preserving competence in activities of daily living for longer. If handled correctly, these treatments have the potential to offer cost savings for many patients, and cost-effectiveness improvements look probable.

The future of clinical research in mental disorders of late life

After years of neglect, clinical research into late-life mental disorders is receiving the attention it deserves. Geriatric psychiatry is a growing field and the insights gained from research in this area have improved the diagnosis and treatment of mental illness in older persons. The challenge for the future is to continue to maintain a leadership role in mental health while working within the constraints of the managed care system in the United States.

Challenges for acute care geriatric inpatient units under the present Medicare prospective payment system

The Mount Sinai Medical Center's Geriatric Evaluation and Treatment Unit (GETU) is a 16-bed acute care geriatric unit that operates under the Medicare Prospective Payment System (PPS) in an academic medical center environment. The Medicare PPS and the needs of our local health care system have played a considerable role in the development and operation of our inpatient acute care geriatric unit. The GETU provides acute geriatric care and geriatric assessment and is a site for education and clinical research. The GETU serves a targeted group of acutely ill, hospitalized frail elderly with complex, interdisciplinary needs. The multidisciplinary GETU team was financed from generally available and justifiable hospital resources. Geriatric assessment is conducted under the Medicare PPS during the process of acute care without prolonging hospital length of stay. In fact, during the past 6 years, the introduction of geriatric care and assessment programs has been associated with a significant reduction in hospital length of stay and hospital costs for this complex and difficult population. It is our experience that an acute care geriatric unit functioning under traditional Medical Prospective Payment can have the dual effect of enhancing care and reducing hospital costs for the hospitalized frail elderly.