The costs of family contributions to the care of persons with dementia

The Effects on Labor Supply of Living with Older Family Members Needing Assistance with Activities of Daily Living

Using a sample of 18,201 observations of working age respondents drawn from the Medical Expenditure Panel Survey, 1996-2018, this research examined the labor supply effects for younger family members of living with older persons needing assistance with activities of daily living. We report the effects for three labor supply outcomes of younger family members: working hours, full-time work, and occupational flexibility of working hours. Our results indicate that living with an older family member needing assistance significantly reduced younger women's working hours and the probability of working full-time among younger women, but increased both of these labor outcomes among younger men. In addition, living with an older family member needing help led younger women to work in occupations with significantly larger average variances in working hours. This suggests that these women occupied positions that allowed greater flexibility of working hours. We found little effect on flexibility of working hours for younger men. We conclude that the need for assistance among older family members has important effects on the labor market outcomes of younger family members.

Valuation of Informal Care Provided to People Living With Dementia: A Systematic Literature Review

OBJECTIVES

This study aimed to identify the methods used to determine the value of informal care provided to people living with dementia and to estimate the average hourly unit cost by valuation method.

METHODS

A literature search in MEDLINE Complete, CINAHL, PsycINFO, EconLit, EMBASE and NHS Economic Evaluation Database was undertaken. Following the screening of title, abstract, and full text, characteristics of eligible studies were extracted systematically and analyzed descriptively. The corresponding hourly cost estimates were converted into 2018 US dollars based on purchasing power parities for gross domestic product.

RESULTS

A total number of 111 articles were included in this review from 3106 post-deduplication records. Three main valuation methodologies were identified: the replacement cost method (n = 50), the opportunity cost approach (n = 36), and the stated preference method based on willingness to pay (n = 3), with 16 studies using multiple methods and 6 studies not specifying the valuation method. The amount of informal care increased as the condition of dementia progressed, which was reflected in the cost of informal care. The average hourly unit cost used to value informal care was US $16.78 (SD = US $12.11). Although the unit cost was approximately US $15 per hour when using the opportunity cost method and US $14 when using the stated preference method, the highest unit cost was obtained when using the replacement cost method (US $18.37, SD = US $13.12).

CONCLUSIONS

Although costs of informal care should be considered when undertaking an economic evaluation or estimating the overall costs of dementia from a policy and priority-setting perspective, further research into applying consistent approaches to valuation is warranted.

A qualitative exploration of how gender and relationship shape family caregivers' experiences across the Alzheimer's disease trajectory

Caregiving experiences are not static. They change across the disease trajectory and care continuum. However, it is not clear how caregiver gender or relationship type is related to evolving caregiver experiences over time. This qualitative study informed by constructivist grounded theory and framework analysis explored the experiences over time of men and women who were adult children and spousal caregivers to persons with Alzheimer's disease. Forty spousal (10 husbands and 10 wives) and adult children (10 sons and 10 daughters) caregivers to persons with Alzheimer's disease were interviewed using a semi-structured interview guide. Our findings suggest the experiences of caregiving, examined through a gender and relationship type lens, are complex and variable. The caregiving experience was not related to gender or relationship type alone, but often to a combination of the two. For instance, spousal caregivers did not immediately accept the diagnosis, with wives being more optimistic than husbands about a slow progression of the disease. Adult children caregivers were concerned about the ways the caregiving role would impact their personal and career obligations and sought ways to mitigate the changes to their daily lives. Sons and husband caregivers largely utilized home and community health services to assist with personal care tasks, whereas daughters and wives utilized the same services to allow them to complete other caregiving tasks (e.g., housekeeping). Recognition of the complex inter-relationships among gender and relationship type on caregiving experiences supports the need for family-centered interventions. This article also extends sex and gender research as it highlights that an in-depth understanding of the caregiving experience cannot be understood by gender alone and relationship type must also be considered.

Economic and psychosocial problems experienced by pediatric with cancer patients and their families during the treatment and follow-up process

Aim:

To identify the psychosocial and economic problems of the pediatric patients with cancer who were treated at the Dr. Sami Ulus Obstetrics and Gynecology and Child Health and Diseases Training and Research Hospital’s Pediatric Oncology Department and their relatives during this process.

Material and Methods:

We interviewed a total of 100 patients who were treated at Dr. Sami Ulus Obstetrics and Gynecology and Child Health and Diseases Hospital’s Pediatric Oncology Department between 1996 and 2015, and were now followed up without treatment and their relatives using survey questions on the psychosocial and economic problems they experienced.

Results:

Most of patients were from provinces outside Ankara. The average monthly income was below the level that would meet the family needs in 80% of the families and only 16% had extra income. Additional economic support had been received by 93% of the families in the patient group. Twenty-five families (25%) had been forced to sell property during the treatment. Forty-nine (49%) families had borrowed money from acquaintances and relatives or had taken out a bank loan. Serious psychological problems were experienced during and after the treatment by 46% of the mothers; 41% of the families had used religious procedures more commonly during the treatment period to cope with the psychological problems. Education was subject to a 1–2 year pause in 83% of the patients.

Conclusion:

Childhood-age patients with cancer and their families experience significant psychosocial and economic problems during and after the treatment process. Providing medical treatment and psychosocial support in harmony is an important factor that increases the success of cancer treatment. The patient and the family will require psychosocial support mechanisms throughout life, starting from the moment they face the disease. Developing national social support programs and legal regulations to form a basis for such programs are required in our country.

Guilt after placement questionnaire: a new instrument to assess caregiver emotional functioning following nursing home placement

OBJECTIVE

Guilt is a core feature of dementia caregivers' experiences following placement. This study describes and validates a new assessment tool for monitoring caregiver adjustment after placement.

METHODS

Forty-six items addressing ambivalence and guilt about placement were tested with 170 dementia caregivers (M age = 56.79, SD = 13.19; 69.4% female; 54.7% adult child).

RESULTS

Using principal axis factor analysis, 10 items were retained that showed acceptable internal consistency (Cronbach's alpha of 0.92). Construct validity was established in a subset of the sample (n = 53) with measures of depression (r = 0.53), burden (r = 0.48), conflict with staff (r = 0.47), and well-being (r = -0.30).

CONCLUSIONS

This scale may be used to identify caregivers at risk for adjustment problems following placement and to monitor adjustment over time.

An Examination of the Relations Between Symptom Distributions in Children Diagnosed with Autism and Caregiver Burden, Anxiety and Depression Levels

High stress levels and impairment of physical/mental health in parents can delay early and effective intervention in autism. The purpose of this study was to examine relations between the clinical characteristics of children diagnosed with autism spectrum disorder (ASD) and caregiver burden, and anxiety and depression levels. Seventy cases under monitoring at the Namık Kemal University Medical Faculty Child and Adolescent Psychiatric Polyclinic with a diagnosis of ASD, and their principal caregivers, were included in the study. The Autism Behavior Checklist (ABC), Beck Depression Inventory (BDI), Beck Anxiety Inventory, and the Zarit Caregiver Burden Scale were completed. At multiple regression analysis, autism symptom severity and caregiver depressive symptom levels emerged as significant predictors of total caregiver burden scores. Only the ABC language subscale score had a determining effect on caregiver burden (r = 0.51, r² = 0.26, p = 0.04). ABC body and object use subscale scores were identified as the symptom cluster affecting depression and anxiety scores (r = 0.25, r² = 0.06, p = 0.03 and r = 0.28, r² = 0.08, p = 0.01). Our findings show that ASD symptom severity and depressive symptoms in the caregiver are the most important factors giving rise to the caregiver burden, and that the main ASD symptom cluster affecting the caregiver burden was problems associated with language development. Better understanding of variables impacting on the caregiver burden will increase the quality of psychosocial services for caregivers.

Caregiver Out-of-Pocket Costs for Octogenarian Intensive Care Unit Patients in Canada

ABSTRACTMedical issues facing the aging population are of growing concern with consequences for patients and their caregivers. This study determined the indirect and out-of-pocket costs incurred by the caregivers of elderly patients in Canadian Intensive Care Units (ICUs). Primary family caregivers were surveyed capturing out-of-pocket costs, hours of work, and hours of leisure forgone in providing patient care while the patient was in the ICU. Total costs of care per month were reported across caregiver sex, age, and geographic region. Average out-of-pocket costs were $791 (2016 Canadian dollars) in the first month of ICU care. The mean total cost to family caregivers per patient was $162 per day. Male primary caregivers had higher mean out-of-pocket costs than female caregivers. Subsidization programs covering expenses such as travel, meals, accommodation, and parking are needed to support family caregivers of elderly ICU patients who are incurring considerable out-of-pocket costs.

Frontal lobe function in elderly patients with Alzheimer's disease and caregiver burden

AIM

Understanding of the relationship between caregiver burden and the degree of behavioural deficits in patients with Alzheimer's disease (AD) is relatively limited. Therefore, it is worthwhile to examine the correlations between the various relevant factors to improve the efficacy of care for patients with AD. The aim of this study was to investigate the specific contributions of frontal lobe dysfunction in AD patients to caregiver burden, while controlling for other predictor variables.

METHODS

Participants included 30 pairs of caregivers and patients with AD. The Zarit Burden Interview and Frontal Assessment Battery were used to measure the caregiver burden and patients' frontal lobe function, respectively. To investigate the effects of frontal lobe dysfunction on caregiver burden, hierarchical regression equations with steps incorporating additional predictor variables were fitted. We also performed a correlation analysis between the individual subdomains of the Zarit Burden Interview and the predictor variables.

RESULTS

Our study suggests that the degree of frontal lobe dysfunction in AD patients predicts their caregiver burden, when other factors of daily functional limitations and neuropsychiatric symptoms are controlled. Daily functional limitations and neuropsychiatric symptoms affected caregivers' psychosocial burden, whereas frontal lobe dysfunction affected caregivers' burden due to the increase in the dependency of the patients.

CONCLUSION

Our findings indicate that to ameliorate the disabilities of patients and reduce caregiver burden, there is a need for interventions that focus on psychosocial burdens, as shown in previous studies, as well as on excessive dependency due to frontal lobe dysfunction.

Impact of Cognitive Status and Decline on Service and Support Utilization among Older Adults in Taiwan

Using a sample of older adults in Taiwan, this study examines the impact of cognition on the use of informal support and formal health services. Results confirm the hypothesis that cognitive impairment is associated with increased use of informal care, while effects on formal service utilization are less consequential. A scale constructed from a subset of the Mini-Mental State Exam is significantly associated with receipt of instrumental activities of daily living assistance, while correlations with use of formal services such as hospitalization and physician visits are insignificant. A decline in cognitive status over time is correlated with the initiation of informal support but is not associated with formal service utilization. Implications of these results for a rapidly aging society such as Taiwan are discussed. With current low levels of fertility, future generations of older adults will have fewer social network resources. Absent of dramatic changes in cultural norms with respect to familial support in old age, the future will see an expanding care burden that must be borne by fewer family members.

Attitudinal Influences on the Elderly's Use of Assistance

This research examines the use of informal and formal assistance with personal and instrumental activities of daily living and the amount received by a randomly selected sample of urban older persons. A modified version of the Andersen behavioral model is used to organize explanatory factors that include the elderly's attitudes toward service use and filial expectations. Findings underscore the important influence of attitudes on assistance use in contrast to self-designated race, which had no influence either independently or in interaction with attitudinal variables. Elderly persons more likely to receive assistance were women of older age with lower incomes, who expressed more concerns about using services and were more physically disabled. Those receiving larger amounts of help had fewer concerns about using formal services and lived with their primary caregivers.

The Impact of the Frequency of Care Activities on the Division of Labor between Primary Caregivers and Other Care Providers

This study examines the division of labor between primary caregivers and other (formal and informal) care providers of elderly and dementia care recipients. Its main focus is on showing how the allocation of care activities among care providers is affected by the sheer quantity of care provided (measured in terms of frequency of care activities across 25 care tasks). Results support the hypothesis that patterns of cooperation and specialization between the primary caregiver and other helpers are more strongly influenced by the frequency of care involvement than by any other social factors, including caregiver gender, employment, and living arrangements. Even when faced with high care demands, caregivers appear to be reluctant to give up control. Instead of specialization, the preferred pattern of cooperation is supplementation, with other helpers assisting in the same care tasks as the primary caregiver.

Couples' experiences with early-onset dementia: An interpretative phenomenological analysis of dyadic dynamics

Objective

The growing interest in early-onset dementia has attracted attention to the situation and experiences of the caregiver, most often the spouse. Several qualitative studies on caregiving spouses have underlined the importance of the feeling of loss, the change of role reported by the caregiving spouses, and the strategies used to protect the person with dementia, all of which raise the question of the relational dynamics at play in these dyads. The present study on 16 couples examines the experiences of each partner, as well as the kinds of interactions taking place within the dyad and how they have evolved since the disease began.

Design

An interpretative phenomenological analysis was conducted on dyadic semi-structured interviews.

Results

Seven axes emerged from the analyses, showing that control over symptoms gradually leads to deterioration of marital interactions and to the components of marital dissolution.

Correlates of Community Service Attitudes Among Family Caregivers

This article examines caregiver and care recipient characteristics associated with community service attitudes. Using Community Service Attitude Inventory subscales that were refined for use across populations, the relationship between caregiver gender, age, relationship, type of medical diagnosis, and scores on attitude subscales were investigated in a sample of 562 family caregivers. Attitudes toward services were found to be associated with caregiver gender, age, and diagnosis. Implications for research and practice are presented.

Correlates of objective and subjective measures of caregiver burden among dementia caregivers: influence of unmet patient and caregiver dementia-related care needs

BACKGROUND

This study examines the relationship of unmet dementia-related care needs of community-dwelling persons, and their caregivers (CGs), to measures of caregiver burden.

METHODS

Cross-sectional baseline data were analyzed from participants in a dementia care coordination trial of community-residing persons with dementia (PWD) (n = 254) and their caregivers (n = 246). Participants were recruited from Northwest Baltimore, Maryland. The Zarit Burden Inventory (ZBI) was used to measure subjective caregiver burden. Objective burden was measured by estimating the total hours per week spent doing things for the PWD and/or how many hours CGs missed paid work in the prior month due to caregiving responsibilities. The Johns Hopkins Dementia Care Needs Assessment was used to identify unmet dementia-related care needs. Bivariate and multivariate linear regressions examined the relationship of unmet needs, demographic, clinical, or functional characteristics with caregiver burden measures.

RESULTS

In adjusted multivariable models, patient neuropsychiatric symptoms and caregiver unmet emotional needs explained 22% of the variance in ZBI scores. In adjusted multivariable models, caregiver need for respite, patient functional dependency, and caregiver unmet specialty medical needs explained 26% of the variance in the hours per week spent caregiving. PWD's level of functional dependency was the sole correlate of missed time at work, explaining 11% of the variance.

CONCLUSIONS

Addressing potentially modifiable unmet caregiver needs may reduce subjective and objective caregiver burden.

Entry and re-entry into informal care-giving over a 3-year prospective study among older people in Nairobi slums, Kenya

This paper analyses data from a 3-year prospective study to understand the factors associated with becoming a caregiver to a person with a chronic illness and examines the dynamics among caregivers over time. A total of 1485 participants were drawn from a study conducted in the slums of Nairobi, Kenya. Two waves of data collected in 2006 for the baseline and a follow-up in 2009 were used. Information on the demographic, self-reported health and socioeconomic characteristics such as education, sources of livelihood and employment status was used. Age was a significant factor in becoming a caregiver, but there were no significant differences by gender or marital status. New caregivers and those with more than one care-giving episode had a higher socioeconomic position than non-caregivers. Caregivers also had poorer health compared with non-caregivers, highlighting the association between being a caregiver and negative health outcomes. Additionally, having cared for someone with a HIV-related illness compared with other chronic conditions increased the likelihood of subsequently caring for another person in need of long-term care. This may be due to the heterosexual mode of HIV transmission in sub-Saharan Africa, hence clustering of infection within family or married couples. This finding draws attention to the need to provide timely interventions to caregivers for people with HIV-related illness who are likely to end up providing care to multiple care recipients. Furthermore, there is a need to enhance the indispensable contribution of informal caregivers through incorporating their role within the continuum of care for effective HIV and AIDS management. Overall, informal caregivers to persons with chronic illnesses perform the tasks of care-giving without any formal support from health or social services. Therefore, it is crucial to initiate policies and programmes to ease the burden of care that is borne by informal caregivers.

Investigation of the effect of self-efficacy levels of caregiver family members of the individuals with schizophrenia on burden of care

Sixty-two individuals with schizophrenia and their families were part of a descriptive study that investigated the effect of self-efficacy levels on the burden of care, using family member caregivers of schizophrenia patients. Data were collected using a questionnaire on the descriptive characteristics of patients and their families, the Self-Efficacy Scale, and Zarit Caregiver Burden Scale. The results for caregivers indicated a total mean self-efficacy score of 76.4±17.76 and a total mean of burden of care score of 68.64±18.60. A negative significant relation was discovered by looking at the correlation between the total mean scores (r=-.260, p<0.05). These results indicate that the burden of care decreases with the increasing level of self-efficacy in caregiver family members.

The worldwide economic impact of dementia 2010

OBJECTIVE

To acquire an understanding of the societal costs of dementia and how they affect families, health and social care services, and governments to improve the lives of people with dementia and their caregivers.

METHODS

The basic design of this study was a societal, prevalence-based, gross cost-of-illness study in which costs were aggregated to World Health Organization regions and World Bank income groupings.

RESULTS

The total estimated worldwide costs of dementia were US$604 billion in 2010. About 70% of the costs occurred in western Europe and North America. In such high-income regions, costs of informal care and the direct costs of social care contribute similar proportions of total costs, whereas the direct medical costs were much lower. In low- and middle-income countries, informal care accounts for the majority of total costs; direct social care costs are negligible.

CONCLUSIONS

Worldwide costs of dementia are enormous and distributed inequitably. There is considerable potential for cost increases in coming years as the diagnosis and treatment gap is reduced. There is also likely to be a trend in low- and middle-income countries for social care costs to shift from the informal to the formal sector, with important implications for future aggregated costs and the financing of long-term care. Only by investing now in research and the development of cost-effective approaches to early diagnosis and care can future societal costs be anticipated and managed.

Palliative caregivers who would not take on the caring role again

CONTEXT

Health and social services rely heavily on family and friends for caregiving at the end of life.

OBJECTIVES

This study sought to determine the prevalence and factors associated with an unwillingness to take on the caregiving role again by interviewing former caregivers of palliative care patients.

METHODS

The setting for this study was South Australia, with a population of 1.6 million people (7% of the Australian population) and used the South Australian Health Omnibus, an annual, face-to-face, cross-sectional, whole-of-population, multistage, systematic area sampling survey, which seeks a minimum of 3000 respondents each year statewide. One interview was conducted per household with the person over the age of 15 who most recently had a birthday. Using two years of data (n=8377; 65.4% participation rate), comparisons between those who definitely would care again and those who would not was undertaken.

RESULTS

One in 10 people across the community provided hands-on care for someone close to them dying an expected death in the five years before being interviewed. One in 13 (7.4%) former caregivers indicated that they would not provide such care again irrespective of time since the person's death and despite no reported differences identified in unmet needs between those who would and would not care again. A further one in six (16.5%) would only "probably care again." The regression model identified that increasing age lessens the willingness to care again (odds ratio [OR] 3.94; 95% confidence interval [CI] 1.56, 9.95) and so does lower levels of education (OR 0.413; 95% CI 0.18, 0.96) controlling for spousal relationship.

CONCLUSION

These data suggest that assessment of willingness to care needs to be considered by clinical teams, especially in the elderly. Despite most active caregivers being willing to provide care again, a proportion would not.

A systematic review to assess the policy-making relevance of dementia cost-of-illness studies in the US and Canada

A systematic review of dementia cost-of-illness (COI) studies in the US and Canada was conducted to explore the policy-making relevance of these studies. MEDLINE, CINAHL, EconLit, AMED and the Cochrane Library were searched from inception to March 2010 for English-language COI articles. Content analysis was used to extract common themes about dementia cost from the conclusions of articles that passed title, abstract and full-text screening. These themes informed our exploration of the policy-making relevance of COI studies in dementia. The literature search retrieved 961 articles and data were extracted from 46 articles. All except three articles reported data from the US; 27 articles included Alzheimer's dementia only. Common themes pertained to general observations about dementia cost, cost drivers in dementia, caregiver cost, items that may lower dementia cost, social service cost, Medicare and Medicaid cost, and cost comparisons with other diseases. The common themes suggest policy-oriented research for the future. However, the extracted COI studies were typically not conducted for policy-making purposes and they did not commonly provide prescriptive policy options. Researchers and policy makers need to consider whether the optimal research focus in dementia should be on programme evaluations instead of more COI studies.

Willingness-to-pay for reductions in care need: estimating the value of informal care in Alzheimer's disease

OBJECTIVE

To estimate the value of informal care in Alzheimer's disease using contingent valuation.

METHODS

A questionnaire was administered to 517 primary carers in four countries (UK, Spain, Sweden, and US). Dichotomous choice and bidding game methods were used to elicit their willingness to pay for a reduction in care burden by 1 h per day, or a total elimination of care needs. Further, the relationship between carer willingness to pay and carer and patient characteristics including disease severity and income was examined.

RESULTS

Carers spend on average about 7-9 h per day on giving care to their patient, of which 4-5 h constituted basic and instrumental ADL tasks. For a 1 h reduction in need for care per day, carers in the UK, Spain, Sweden, and US said that they were willing to pay pound105, pound121, pound59, and pound144 per month respectively. The willingness to pay was higher for carers with higher disposable income while the influence of other determinants varied across countries. About one-third of carers were not willing to pay anything for a reduction in care.

CONCLUSIONS

Carers' stated willingness to pay for reductions in care giving time is substantial and comparable to the prices currently paid for treatments that achieve this benefit. Its determinants seem more directly related to carer status than directly to patient status and may vary by region and by cultural and sociologic factors.

Estimating the cost of care giving on caregivers for people living with HIV and AIDS in Botswana: a cross-sectional study

Background

Community home-based care is the Botswana Government's preferred means of providing care for people living with HIV (PLHIV). However, primary (family members) or volunteer (community members) caregivers experience poverty, are socially isolated, endure stigma and psychological distress, and lack basic care-giving education. Community home-based care also imposes considerable costs on patients, their caregivers and families in terms of time, effort and commitment. An analysis of the costs incurred by caregivers in providing care to PLHIV will assist health and social care decision makers in planning the most appropriate ways to meet future service needs of PLHIV and their caregivers.

Methods

This study estimated the cost incurred in providing care for PLHIV through a stratified sample of 169 primary and volunteer caregivers drawn from eight community home-based care groups in four health districts in Botswana.

Results

The results show that the mean of the total monthly cost (explicit and indirect costs) incurred by the caregivers was $(90.45 ± 9.08) while the mean explicit cost of care giving was $(65.22 ± 7.82). This mean of the total monthly cost is about one and a half times the caregivers' mean monthly income of $66.00 (± 5.98) and more than six times the Government of Botswana's financial support to the caregivers. In addition, the cost incurred per visit by the caregivers was $15.26, while the total expenditure incurred per client or family in a month was $184.17.

Conclusions

The study, therefore, concludes that as the cost of providing care services to PLHIV is very high, the Government of Botswana should substantially increase the allowances paid to caregivers and the support it provides for the families of the clients. The overall costs for such a programme would be quite low compared with the huge sum of money budgeted each year for health care and for HIV and AIDS.

An estimate of the total worldwide societal costs of dementia in 2005

BACKGROUND

The aim of this report was to estimate the worldwide cost of dementia in 2005 from a societal viewpoint.

METHODS

Costs were estimated by combining prevalence estimates, country and region specific data on Gross Domestic Product per person, and average wage with results from previously published cost-of-illness studies in different countries. Direct medical and nonmedical costs as well as costs for informal care were included.

RESULTS

The total worldwide societal cost of dementia, on the basis of a dementia population of 29.3 million persons, was estimated to be US$315.4 billion in 2005, including US$105 billion for informal care (33%). Seventy-seven percent of the total costs occurred in the more developed regions, with 46% of the prevalence.

CONCLUSIONS

Worldwide costs for dementia are enormous, and informal care constitutes a major cost component, in particular in less developed regions. The health economics of dementia is a highly relevant area for further research.

Aging Families and the Demographics of Family Financial Support of Adults With Disabilities

Using data from the 2007 American Community Survey (ACS), the study estimated the degree of family financial support for adult members with disabilities living at home. Using the Internal Revenue Service definition of a “qualifying dependent,” need for financial support was defined in terms ability to financially contribute to one’s own support. Estimates indicated that 32.3% of the family-based population of adults with disabilities needed financial support. Among those meeting the support test, approximately 4 in 10 lived in households where the primary income earner was 60 years or older. Results are discussed in terms of greater attention to the impact of emerging family demographics for policy and assumption of a family perspective in policy making.

Economic considerations in the management of Alzheimer's disease

Alzheimer’s disease is a devastating chronic disease that significantly increases healthcare costs and affects the quality of life (QoL) of the afflicted patients and their caregivers. Population aging and other demographic changes may further increase the already staggering costs of this devastating disease. While few pharmacoeconomic studies have used a prospective health economics design to assess resource utilization, most studies showed beneficial treatment effects and suggested potential savings in healthcare costs and reductions in caregiver burden. Various degrees of cost savings have been reported depending on the type of economic model, treatment evaluated, and region used in the studies. Direct comparisons of the results are difficult because different methods have been used in these evaluations. The preference of patients and families for home care for as long as possible suggests that promoting noninstitutional care for these patients should become a priority. Continued home care for patients under pharmacological treatment may reduce caregiver burden, healthcare costs, and ultimately improve patients’ and caregivers’ QoL.

Premorbid relationship satisfaction and caregiver burden in dementia caregivers

Dementia caregiver appraisal of the quality of their current and premorbid relationship with the care recipient is associated with caregiving behaviors, caregiver mood, and the decision to end home care. This study examined the contribution of premorbid relationship satisfaction to caregiver burden in dementia caregivers. Live-in dementia caregivers (n = 72) completed several psychosocial measures. Caregiver responses were used to divide them into low premorbid relationship satisfaction group (low) versus high premorbid relationship satisfaction group (high). Results indicate that premorbid relationship satisfaction is negatively associated with caregiver burden and quality of family functioning. Caregivers with high satisfaction demonstrated significantly less burden and less reactivity to memory and behavior problems, and better problem solving skills and more effective communication compared with the low caregivers. Findings are independent of length of caregiving, disease severity, care recipient daily functioning, and relationship type. Relationship satisfaction may be an important contributor to caregiver burden.

Impact of frontal systems behavioral functioning in dementia on caregiver burden

Behavioral problems in the dementia patient are some of the strongest predictors of caregiver burden, though the impact of specific types of behavioral problems on burden is limited. This study investigated the contribution of frontal systems behavioral functioning (i.e., apathy, executive dysfunction, and disinhibition) on caregiver burden. Seventy-two family caregivers completed the Frontal Systems Behavior Scale and measures of mood, perceived burden, and patient ratings of functional impairment. Regression analyses indicated that frontal systems behavioral problems were predictive of caregiver burden after controlling for dementia severity and caregiver depression. Analyses of subscales revealed that executive dysfunction and disinhibition were predictors of caregiver burden. Results argue for including strategies for managing frontal systems behavioral problems, particularly executive dysfunction and disinhibition, in dementia caregiver interventions.

Validity and reliability of assessments of time

When the costs of dementia are analyzed, interviews regarding caregiver time (both informal or formal) and other kinds of resource use are frequently used. However, it is unclear how valid such data are. The aims were to investigate the validity and reliability of interview-based estimated resource use, particularly caregiver time. Twenty institutionalized demented persons were studied during 3 months. A special team recorded the amount of time the caregivers spent on personal activities of daily living (PADL), instrumental activities of daily living (IADL), and supervision. After each session, the caregivers estimated the amount of time they had spent on care. Observed time was regarded as the golden standard. Intra-rater reliability was tested with proxy informants on 25 elderly living at home. In total, 110 observations and 108 estimations of caregiver time were made. The correlation coefficient between observed and estimated PADL-time was 0.81 (p < 0.001), in IADL 0.29 (p = 0.03), and in supervision 0.51 (p < 0.001). The intra-rater reliability was high for almost all items (Cronbach's alpha and intraclass correlation coefficient >0.9). There was a high correlation between interview-based data and register data regarding hospital care, family physician, and district nurse visits. In conclusion, interviews may serve as a valid and reliable substitute for observations.

Clinical features associated with costs in early AD: baseline data from the Predictors Study

BACKGROUND

Few studies on cost of caring for patients with Alzheimer disease (AD) have simultaneously considered multiple dimensions of disease costs and detailed clinical characteristics.

OBJECTIVE

To estimate empirically the incremental effects of patients' clinical characteristics on disease costs.

METHODS

Data are derived from the baseline visit of 180 patients in the Predictors Study, a large, multicenter cohort of patients with probable AD followed from early stages of the disease. All patients initially lived at home, in retirement homes, or in assisted living facilities. Costs of direct medical care included hospitalizations, outpatient treatment and procedures, assistive devices, and medications. Costs of direct nonmedical care included home health aides, respite care, and adult day care. Indirect costs were measured by caregiving time. Patients' clinical characteristics included cognitive status, functional capacity, psychotic symptoms, behavioral problems, depressive symptoms, extrapyramidal signs, comorbidities, and duration of illness.

RESULTS

A 1-point increase in the Blessed Dementia Rating Scale score was associated with a $1,411 increase in direct medical costs and a $2,718 increase in unpaid caregiving costs. Direct medical costs also were $3,777 higher among subjects with depressive symptoms than among those who were not depressed.

CONCLUSIONS

Medical care costs and unpaid caregiving costs relate differently to patients' clinical characteristics. Poorer functional status is associated with higher medical care costs and unpaid caregiving costs. Interventions may be particularly useful if targeted in the areas of basic and instrumental activities of daily living.

The effect of multiple roles on caregiver stress outcomes

Some caregivers focus exclusively on the caregiving role; others try to balance caregiving responsibilities with a simultaneous work role outside the home. This study examined competing hypotheses about the impact that greater immersion in a work role would have on the stress outcomes of individuals who provide care for a person with a disability. The authors used national survey data to examine whether hours of work were associated with caregiver stress outcomes. The authors also investigated whether type of disability moderated the relationship between hours worked and stress outcomes. Results suggest that spending more time in a work role generally has no effect on caregiver stress outcomes. However, caregivers who were caring for a person with a mental disability experienced significantly fewer stress outcomes as they spent more hours engaged in outside work.

Recognition and treatment of Alzheimer's disease: a case-based review

Early recognition and treatment initiation are pivotal in managing Alzheimer's disease (AD). Once a diagnosis of AD is made, a treatment plan is developed and should include treatment initiation with cholinesterase inhibitors (ChEIs) to improve cognition, management of comorbid conditions, and treat behavioral symptoms. Caregiver compliance is integral to AD treatment success. The purpose of this report is to present two real case studies of "suspected" AD or related dementia and stress the significance of early and accurate diagnosis in disease management. In case 1, a caregiver reports gradual but progressive loss of memory, and the patient himself complains of memory impairment. Neuroimaging analysis confirms "typical " AD. In case 2, initiation of ChEI therapy is followed by substantial clinical improvement in the face of a complex medical picture, and neuroimaging revealing more neurodegenerative changes than could be accounted for by "pure" AD.

Reduction of caregiver burden in Alzheimer's disease by treatment with galantamine

Alzheimer's disease is a progressive condition characterized by a loss of cognition, altered behavior, and a loss of functional ability, such as bathing, dressing, toileting, and organizing finances. Family and friends provide nearly three quarters of all care for patients with Alzheimer's disease. This informal care results in significant burden to caregivers. Caregiver burden is the set of physical, psychological or emotional, social, and financial problems that family members may experience when caring for impaired older adults. Caregivers of Alzheimer's disease patients report higher rates of physical symptoms, mortality, depression, and fatigue, as well as adverse effects on employment compared with those who are not caregivers for Alzheimer's disease patients. In many cases, the same family members are responsible for both out-of-pocket expenditures and caregiving duties. For this article, a MEDLINE search using the key words "caregiver and Alzheimer's disease" and "cost and Alzheimer's disease" was performed. The purpose of this article is to review the literature on caregiver burden, the components of caregiver burden, effects of caregiving on the health of caregivers, the cost of Alzheimer's disease on the caregiver and society, and the benefits attainable with treatment.

Economics of dementia and pharmacoeconomics of dementia therapy

BACKGROUND

The economic impact of dementia is not well appreciated, even though Alzheimer's disease and related dementias were the third most expensive health condition in the United States in 2000. In 1997, the cost of managing patients with Alzheimer's disease and other dementias was estimated at US dollar 100 billion. Direct medical costs are compounded by indirect costs of care, including unpaid care and loss of earnings.

OBJECTIVE

The aim of this review was to examine studies of the economic impact of approved treatments for dementia therapy.

METHODS

Searches of the MEDLINE database were conducted to identify prospective, randomized trials and retrospective or modeling studies of the economic impact of dementia medications, as well as analyses of managed care data (years 1996-2004; English language; search terms: dementia or Alzheimer's cross-referenced with economic or costs).

RESULTS

Only 3 studies directly examined the economic effects of dementia therapy. Two of these demonstrated economic benefits of treatment, whereas the third study concluded that there were no benefits; however, the conclusions of the latter study may have been weakened by such factors as the high rate of attrition and biased selection of study participants. Modeling studies and analyses of managed care data also indicate economic benefits from approved treatments.

CONCLUSIONS

Therapies that are efficacious early in the disease can postpone the progression of dementia to more severe stages and may offer economic benefit to patients' families, caregivers, and society.

Cognitively Impaired Elderly and Their Adult Children

An aging parent’s development of a cognitive impairment requires significant changes in the lives of that individual and his or her family. Adult children may be required to assume caregiving responsibilities and may experience feelings of loss, as well as conflicting feelings of guilt, apprehension, anger, and resentment towards these responsibilities. This article explores the dynamic that underlies these sentiments and suggests strategies to maximize parent-child communication and facilitate the relationship between cognitively impaired elderly adults and their adult children.

Physical and Psychosocial Health in Family Caregiving: A Comparison of AIDS and Cancer Caregivers

The objectives of this study were to compare cancer and AIDS family caregivers in regard to their physical and emotional health. The sample consisted of 26 caregivers of persons with cancer or AIDS. Study participants completed a questionnaire that included measures of depression, grief, symptoms of stress, caregiving demands, interpersonal relationships, health status, and quality of life. The data revealed that both AIDS and cancer caregivers reported high levels of stress and depression as compared to community norms. No significant differences were found between AIDS and cancer caregivers for any of the scale scores; however, the two groups differed on several individual subscales. Cancer caregivers demonstrated higher social functioning and were more likely to report that the work of caregiving itself disrupted their ability to socially engage with others. In contrast, AIDS caregivers were more likely to report that their own health limited their ability to socialize. Even though AIDS caregivers experienced less family support than cancer caregivers, they reported more rewards from caregiving. Results suggest that support delivered to caregivers emphasize a more inclusive approach to program delivery, versus a disease-specific perspective, in order to increase the depth and breath of services provided to families undertaking these challenges.

The Needs of the Caregiver in the Long-Term Treatment of Alzheimer Disease

The long-term well-being of caregivers should be included as part of the treatment of patients with Alzheimer disease (AD). Throughout the process of caring for patients with AD, caregivers frequently experience social, emotional, physical, and financial losses, which become more significant as the disease progresses. Minimizing these losses is a goal in the overall management of AD. Successful treatment of the patient has been shown to positively impact quality of life for the caregiver. Randomized, controlled studies of acetylcholinesterase inhibitors (AChEIs) have demonstrated the effectiveness of these agents in stabilizing cognitive function and delaying behavioral symptoms. Moreover, a decrease in the incidence of nursing home placement has been associated with this therapy. The growing burden of AD on families and society as a whole warrants the investigation of ways to minimize the impact of AD. AChEIs play an important role in this effort. Further studies are needed to more closely examine the impact of specific AChEIs on caregiver burden.

The effects of galantamine treatment on caregiver time in Alzheimer's disease

AIM

The aim of the study was to determine whether the clinical benefits of galantamine for patients with Alzheimer's disease lead to benefits for caregivers.

METHODS

Data were pooled from two concurrent, multi-centre, randomized, double-blind, placebo-controlled, 6-month trials. Time caregivers spent assisting with activities of daily living (ADL) and time patients could be left unsupervised each day were assessed using the Allocation of Caregiver Time Survey. In total, 825 patients with mild-to-moderate Alzheimer's disease were included.

RESULTS

At endpoint, caregivers of galantamine-treated patients were more likely to report reductions (41% vs 37%), maintenance (19% vs 14%) or smaller increases (26% vs 34% reporting an increase >30 minutes) in time assisting with ADL compared with the placebo group (p=0.026; Wilcoxon rank-sum test). The mean daily time difference was 32 minutes (p=0.011). Among patients with moderate Alzheimer's disease, caregivers of galantamine-treated patients were even more likely to report reductions (46% vs 37%), maintenance (15% vs 6%) or smaller increases (25% vs 42% for increases >30 min) vs placebo (p=0.004), with a mean daily time saving of 53 minutes (p=0.021). Caregivers of galantamine-treated patients were more likely to report increases (22% vs 18%), maintenance (45% vs 43%) or smaller reductions (30% vs 37% for reductions >30 minutes) in time the patient could be left unsupervised compared with placebo (p=0.027). Mean daily time saving was 27 minutes. Among patients with moderate Alzheimer's disease, the treatment effect was greater (p=0.029), with caregivers in the galantamine group reporting the change in time left unsupervised as 68 minutes longer each day than caregivers of patients receiving placebo.

CONCLUSION

The clinical benefits of galantamine for patients with Alzheimer's disease are also associated with benefits to caregiving.

Cognitive function and acute care utilization

OBJECTIVES

Little is known about variation in cognitive function across the aged population, or how use and costs of health care vary with cognitive impairment. This study was designed to create a typology of cognitive function in a nationally representative sample, and evaluate acute care use in relation to cognitive function, holding constant confounding factors. By including proxy assessments of cognitive function, this is the first study to include individuals unable to respond themselves.

METHODS

We analyzed the baseline year of the Asset and Health Dynamics Among the Oldest Old (AHEAD) survey, sponsored by the National Institute on Aging, to create three levels of cognitive function, using direct measures for self-respondents (n = 6,651) and proxy evaluations for the others (n = 792). We used a two-part model to predict the likelihood of using various health services and to evaluate intensity of care among users.

RESULTS

Sixteen percent, 64%, and 20% of the sample fell into the low, moderate, and high cognitive function groups, respectively, that differed significantly on almost all demographic and health status measures, and some utilization measures. Controlling for other health and functional status measures, lower cognitive function had a significant and negative effect on outpatient services, but did not affect hospital use directly.

DISCUSSION

Lower cognitive function may be a barrier to outpatient care, but these analyses should be repeated using administrative use and cost data.

Resource utilisation and cost analysis of memantine in patients with moderate to severe Alzheimer's disease

BACKGROUND

Alzheimer's disease (AD) is a devastating illness that causes enormous emotional stress to affected families and is associated with substantial medical and nonmedical costs.

OBJECTIVE

To determine the effects of 28 weeks of memantine treatment for patients with AD on resource utilisation and costs.

STUDY DESIGN AND METHODS

Multicentre, prospective, double-blind, randomised, placebo-controlled clinical trial performed in the US. The Wilcoxon-Mann-Whitney test was used to examine the resource utilisation variables and logistic regression models were used for multivariate resource utilisation analyses. Analysis of covariance (ANCOVA) models (log and non-log) were computed to examine costs from a societal perspective. All costs were calculated in 1999 US dollars.

STUDY POPULATION

Outpatients with moderate to severe AD. Overall, 252 patients received randomised treatment, and 166 patients (placebo n = 76, memantine n = 90) formed the treated-per-protocol (TPP) subset for the health economic analyses, on which the main cost analysis was based.

MAIN OUTCOME MEASURE

Resource Utilisation in Dementia (RUD) scale, measuring patient and caregiver resource utilisation, and various sources for cost calculations.

RESULTS

Controlling for baseline differences between the groups, significantly less caregiver time was needed for patients receiving memantine than for those receiving placebo (difference 51.5 hours per month; 95% CI -95.27, -7.17; p = 0.02). Analysis of residential status also favoured memantine: time to institutionalisation (p = 0.052) and institutionalisation at week 28 (p = 0.04 with the chi-square test). Total costs from a societal perspective were lower in the memantine group (difference dollars US 1089.74/month [non-overlapping 95% CI for treatment difference -1954.90, -224.58]; p = 0.01). The main differences between the groups were total caregiver costs (dollars US-823.77/month; p = 0.03) and direct nonmedical costs (dollars US-430.84/month; p = 0.07) favouring memantine treatment. Patient direct medical costs were higher in the memantine group (p < 0.01), mainly due to the cost of memantine.

CONCLUSION

Resource utilisation and total health costs were lower in the memantine group than the placebo group. The results suggest that memantine treatment of patients with moderate to severe AD is cost saving from a societal perspective.

"Value for money" in treating Alzheimer's disease with the new cholinesterase inhibitors

The absolute number of dementia cases is likely to increase due to the impending demographic changes. Several cost-of-illness studies of Alzheimer's disease, mainly from a societal perspective in developed countries, have demonstrated a huge economic burden. A substantial component of this huge economic burden is the direct costs of institutionalization and the indirect cost incurred by informal carers. This huge economic burden is of great interest because of the emergence of several cholinesterase inhibitors with proven efficacy in the treatment of Alzheimer's disease. Several cost-effectiveness studies of these drugs, based mainly on Markov modelling techniques and using data from population-based epidemiological studies and efficacy trials, have indicated that these drugs are cost-effective. A theoretical delay in placement into a residential or a nursing home and consequent cost savings may explain this cost-effectiveness. In the UK, although health authorities would fund the prescription of these drugs, social services would benefit from the cost savings; thus there is little financial incentive for health authorities to fund these drugs.

Dementia caregiving: recent research on negative health effects and the efficacy of caregiver interventions

Provision of care to an older adult with dementia is an important societal resource. This resource may also come at a high cost to informal caregivers, most of whom are family members. In this paper we provide an overview of recent research on dementia caregiving and caregiver interventions. First, we provide background information on the prevalence and costs of Alzheimer's disease and related disorders. Second, we describe the specific stressors and broader mental and physical health outcomes of dementia caregiving. Third, recent evidence of the efficacy of caregiver interventions for both caregiver and patient outcomes is reviewed. Throughout the paper, we describe promising new directions for future research in this area, including assessment and intervention with family caregivers of older patients with comorbid dementia and depression, and the focus on sleep disturbance as a critical health consequence of dementia caregiving.

Time spent on informal and formal care giving for persons with dementia in Sweden

The purpose of this paper was to explore the time spent on caring by families of persons with dementia in Sweden. As part of a European Commission project, interviews were carried out on a sample of 92 carers, caring for persons with dementia. The interviews focused on time spent on caring, IADL, ADL and surveillance, as well as formal support received and used. Informal care, measured as hours spent caring, was about 8.5 times greater than formal services (299 and 35 h per month, respectively). Approximately 50% of the total informal care consisted of time spent on surveillance (day and night). Formal care input and informal support, in terms of ADL increased with dementia severity. A regression analysis showed that dementia severity, behavioural disturbances and coping were associated with the amount of informal care. This study gives some new perspectives on informal care giving for persons with dementia and support strategies in general. Some carers do carry a very heavy 24 h responsibility. This aspect of caring must be addressed by the development of well-targeted respite and relief support programmes.

Alzheimer's disease in the UK: comparative evidence on cost of illness and volume of health services research funding

OBJECTIVE

To review the economic cost of Alzheimer's disease, to determine the level of research expenditure directed at this illness and to make comparisons with cancer, stroke and heart disease.

METHOD

A literature search of cost-of-illness studies was conducted and major funders of research were contacted. Cost-of-illness estimates were updated and adjusted to enable comparability across the four disease areas.

RESULTS

The direct costs of Alzheimer's disease were estimated to be between 7.06 billion pounds sterling and 14.93 billion pounds sterling , which was substantially greater than stroke (3.2 billion pounds sterling), heart disease (4.05 billion pounds sterling ) and cancer (1.6 billion pounds sterling excluding informal care costs). Research expenditure on Alzheimer's disease was 57% of that on stroke, 10% of that on heart disease and 3% of that on cancer.

DISCUSSION

Alzheimer's disease imposes a high economic burden. However, spending on research is disproportionately low compared with spending on other major illnesses. In the light of these two findings we recommend further discussion of the distribution of public funding for research into this disease.

National estimates of the quantity and cost of informal caregiving for the elderly with dementia

OBJECTIVE

Caring for the elderly with dementia imposes a substantial burden on family members and likely accounts for more than half of the total cost of dementia for those living in the community. However, most past estimates of this cost were derived from small, nonrepresentative samples. We sought to obtain nationally representative estimates of the time and associated cost of informal caregiving for the elderly with mild, moderate, and severe dementia.

DESIGN

Multivariable regression models using data from the 1993 Asset and Health Dynamics Study, a nationally representative survey of people age 70 years or older (N = 7,443).

SETTING

National population-based sample of the community-dwelling elderly.

MAIN OUTCOME MEASURES

Incremental weekly hours of informal caregiving and incremental cost of caregiver time for those with mild dementia, moderate dementia, and severe dementia, as compared to elderly individuals with normal cognition. Dementia severity was defined using the Telephone Interview for Cognitive Status.

RESULTS

After adjusting for sociodemographics, comorbidities, and potential caregiving network, those with normal cognition received an average of 4.6 hours per week of informal care. Those with mild dementia received an additional 8.5 hours per week of informal care compared to those with normal cognition (P < .001), while those with moderate and severe dementia received an additional 17.4 and 41.5 hours (P < .001), respectively. The associated additional yearly cost of informal care per case was 3,630 dollars for mild dementia, 7,420 dollars for moderate dementia, and 17,700 dollars for severe dementia. This represents a national annual cost of more than 18 billion dollars.

CONCLUSION

The quantity and associated economic cost of informal caregiving for the elderly with dementia are substantial and increase sharply as cognitive impairment worsens. Physicians caring for elderly individuals with dementia should be mindful of the importance of informal care for the well-being of their patients, as well as the potential for significant burden on those (often elderly) individuals providing the care.

Reduced employment in caregivers of frail elders: impact of ethnicity, patient clinical characteristics, and caregiver characteristics

BACKGROUND

Without family caregivers, many frail elders who live at home would require nursing home care. However, providing care to frail elders requires a large time commitment that may interfere with the caregiver's ability to work. Our goal was to determine the patient and caregiver characteristics associated with the reduction of employment hours in caregivers of frail elders.

METHODS

This was a cross-sectional study of 2806 patients (mean age 78, 73% women, 29% African American, 12% Hispanic, 54% with dementia) with at least one potentially working caregiver (defined as one who is either currently employed or who would have been employed if they had not been providing care) and their 4592 potentially working caregivers. Patients were enrollees at 11 sites of the Program of All-Inclusive Care for the Elderly (PACE). Social workers interviewed patients and caregivers at the time of PACE enrollment. Caregivers were asked if they had reduced the hours they worked or had stopped working to care for the patient. Nurses interviewed patients and caregivers to assess independence in activities of daily living (ADLs) and the presence of behavioral disturbances. Comorbid conditions were assessed by physicians during enrollment examinations.

RESULTS

A total of 604 (22%) of the 2806 patients had at least one caregiver who either reduced the number of hours they worked or quit working to care for the patient. Patient characteristics independently associated with a caregiver reducing hours or quitting work were ethnicity, 95% confidence interval [CI] 1.14-1.78 for African American;, 95% CI 1.43-2.52 for Hispanic), ADL function below the median (, 95% CI 1.44-2.15), a diagnosis of dementia (, 95% -2.17 if associated with a behavioral disturbance;, 95% CI 1.06-1.63 if not associated with a behavioral disturbance), or a history of stroke (OR = 1.42, 95% CI 1.16-1.73). After controlling for these patient characteristics, caregiver characteristics associated with reducing work hours included being the daughter or daughter-in-law of the patient (OR = 1.69, 95% CI 1.37-2.08) and living with the patient (OR = 4.66, 95% CI 3.65-5.95 if no other caregiver lived at home, OR = 2.53, 95% CI 2.03-3.14 if another caregiver lived at home).

CONCLUSIONS

Many caregivers reduce the number of hours they work to care for frail elderly relatives. The burden of reduced employment is more likely to be incurred by the families of ethnic minorities and of patients with specific clinical characteristics. Daughters and caregivers who live with the patient are more likely to reduce work hours than other caregivers. Future research should examine the impact of lost caregiver employment on patients' families and the ways in which the societal responsibility of caring for frail elders can be equitably shared.