Dementia in the USA: state variation in prevalence

Regional variability of the impact of cardiometabolic diseases on incident dementia in United States Medicare beneficiaries

INTRODUCTION

Understanding the impact of cardiometabolic diseases (CMDs) on dementia risk can inform primary preventative measures.

METHODS

We leveraged a nationwide, population-based Medicare dataset of 20,789,037 beneficiaries (756,321 with incident dementia and 20,032,716 controls) from 2017 to compute the individual and combined population attributable fractions (PAFs) of dementia attributed to eight CMDs, adjusted for age, sex, and race. We mapped PAFs at the county level to investigate the geospatial patterns of CMD burden on dementia across the United States.

RESULTS

The nationwide combined weighted PAF for the eight CMDs was 37% overall, with hypertension (9.6%), ischemic heart disease (6.7%), and chronic heart failure (5.7%) associated with the greatest attributable fractions of dementia cases. The greatest fraction of county-level dementia cases attributed to CMDs were in the Southeastern United States.

DISCUSSION

A substantial proportion of incident dementia cases in the United States can be attributed to CMDs, especially in the Southeastern United States.

HIGHLIGHTS

Investigated the combined effect of cardiometabolic diseases (CMDs) on dementia. Used novel geospatial techniques to map the burden of dementia attributed to CMDs. If eight CMDs are mitigated, 37% of incident dementia cases could be eliminated. Identified regions of the United States with high CMD burden on dementia.

Mapping disparities in access to lecanemab in Georgia

INTRODUCTION

The approval of lecanemab-irmb offers potential disease-modifying treatments for Alzheimer's disease (AD), but geographical access barriers to infusion and amyloid positron emission tomography (PET) imaging sites might prevent timely access to the drug. We examined disparities in access to lecanemab infusion sites and amyloid PET scan facilities in Georgia's 159 counties.

METHODS

Facility location maps were used to examine lecanemab access. We used drive time analysis to identify and map counties by drive time.

RESULTS

No rural county had an amyloid PET scan center and only one had a lecanemab infusion center. Residents in rural counties need to drive > 1 hour on average to reach the nearest facility, which is statistically significantly longer than those in non-rural counties.

DISCUSSION

Lack of access and long drive times pose health equity issues for those in rural counties, which already have a higher percentage of older residents and a higher prevalence of behavioral AD risk factors.

HIGHLIGHTS

We mapped amyloid positron emission tomography (PET) scan and lecanemab infusion facilities in Georgia. We examined the drive time to the nearest facility in each county. One lecanemab infusion facility and no amyloid PET scan facilities were found in rural counties. The mean drive time to the nearest facility is significantly longer for rural counties. The results call for policies and resources to address this health disparity issue.

Regional variations in healthcare in people living with dementia in Germany: protocol for a mixed-methods study

INTRODUCTION

Care for people living with dementia is both important and complex, and there is evidence of large regional variations in the quality of care. This study protocol describes design, methods and objectives of an investigation of regional variations in the utilisation, the quality and the costs of care for people living with dementia in Germany.

METHODS AND ANALYSIS

An exploratory, naturalistic, mixed-methods study is being conducted with three modules: Module A: A quantitative analysis of claims data of statutory health insurance will be conducted to investigate regional variations in the utilisation and costs of care. Module B: In selected regions of interest that deviate significantly from the average in terms of utilisation in Module A, the quality of care and patient characteristics, variations and possible causes of these variations in care will be examined in more detail using quantitative and qualitative assessments. Module C: The claims and primary data from modules A and B will be combined, synthesised and evaluated to elicit recommendations for regional healthcare using a participatory consensus method.

ETHICS AND DISSEMINATION

The study is overseen by the German Alzheimer's Association. The study's ethics and data protection plan was approved by the data and ethics committee of the leading university, Brandenburg Medical School Theodor Fontane (reference number: 152092023-BO-E) as well as the data committee of the three participating health insurances. Dissemination plans include dissemination of our main results to the general public, people affected, the scientific community and funding-, policy- and decision makers. Study outcomes and conclusions will be published on our own and the funder's websites, through presentations at conferences and in scientific journals. The funder ensures dissemination of main study results and recommendations for action to relevant organisations and institutions. Publication of the study's main results is planned within 6 months of the study's conclusion.

TRIAL REGISTRATION NUMBER

DRKS00031944 (https://trialsearch.who.int/Trial2.aspx?TrialID=DRKS00031944).

Mapping the Numbers of Dementia in Brazil: A Delphi Consensus Study

OBJECTIVES

As the global dementia crisis intensifies, especially in low-and middle-income countries (LMICs), there is a pressing need for comprehensive prevalence data across diverse regions, including Brazil, where studies have been predominantly limited to affluent urban centers. This study aimed to conduct an expert consensus to determine the prevalence of all-cause dementia in Brazil, considering various age groups, sexes, and geographical areas.

METHODS

A Delphi consensus process with clinical and academic experts from across Brazil was conducted to provide dementia prevalence estimates in people aged ≥ 60 years living throughout Brazil for 2019. Each round consisted of answering structured questionnaires that incorporated information from the literature. A priori criteria were used to ascertain the point in which consensus was achieved for > 70% of the 15 prevalence estimates-for (1) total, (2) women and men, and (3) the five Brazilian macro-regions. The current and projected dementia cases in Brazil were calculated based on age and sex population distributions.

RESULTS

Fifteen experts, with a mean professional experience of 25 ± 10 years, reached a consensus in the fourth round. Experts agreed with a mean all-cause dementia prevalence of 8.5% among Brazilians aged ≥ 60 years, which comprised 2.46 million people in 2019 in this age. They reported higher dementia rates in women (9.1%) than men (7.7%); the highest total prevalence was in those over 80 where it exceeds 20%. Regional variations were also noted, with lower prevalence in the South (7.3%) and higher in the North (8.9%) and Northeast (10.1%). Projections estimate that considering Brazil's rapidly aging population, dementia cases will rise to 8.89 million by 2060.

CONCLUSIONS

This Delphi study estimated that dementia already affects roughly 1 in 12 older Brazilians aged 60 and above, with slightly higher prevalence in women and significant geographical variations. These results underscore the urgency for targeted public health strategies in Brazil and offer a framework for similar challenges in other LMICs, especially given that dementia cases are projected to increase by approximately 3.6 times in 4 decades.

Regional variation in diagnostic intensity of dementia among older U.S. adults: An observational study

INTRODUCTION

Geographic variation in diagnosed cases of Alzheimer's disease and related dementias (ADRD) could be due to underlying population risk or differences in intensity of new case identification. Areas with low ADRD diagnostic intensity could be targeted for additional surveillance efforts.

METHODS

Medicare claims were used for a cohort of older adults across hospital referral regions (HRRs). ADRD-specific regional diagnosis intensity was measured as the ratio of expected new ADRD cases (estimated using population demographics, risk factors, and practice intensity) compared to observed ADRD-diagnosed cases.

RESULTS

Crude new ADRD diagnosis rate ranged from 1.7 to 5.4 per 100 across HRRs. ADRD-specific diagnosis intensity ranged from 0.69 to 1.47 and varied most for Black, Hispanic, and the youngest (66-74) subgroups. Across all subgroups, ADRD diagnosis intensity was associated with 2-fold difference in receiving an ADRD diagnosis.

DISCUSSION

Where one resides influences the likelihood of receiving an ADRD diagnosis, particularly among those 66-74 years of age and minoritized groups.

HIGHLIGHTS

Rate of new Alzheimer's disease and related dementias (ADRD) case identification varies geographically across the United States. Variation in case identification is greatest in Black, Hispanic, and young-old groups. Intensity of diagnosis (ie, case identification) unrelated to population risk differs across place. Likelihood of receiving an ADRD diagnosis varies 2-fold based on place of residence.

Geographic Patterns of Dementia in the United States: Variation by Place of Residence, Place of Birth, and Subpopulation

OBJECTIVES

The prevalence of dementia varies geographically in the United States. However, the extent to which this variation reflects contemporary place-based experiences versus embodied exposures from earlier in the life course remains unclear, and little is known regarding the intersection of place and subpopulation. This study, therefore, evaluates whether and how risk for assessed dementia varies by place of residence and birth, overall and by race/ethnicity and education.

METHODS

We pool data from the 2000 to 2016 waves of the Health and Retirement Study, a nationally representative panel survey of older U.S. adults (n = 96,848 observations). We estimate the standardized prevalence of dementia by Census division of residence and birth. We then fit logistic regression models of dementia on region of residence and birth, adjusting for sociodemographic characteristics, and examine interactions between region and subpopulation.

RESULTS

The standardized prevalence of dementia ranges from 7.1% to 13.6% by division of residence and from 6.6% to 14.7% by division of birth, with rates highest throughout the South and lowest in the Northeast and Midwest. In models accounting for region of residence, region of birth, and sociodemographic covariates, Southern birth remains significantly associated with dementia. Adverse relationships between Southern residence or birth and dementia are generally largest for Black and less-educated older adults. As a result, sociodemographic disparities in predicted probabilities of dementia are largest for those residing or born in the South.

DISCUSSION

The sociospatial patterning of dementia suggests its development is a lifelong process involving cumulated and heterogeneous lived experiences embedded in place.

Rural versus Urban Residence in Adulthood and Incident Cognitive Impairment

INTRODUCTION

Rural versus urban living is a social determinant of cognitive health. We estimated the association of rural versus urban residence in the USA with incident cognitive impairment (ICI) and assessed effect heterogeneity by sociodemographic, behavioral, and clinical factors.

METHODS

The Reasons for Geographic and Racial Differences in Stroke Study (REGARDS) is a population-based prospective observational cohort of 30,239 adults, 57% female, 36% Black, aged 45+ years, sampled from 48 contiguous states in the USA in 2003-2007. We analyzed 20,878 participants who at baseline were cognitively intact with no history of stroke and had ICI assessed on average 9.4 years later. We classified participants' home addresses at baseline as urban (population ≥50,000), large rural (10,000-49,999), or small rural (≤9,999) by Rural-Urban Commuting Area codes. We defined ICI as ≥1.5 SD below the mean on at least 2 of the following tests: word list learning, word list delayed recall, and animal naming.

RESULTS

Participants' home addresses were 79.8% urban, 11.7% large rural, and 8.5% small rural. ICI occurred in 1,658 participants (7.9%). Small rural residents had higher odds of ICI than urban residents, adjusted for age, sex, race, region, and education (OR = 1.34 [95% CI: 1.10, 1.64]), and after further adjustment for income, health behaviors, and clinical characteristics (OR = 1.24 [95% CI: 1.02, 1.53]). Former smoking versus never, nondrinking versus light alcohol drinking, no exercise versus ≥4 times/week, CES-D depressive symptom score of 2 versus 0, and fair versus excellent self-rated health had stronger associations with ICI in small rural areas than in urban areas. For example, in urban areas, lack of exercise was not associated with ICI (OR = 0.90 [95% CI: 0.77, 1.06]); however, lack of exercise combined with small rural residence was associated with 1.45 times the odds of ICI compared with ≥4 bouts of exercise/week in urban areas (95% CI: 1.03, 2.03). Overall, large rural residence was not associated with ICI; however, black race, hypertension, and depressive symptoms had somewhat weaker associations with ICI, and heavy alcohol drinking a stronger association with ICI, in large rural areas than in urban areas.

CONCLUSION

Small rural residence was associated with ICI among USA adults. Further research to better understand why rural residents are at higher risk for developing ICI and mechanisms to ameliorate that risk will support efforts to advance rural public health.

Regional variation in U.S dementia trends from 2000-2012

Although recent studies report a decline in dementia prevalence among U.S. older adults, national trends may mask subnational variation, particularly given large health and social inequalities linked to geography. To address this gap, we determined if there was subnational variation in reported national dementia trends and if region-specific trends were explained by sociodemographic and health characteristics. Data come from the 2000 (n = 10,447) and 2012 (10,426) waves of the Health and Retirement Study. We used validated methods for dementia classification using proxy and self-respondents. Logistic regression models, adjusted for within-person clustering over time, estimated trends in dementia prevalence by region and census division. We found subnational variation in dementia prevalence in both 2000 and 2012, as well as in change in dementia prevalence during this period. In 2000, dementia prevalence was lowest in the West (8.6%), higher in the Midwest (10.0%) and Northeast (11.1%), and highest in the South (14.6%). Dementia prevalence declined over time across all regions of the U.S. from 2000 to 2012 but remained highest in the South (10.7%) compared to the other regions (7.0-7.8%). Despite downward trends in dementia across the U.S., the prevalence of dementia in the South in 2012 approximated levels found in other regions in 2000. There was relatively less change over time in the West compared to other regions, but dementia prevalence was already quite low in the West in 2000. Within region, trends in dementia prevalence between 2000 and 2012 also varied slightly across census divisions. Subnational variation in changes in dementia prevalence were largely explained by education and health status. Variation in baseline prevalence, as well as differential rates of change, highlight the importance of examining subnational variation in dementia trends.

Use of multidimensional item response theory methods for dementia prevalence prediction: an example using the Health and Retirement Survey and the Aging, Demographics, and Memory Study

BACKGROUND

Data sparsity is a major limitation to estimating national and global dementia burden. Surveys with full diagnostic evaluations of dementia prevalence are prohibitively resource-intensive in many settings. However, validation samples from nationally representative surveys allow for the development of algorithms for the prediction of dementia prevalence nationally.

METHODS

Using cognitive testing data and data on functional limitations from Wave A (2001-2003) of the ADAMS study (n = 744) and the 2000 wave of the HRS study (n = 6358) we estimated a two-dimensional item response theory model to calculate cognition and function scores for all individuals over 70. Based on diagnostic information from the formal clinical adjudication in ADAMS, we fit a logistic regression model for the classification of dementia status using cognition and function scores and applied this algorithm to the full HRS sample to calculate dementia prevalence by age and sex.

RESULTS

Our algorithm had a cross-validated predictive accuracy of 88% (86-90), and an area under the curve of 0.97 (0.97-0.98) in ADAMS. Prevalence was higher in females than males and increased over age, with a prevalence of 4% (3-4) in individuals 70-79, 11% (9-12) in individuals 80-89 years old, and 28% (22-35) in those 90 and older.

CONCLUSIONS

Our model had similar or better accuracy as compared to previously reviewed algorithms for the prediction of dementia prevalence in HRS, while utilizing more flexible methods. These methods could be more easily generalized and utilized to estimate dementia prevalence in other national surveys.

Geographic disparities in mortality from Alzheimer's disease and related dementias

OBJECTIVES

The regions with highest and lowest Alzheimer's disease (AD) mortality across the United States at state/county levels were identified and their contribution to the differences in total mortality rates between these regions was evaluated. The disease, disease group, sex, race/ethnicity, and place-of-death-related inter-region differences that engender the disparity in mortality were quantitatively described. The hypothesis that inter-regional differences in filling out death certificates are a major contributor to differences in AD mortality was tested.

DESIGN

Retrospective evaluation of death certificate data.

SETTING

The United States.

PARTICIPANTS

Deceased US residents, 1999-2018.

METHODS

Region-specific age-adjusted mortality rates and group-specific rate decomposition.

RESULTS

The county clusters with the highest and lowest AD mortality rates were in Washington (WA) and New York (NY), respectively, with other notable high-mortality clusters on the border of Tennessee, Georgia, and Alabama as well as in North Dakota and South Dakota. These patterns were stable over the 1999-2018 period. AD had the highest contribution to total mortality difference between WA and NY (156%, higher in WA), in contrast circulatory diseases had a contribution of comparable magnitude (154%) but were higher in NY. Differences in cause-of-death certificate coding, either through coding of non-AD dementias, or other conditions accompanying a potential AD death could not account for differences in AD mortality between NY and WA.

CONCLUSIONS

Inter-regional differences in filling out death certificates were not a major contributor to variation in AD mortality between the regions with the highest and lowest rates. The respective mitigation of the effects of neural and circulatory diseases and several other high-impact conditions would not negate the disparity in mortality between NY and WA.

The Association of Osteoarthritis and Related Pain Burden to Incident Alzheimer's Disease and Related Dementias: A Retrospective Cohort Study of U.S. Medicare Beneficiaries

BACKGROUND

Emerging evidence suggests osteoarthritis (OA) and related symptom burden may increase risk for Alzheimer's disease and related dementias (ADRD). However, longitudinal studies are sparse, and none have examined the potential mediating effects of mood or sleep disorders.

OBJECTIVE

To determine the association of OA and related pain to incident ADRD in U.S. elders.

METHODS

In this retrospective cohort study, we used baseline and two-year follow-up data from linked Medicare claims and Medicare Current Beneficiary Survey files (11 pooled cohorts, 2001-2013). The study sample comprised 16,934 community-dwelling adults≥65 years, ADRD-free at baseline and enrolled in fee-for-service Medicare. Logistic regression was used to assess the association of OA and related pain (back, neck, joint, neuropathic) to incident ADRD, explore the mediating inlfuence of mood and insomnia-related sleep disorders, and (sensitivity analyses) account for potential survival bias.

RESULTS

Overall, 25.5% of beneficiaries had OA at baseline (21.0% with OA and pain); 1149 elders (5.7%) were subsequently diagnosed with ADRD. Compared to beneficiaries without OA, those with OA were significantly more likely to receive a diagnosis of incident ADRD after adjustment for sociodemographics, lifestyle characteristics, comorbidities, and medications (adjusted odds ratio (AOR) = 1.23 (95% confidence interval (CI) 1.06, 1.42). Elders with OA and pain at baseline were significantly more likely to be diagnosed with incident ADRD than were those without OA or pain (AOR = 1.31, CI 1.08, 1.58). Sensitivity analyses yielded similar findings. Inclusion of depression/anxiety, but not sleep disorders, substantially attenuated these associations.

CONCLUSION

Findings of this study suggest that: OA is associated with elevated ADRD risk, this association is particularly pronounced in those with OA and pain, and mood disorders may partially mediate this relationship.

Vitamin D Attenuates Alzheimer-like Pathology Induced by Okadaic Acid

Many elderly individuals suffer from Alzheimer's disease (AD), which causes a growing concern. We investigated the mechanism underlying the effects of vitamin D (VD) as a prophylactic treatment. A mouse model of okadaic-acid-induced AD-like pathology was used in vivo and in vitro. Morris water maze and field trials were used to assess cognitive function. The expression levels of VDR, MTHFR, LCMT-1, PP2A, p-TAU (Thr396), and T-TAU and the methylation level of PP2A were measured by Western blotting, and a reversal of the increase in the levels of these proteins in an AD cell model was observed. We used MTHFR-knockdown SH-SY5Y cells to further test the effects of VD, treated these cells with cycloheximide and MG132, and used RT-PCR to explore the mechanism underlying MTHFR targeting. We found that the effects of VD on AD were impaired by MTHFR knockdown through a pretranscriptional mechanism. In addition, VD attenuated AD-induced cognitive impairment and significantly suppressed the expression of TAU. Our findings indicated that VD treatment alleviated TAU accumulation and rescued methylated PP2A by increasing the expression of LCMT-1 and MTHFR.

U.S. state correlations between oral health metrics and Alzheimer's disease mortality, prevalence and subjective cognitive decline prevalence

Given the association between periodontal disease (PdD) and Alzheimer’s disease (AD), we examined correlations between states’ age-adjusted AD mortality rates, AD prevalence, subjective cognitive decline (SCD) prevalence, and oral health data. Data sources include the Centers for Disease Control and Prevention, scientific literature, and oral health rankings formulated by WalletHub.com and Toothbrush.org. Pearson (r) or Spearman (r_s) correlation coefficients were generated and evaluated. AD mortality rates correlate with dental visits (r = − 0.50, p = 0.0003), partial (r = 0.39, p = 0.005) or total (r = 0.44, p = 0.001) edentulism, WalletHub.com (r_s = 0.30, p = 0.03) and Toothbrush.org (r_s = 0.35, p = 0.01) rankings. AD prevalence correlates with dental visits (r = − 0.30, p = 0.03), partial (r = 0.55, p = 0.00003) or total (r = 0.46, p = 0.0009) edentulism, prevalence of any (r = 0.38, p = 0.006) or severe-stage (r = 0.46, p = 0.0009) PdD, and WalletHub.com (r_s = 0.38, p = 0.006) rankings. SCD prevalence in adults aged ≥ 45 years correlates with dental visits (r = − 0.69, p < 0.00001), partial (r = 0.33, p = 0.02) or total (r = 0.37, p = 0.008) edentulism, prevalence of any (r = 0.53, p = 0.0001) or severe-stage (r = 0.57, p = 0.00002) PdD, WalletHub.com (r_s = 0.53, p = 0.00008) and Toothbrush.org (r_s = 0.60, p < 0.00001) rankings. State metrics indicative of compromised oral health correlate with AD mortality rates, AD prevalence and SCD prevalence.

Risk Factors for Alzheimer's Disease and Related Dementia Diagnoses in American Indians

The burden of Alzheimer's disease and related dementias (ADRD) has increased substantially in the United States, particularly in health disparity populations. Little is known about the epidemiology of ADRD in American Indian (AI) adults, although they have a high prevalence of ADRD risk factors including hypertension, diabetes, obesity, and smoking. Using electronic health records from a large health care organization during 2016-18, we describe characteristics of AI patients aged ≥55 years with and without an ADRD diagnosis, assess ADRD risk factors and contrast findings with results from age- and sex-matched non-Hispanic White (NHW) patients. To identify factors associated with ADRD diagnoses, we estimated population-averaged prevalence rate ratios to approximate relative risk (RR) using generalized estimating equations models adjusted for age, sex, and marital and rural residency status. The age-adjusted prevalence of ADRD diagnosis was 6.6% of AI patients, compared with 4.4% in NHW patients. Patient age and diagnosis of hypertension, depression, hyperlipidemia, or diabetes were significantly associated with higher risk of ADRD diagnosis in AIs (RR range: 1.1-2.8) whereas female sex or being married/having a partner were associated with lower risk of ADRD diagnosis (each RR=.7). ADRD risk factors were generally similar between AI and NHW patients, except for sex and marital status. However, the adjusted risk of ADRD was approximately 49% higher in AI patients. To our knowledge, our study is the first to examine ADRD diagnoses and comorbidities in AIs across a large geographical region in southwest United States. Future efforts to confirm our findings in diverse AI communities are warranted.

An updated measure for investigating basic knowledge of Alzheimer's disease in underserved rural settings

Objective: Older rural adults face a higher burden of Alzheimer's disease (AD) and delayed detection. This risk is heightened in rural populations that are ethnically diverse. Patients and providers are often hesitant to participate in screening, partially due to gaps in knowledge of the current science. The purpose of this paper is to describe the results of administering the revised version of the Basic Knowledge of Alzheimer's Disease (BKAD) measure in small rural communities in five different states.Methods: The BKAD measure was revised after first being tested in rural Appalachia. Revisions including eliminating non-discriminating items and adding questions regarding early detection, sleep, head injury, and vision changes. Reliability and validity testing included Cronbach's alpha and Rasch item analysis, test-retest, and predictive validity. Descriptive measures and independent sample t-tests were used to analyze knowledge gaps and sociodemographics.Results: Tests for reliability and validity were highly favorable, including Cronbach's alpha = .85 and overall Rasch item analysis of .94. Three-fourths of participants knew that annual cognitive screening was recommended for older adults, but only one-fourth had been previously screened. Sociodemographic findings revealed that a majority of participants (86%) would participate in annual memory screening if offered, regardless of education or health literacy level.Conclusion: The BKAD measure is a good fit for use in rural and underserved populations. BKAD results can inform the design of culturally relevant programs for raising awareness of the importance of early AD detection and treatment.

State Variability in the Prevalence and Healthcare Utilization of Assisted Living Residents with Dementia

OBJECTIVES

Almost 1 million older and disabled adults who require long-term care reside in assisted living (AL), approximately 40% of whom have a diagnosis of Alzheimer's disease and related dementias (ADRD). States vary in their regulations specific to dementia care that may influence the presence of residents with ADRD in AL and their outcomes. The objectives of this study were to describe the state variability in the prevalence of ADRD among Medicare beneficiaries residing in larger (25+ bed) ALs and their healthcare utilization.

DESIGN

Retrospective observational national study.

PARTICIPANTS

National cohort of 293,336 Medicare fee-for-service enrollees residing in larger (25+ bed) ALs in 2016 and 2017 including 88,867 (30.3%) residents with ADRD. We compared this cohort's characteristics and healthcare utilization with that of individuals with ADRD who resided in nursing homes (NHs; n = 602,521) and the community (n = 2,074,420).

METHODS

Medicare enrollment data, claims, and the NH Minimum Data Set were used to describe differences among ADRD patients in AL, NHs, and the community. We present rates of NH admission and hospitalization, by state, adjusting for age, sex, race, dual eligibility, and chronic conditions.

RESULTS

The prevalence of ADRD among AL residents varied by state, ranging from 24% to 47%. In 2017, AL residents with ADRD had higher rates of NH admission than their community-dwelling counterparts (adjusted national average = 24%, ranging from 14% to 35% among states). AL residents with ADRD had higher rates of hospitalization (38%) than populations in either NHs (29%) or the community (34%), and ranged from 29% to 45% of residents among states.

CONCLUSION

These findings have implications for states as they regulate AL and for healthcare professionals whose patients reside in AL. Future work is needed to understand specific elements of states' regulatory environments and local markets that may impact access and outcomes for this vulnerable population of residents with ADRD. J Am Geriatr Soc 68:1504-1511, 2020.

Years Lived with Disability due to Alzheimer's Disease and Other Dementias in Asian and North African Countries: A Trend Analysis

In Asia, which has a rapidly aging population, dementia is the most prominent disease. This article presents an application of Latent Growth Mixture Model (LGMM) to identify classes of individual Alzheimer’s Disease (AD) and other dementias Years Lived with Disability (YLD) rates for Asian and North African countries based on the unobserved heterogeneity. The AD and other dementias YLD data for both sexes and age-standardized groups reported by the Global Burden of Disease (GBD) Study database during 1990–2015 for 55 Asian and North African countries were analyzed via LGMM. Findings of LGMMs identified four classes of YLD trajectories. Among the specified classes, a class was related to a single country (Turkey) with the highest starting point in 1990 (intercept of 218.52 per 100,000) and upward trend. Another class with increasing trend (a slope of 2.66 per 100,000) consisted of India, China, Singapore, Japan, and Egypt. Other countries in Asia and North Africa (Classes 3 and 4) had a downward trend of YLD rates. The upward trend for some parts of Asia and North Africa might be attributed to appropriate therapeutic strategies, higher levels of awareness, related medical cares, and increase in life expectancy in these countries.

Risks and Benefits of Screening for Dementia in Primary Care: The Indiana University Cognitive Health Outcomes Investigation of the Comparative Effectiveness of Dementia Screening (IU CHOICE)Trial

BACKGROUND/OBJECTIVE

The benefits and harms of screening of Alzheimer disease and related dementias (ADRDs) are unknown. This study addressed the question of whether the benefits outweigh the harms of screening for ADRDs among older adults in primary care.

DESIGN, SETTING, AND PARTICIPANTS

Single-blinded, two-arm, randomized controlled trial (October 2012-September 2016) in urban, suburban, and rural primary care settings in Indiana. A total of 4005 primary care patients (aged ≥65 years) were randomized to ADRD screening (n = 2008) or control (n = 1997).

INTERVENTION

Patients were screened using the Memory Impairment Screen or the Mini-Cog and referred for a voluntary follow-up diagnostic assessment if they screened positive on either or both screening tests.

MEASUREMENTS

Primary measures were health-related quality of life (HRQOL; Health Utilities Index) at 12 months, depressive symptoms (Patient Health Questionnaire-9), and anxiety symptoms (Generalized Anxiety Disorder seven-item scale) at 1 month.

RESULTS

The mean age was 74.2 years (SD = 6.9 years); 2257 (66%) were female and 2301 (67%) were white. At 12 months, we were unable to detect differences in HRQOL between the groups (effect size = 0.009 [95% confidence interval {CI} = -0.063 to 0.080]; P = .81). At 1 month, differences in mean depressive symptoms (mean difference = -0.23 [90% CI = -0.42 to -0.039]) and anxiety symptoms (mean difference = -0.087 [90% CI = -0.246 to 0.072]) were within prespecified equivalency range. Scores for depressive and anxiety symptoms were similar between the groups at all time points. No differences in healthcare utilization, advance care planning, and ADRD recognition by physicians were detected at 12 months.

CONCLUSION

We were unable to detect a difference in HRQOL for screening for ADRD among older adults. We found no harm from screening measured by symptoms of depression or anxiety. Missing data, low rates of dementia detection, and high rate of refusal for follow-up diagnostic assessments after a positive screen may explain these findings. J Am Geriatr Soc 68:535-543, 2020.

Long-term effect of fine particulate matter on hospitalization with dementia

BACKGROUND

New evidence suggests that particulate matter less than 2.5 μm in diameter (PM_2.5) is associated with late-onset dementia (LOD). However, epidemiological studies for the entire population are lacking.

METHODS

We analyzed approximately 94 million follow-up records from fee-for-service Medicare records for 13 million Medicare beneficiaries residing in the southeastern United States (U.S.) from 2000 to 2013. We used spatially and temporally continuous PM_2.5 exposure data. To account for time-varying PM_2.5 levels, we applied an Andersen-Gill counting process proportional hazard model; we stratified our analyses by subtype of dementia and level of urbanization of residence.

RESULTS

During a median follow-up of 6 years, 1,409,599 hospitalizations with dementia occurred. The adjusted hazard ratio (HR) of hospitalization with dementia was 1.049 (95% confidence interval [CI], 1.048 to 1.051) per 1 μg/m³ increase in annual PM_2.5. The hazard ratio for vascular dementia was higher (HR, 1.086; 95% CI, 1.082 to 1.090). In large, the magnitude of the effect grew as the level of urbanization increased (HR, 1.036; 95% CI, 1.031 to 1.041 in rural areas versus HR, 1.052; 95% CI, 1.050 to 1.054 in metropolitan areas).

CONCLUSIONS

Long-term exposure to higher PM_2.5 was associated with increased hospitalizations with dementia.

Effect of metformin on neurodegenerative disease among elderly adult US veterans with type 2 diabetes mellitus

OBJECTIVE

This study aimed to evaluate the association between metformin treatment and the risk of neurodegenerative disease (ND) among elderly adults with type 2 diabetes mellitus (T2DM).

DESIGN/SETTING/PARTICIPANTS

This retrospective longitudinal cohort study examined the effects of the length of metformin exposure on ND among elderly US veterans with T2DM and insulin treatment using the Veterans Affairs electronic medical record database.

PRIMARY AND SECONDARY OUTCOME MEASURES

The primary clinical outcome was defined as diagnosis of ND including dementia, Alzheimer's disease (AD), Parkinson's disease (PD), Huntington's disease (HD) and mild cognitive impairment during the follow-up period. The secondary clinical outcomes were separately measured by AD, PD, HD, dementia and mild cognitive impairment.

RESULT

Adjusted by propensity score weight, a total of 5528 patients (mean age, 63.2±10.9 years; male, 98%; white, 60%) with a median follow-up of 5.2 years were selected. Those with ND or other mental disorders at baseline or who were on insulin for less than two-thirds of the study period were excluded. The incidence rate of ND was 11.48 per 1000 person-years among patients with metformin treatment, compared with 25.45 per 1000 person-years for those without metformin. Compared with no metformin use, 2-4 years and >4 years of metformin exposure were significantly associated with lower risk of ND (adjusted HR (aHR)=0.62, 95% CI 0.45 to 0.85; aHR=0.19, 95% CI 0.12 to 0.31, respectively), while metformin exposure in the first 2 years showed no significant influence.

CONCLUSION

We conclude that long-term metformin therapy (>2 years) was associated with lower incidence of ND among elderly veterans with T2DM. We need to conduct a study with more representative population and more robust method for causal inferences. Further investigation into the mechanism involved is needed along with randomised trials to confirm a potential neuroprotective effect of metformin.

State-level prevalence, health service use, and spending vary widely among Medicare beneficiaries with Parkinson disease

State-level variations in disease, healthcare utilization, and spending influence healthcare planning at federal and state levels and should be examined to understand national disparities in health outcomes. This descriptive study examined state-level variations in Parkinson disease (PD) prevalence, patient characteristics, Medicare spending, out-of-pocket costs, and health service utilization using data on 27.5 million Medicare beneficiaries in the US in 2014. We found that 45.8% (n = 179,496) of Medicare beneficiaries diagnosed with PD were women; 26.1% (n = 102,205) were aged 85+. The District of Columbia, New York, Illinois, Connecticut, and Florida had the highest age-, race-, and sex-adjusted prevalence of Parkinson disease among Medicare beneficiaries in the US. Women comprised over 48.5% of PD patient populations in West Virginia, Kentucky, Mississippi, Louisiana, and Arkansas. More than 31% of the PD populations in Connecticut, Pennsylvania, Hawaii, and Rhode Island were aged 85+. PD patients who were "dual-eligible"-receiving both Medicare and Medicaid benefits-also varied by state, from <10% to >25%. Hospitalizations varied from 304 to 653 stays per 1000 PD patients and accounted for 26.5% of the 7.9 billion United States Dollars (USD) paid by the Medicare program for healthcare services delivered to our sample. A diagnosis of PD was associated with greater healthcare use and spending. This study provides initial evidence of substantial geographic variation in PD patient characteristics, health service use, and spending. Further study is necessary to inform the development of state- and federal-level health policies that are cost-efficient and support desired outcomes for PD patients.

Opioid use and the presence of Alzheimer's disease and related dementias among elderly Medicare beneficiaries diagnosed with chronic pain conditions

Introduction

There is scant literature on the use of opioids among community-dwelling elderly with Alzheimer's disease and related dementias (ADRD).

Methods

We adopted a retrospective, cross-sectional study design using Medicare Current Beneficiary Survey data from 2006 to 2013. The study sample included elderly community-dwelling Medicare beneficiaries who were diagnosed with chronic pain conditions and had Medicare fee-for-service plans for the entire year. We conducted bivariate χ² test and multivariate logistic regression to examine the relationship between opioid use and ADRD status.

Results

The study sample included 19,347 Medicare beneficiaries; 7.7% of them had ADRD. We found no statistically significant difference in opioid use by ADRD status in the unadjusted analysis; however, controlling for various factors, those with ADRD had lower odds of opioid use (adjusted odds ratio = 0.81, 95% confidence interval = 0.71, 0.93) than those without ADRD.

Discussion

This population-based study suggests that elderly Medicare beneficiaries with ADRD and chronic pain conditions may have undertreatment of pain.

Alzheimer Disease and Related Disorders and Out-of-Pocket Health Care Spending and Burden Among Elderly Medicare Beneficiaries

OBJECTIVE

To estimate the excess burden of out-of-pocket health care spending associated with Alzheimer disease and related disorders (ADRD) among older individuals (age 65 y and older).

METHODS

We adopted a retrospective, cross-sectional study design with data from 2012 Medicare Current Beneficiary Survey. The study sample comprised of elderly community-dwelling individuals who had positive total health care expenditures, and enrolled in Medicare throughout the calendar year (462 with ADRD, and 7160 without ADRD). We estimated the per-capita total annual out-of-pocket spending on health care and out-of-pocket spending by service type: inpatient, outpatient, home health, prescription drugs, and other services. We measured out-of-pocket spending burden by calculating the percentage of income spent on health care and defined high out-of-pocket spending burden as having this percentage above 10%. Multivariable analyses included ordinary least squares regressions and logistic regressions and these analyses adjusted for predisposing, enabling, need, personal health care practices and external environment characteristics.

RESULTS

The average annual per-capita out-of-pocket health care spending was greater among individuals with ADRD compared with those without ADRD ($3285 vs. $1895); home health and prescription drugs accounted for 52% of total out-of-pocket spending among individuals with ADRD and 34% among individuals without ADRD. Elderly individuals with ADRD were more likely to have high out-of-pocket spending burden (adjusted odds ratio, 1.49; 95% confidence interval, 1.13-1.97) compared with those without ADRD.

CONCLUSION

ADRD is associated with excess out-of-pocket health care spending, primarily driven by prescription drugs and home health care use.

Treatment Patterns with Antidementia Drugs in the United States: Medicare Cohort Study

OBJECTIVES

To evaluate frequency of use of two anti-dementia drug classes approved for treatment of symptoms, whether populations most likely to benefit are treated, and correlates of treatment initiation.

DESIGN

Nationally representative cohort study.

SETTING

Fee-for-service Medicare.

PARTICIPANTS

Elderly adults with dementia enrolled in Medicare Parts A, B, and D in 2009 (N = 433,559) and a subset with incident dementia (n = 185,449).

MEASUREMENTS

Main outcome was any prescription fill for antidementia drugs (cholinesterase inhibitors (ChEIs) or memantine) within 1 year.

RESULTS

Treatment with antidementia drugs occurred in 55.8% of all participants with dementia and 49.3% of those with incident dementia. There was no difference between ChEIs and memantine use according to dementia severity (measured as death within first year or living in residential care vs in a community setting) even though memantine is not indicated in mild disease. In incident cases, initiation of treatment was lower in residential care (relative risk (RR) = 0.82, 95% confidence interval (CI) = 0.81-0.83) and with more comorbidities (RR = 0.96, 95% CI = 0.96-0.96). Sixty percent of participants were managed in primary care alone. Seeing a neurologist (RR = 1.07, 95% CI = 1.06-1.09) or psychiatrist (RR = 1.17, 95% CI = 1.16-1.19) was associated with higher likelihood of treatment than seeing a primary care provider alone, and seeing geriatrician was associated with with lower likelihood (RR = 0.96, 95% CI = 0.93-0.99). Across the United States, the proportion of newly diagnosed individuals started on antidementia treatment varied from 32% to 66% across hospital referral regions.

CONCLUSION

Antidementia drugs are used less often in people with late disease, but there is no differentiation in medication choice. Although primary care providers most often prescribe antidementia medication without specialty support, differences in practice between specialties are evident.

Using Administrative Data to Examine Health Disparities and Outcomes in Neurological Diseases of the Elderly

The fields of neurodegenerative disease and dementia research have grown considerably in the last several decades. Due to tremendous efforts of basic and clinical research scientists, we know a great deal about dementia risk factors and have multiple treatment options. Clinician recognition of cognitive impairment has increased considerably, national policies which support screening for and documenting cognitive dysfunction now exist, and public awareness of neurodegenerative disease has never been greater. These conditions promote (and demand) the growth of translational epidemiology and health services research, which focuses on examining outcomes in groups of individuals as a function of health care experiences. This review discusses the use of administrative data to answer health care outcomes and disparities questions in dementia. Of particular interest are publically available datasets that contain varying amounts of diagnostic, clinical, pharmacy, and patient information. Methodological challenges that are frequently encountered and must be understood to minimize biased inference are also discussed.

Cognitive and Functional Decline among Individuals 50 Years of Age or Older in Cambé, Paraná, Brazil: A Population-Based Study

AIMS

To identify the frequency of cognitive and functional decline (CFD) among adults 50 years of age and older by a population-based study.

METHODS

Cognitive function was analyzed by the Mini-Mental State Examination, and the functional conditions were based on instrumental activities of daily living (IADL). Cases of CFD included individuals with cognitive decline and 2 or more compromised IADL.

RESULTS

A total of 693 individuals were studied. The frequency of CFD was 16.3%. A low socioeconomic profile was associated with greater CFD independent of gender, age, education, and presence of depression (OR = 2.46; 95% CI: 1.53-3.97).

CONCLUSIONS

These data show a high frequency of CFD among adults 50 years and older. Individuals with less education and a lower socioeconomic level exhibited poorer cognitive and functional conditions.

Risk Factors and Hospitalization Costs of Dementia Patients: Examining Race and Gender Variations

AIMS

To examine the variation in risk factors and hospitalization costs among four elderly dementia cohorts by race and gender.

MATERIALS AND METHODS

The 2008 Tennessee Hospital Discharged database was examined. The prevalence, risk factors and cost of inpatient care of dementia were examined for individuals aged 65 years and above, across the four race gender cohorts - white males (WM), black males (BM), white females (WF), and black females (BF).

RESULTS

3.6% of patients hospitalized in 2008 had dementia. Dementia was higher among females than males, and higher among blacks than whites. Further, BF had higher prevalence of dementia than WF; similarly, BM had a higher prevalence of dementia than WM. Overall, six risk factors were associated with dementia for the entire sample including HTN, DM, CKD, CHF, COPD, and stroke. These risk factors varied slightly in predicting dementia by race and gender. Hospital costs were 14% higher among dementia patients compared to non-dementia patients.

CONCLUSIONS

There exist significant race and gender disparities in prevalence of dementia. A greater degree of co-morbidity, increased duration of hospital stay, and more frequent hospitalizations, may result in a higher cost of inpatient dementia care. Aggressive management of risk factors may subsequently reduce stroke and cost of dementia care, especially in the black population. Race and gender dependent milestones for management of these risk factors should be considered.