Implications of Comorbidity on Costs for Patients With Alzheimer Disease

Incremental Healthcare Costs of Dementia and Cognitive Impairment in Community-Dwelling Older Adults: A Prospective Cohort Study

BACKGROUND

Cognitive impairment and dementia are associated with higher healthcare costs; whether these increased costs are attributable to a greater comorbidity burden is unknown. We sought to determine associations of cognitive impairment and dementia with subsequent total and sector-specific healthcare costs after accounting for comorbidities and to compare costs by method of case ascertainment.

METHODS

Index examinations (2002-2011) of 4 prospective cohort studies linked with Medicare claims. 8 165 community-dwelling Medicare fee-for-service beneficiaries (4 318 women; 3 847 men). Cognitive impairment identified by self-or-proxy report of dementia and/or abnormal cognitive testing. Claims-based dementia and comorbidities derived from claims using Chronic Condition Warehouse algorithms. Annualized healthcare costs (2023 dollars) were ascertained for 36 months following index examinations.

RESULTS

521 women (12.1%) and 418 men (10.9%) met the criteria for cognitive impairment; 388 women (9%) and 234 men (6.1%) met the criteria for claims-based dementia. After accounting for age, race, geographic region, and comorbidities, mean incremental costs of cognitive impairment versus no cognitive impairment in women (men) were $6 883 ($7 276) for total healthcare costs, $4 160 ($4 047) for inpatient costs, $1 206 ($1 587) for skilled nursing facility (SNF) costs, and $689 ($668) for home healthcare (HHC) costs. Mean adjusted incremental total and inpatient costs associated with claims-based dementia were smaller in magnitude and not statistically significant. Mean adjusted incremental costs of claims-based dementia versus no claims-based dementia in women (men) were $759 ($1 251) for SNF costs and $582 ($535) for HHC costs.

CONCLUSIONS

Cognitive impairment is independently associated with substantial incremental total and sector-specific healthcare expenditures not fully captured by claims-based dementia or comorbidity burden.

Survival outcomes among hospitalized patients with dementia: a propensity score matching analysis

BACKGROUND

Hospitalized patients with dementia exhibit high mortality rates, underscoring the importance of investigating variables associated with reduced survival. This study aims to determine the incidence of dementia among hospitalized patients and survival rates at 1 and 3 years post-hospitalization.

METHODS

A retrospective cohort study was conducted using administrative databases from the Ministry of Health of Colombia. One- and three-year survival rates, along with adjusted hazard ratios for survival accounting for comorbidities included in the Charlson Index, were assessed using a Cox proportional hazards model. This analysis was performed for patients with dementia versus a control group without dementia. Additionally, findings were compared with those from an inverse propensity score weighting model.

RESULTS

6.769 (1.04%) patients were diagnosed with dementia, and 5798 (85.65%) were over 65 years of age. The unadjusted HR, the HR adjusted using the proportional hazards Cox model, and the HR obtained through propensity score matching (PSM) were 10.32 (95% CI 9.82 to 10.84), 1.69 (95% CI 1.60 to 1.78), and 1.32 (95% CI 1.02 to 1.71), respectively. The 1-year adjusted mortality rates for patients with dementia and those without were 12.5% and 1.31%, respectively, while the corresponding 3-year adjusted mortality rates were 21.25% and 2.76%. Through PSM, we determined that the mean survival time for patients with dementia, in comparison to those without, was - 0.98 months (95% CI: -0.65 to -1.94; p < 0.001).

CONCLUSIONS

Dementia significantly reduces survival rates of hospitalized patients, regardless of other comorbidities. Specifically, our research revealed that dementia was associated with a decrease in 3-year survival by an average of 0.98 months.

Patients with dementia: prevalence and type of drug-drug interactions

Background

Patients with Alzheimer's disease (AD) and other dementias are more frequently exposed to polymedication, mainly due to the presence of comorbidities, are particularly vulnerable to drug-related problems, and present greater risk of adverse effects due to drug-drug interactions (DDIs).

Purpose

To assess the prevalence of clinically relevant interactions in dementia patients using a routine database, we describe the most frequent interactions and risk factors associated with them to facilitate specific interventions and programs to prevent and minimize them.

Methods

An observational, descriptive, and cross-sectional study that included patients with AD and other types of dementia (n = 100, 64% female) was conducted to identify potential DDI in their treatment using the Lexi-Interact/Lexicomp® database.

Results

A total of 769 drugs were prescribed, involving 190 different active ingredients; 83% of the treatments included five or more drugs. DDI occurred in 87% of the patients, of which 63.2% were female. A total of 689 DDIs were found, grouped in 448 drug pairs, with a mean of 6.9 ± 7.1 (range, 0-31) DDIs per patient, and 680 DDIs were considered clinically relevant. It was observed that 89.8% of the DDIs had a moderate level of severity, 23.5% had a good level of relevance, and pharmacodynamic-based DDIs accounted for 89.5%. The drugs most frequently involved in DDIs were quetiapine (24.5%) and acetylsalicylic acid (10%). A total of 97 DDIs were detected between the acetylcholinesterase inhibitors (AChEIs), and the remaining drugs were administered concomitantly. One of the most frequent DDIs was between AChEIs and beta-blocking agents (n = 29, 4.3%). The most important factors that showed the strongest association with the presence of drug interactions were the use of AChEIs (p = 0.01) and the total number of drugs (p = 0.014) taken by the patient.

Conclusion

Patients with dementia present increased risk of DDIs. Among the most common drugs are psychotropic drugs, which are involved in pharmacodynamic interactions caused by the concomitant use of CNS-targeted drugs. The results highlight the difficulty to evaluate DDIs in clinical practice due to polymedication and variety of comorbidities. Therefore, it is important to review their treatment and consider metabolism inhibition or induction, and potentially P450 substrate overlapping.

Healthcare burden of cognitive impairment: Evidence from a Singapore Chinese health study

Background

Cognitive impairment (CI) raises risks for unplanned healthcare utilisation and expenditures and for premature mortality. It may also reduce risks for planned expenditures. Therefore, the net cost implications for those with CI remain unknown.

Method

We examined differences in healthcare utilisation and cost between those with and without CI. Using administrative healthcare utilisation and cost data linked to the Singapore Chinese Health Study cohort, we estimated regression-adjusted differences in annual healthcare utilisation and costs by CI status determined by modified Mini-Mental State Exam. Estimates were stratified by ex ante mortality risk constructed from out-of-sample Cox model predictions applied to the full sample, with a separate analysis restricted to decedents. These estimates were used to project differential healthcare costs by CI status over 5 years.

Results

Patients with CI had 17% higher annual cost compared to those without CI (SGD4870 versus SGD4177, P<0.01). Accounting for the greater mortality risk, individuals with CI cost 9% to 17% more over 5 years, or SGD2500 (95% confidence interval 1000-4200) to SGD3600 (95% confidence interval 1300-6000) more, depending on their age. Higher cost was mainly due to more emergency department visits and subsequent admissions (i.e. unplanned). Differences attenuated in the last year of life when costs increased dramatically for both groups.

Conclusion

Ageing populations and higher rates of CI will further strain healthcare resources primarily through greater use of emergency department visits and unplanned admissions. Efforts should be made to identify at risk patients with CI and take appropriate remediation strategies.

Economic Burden of Alzheimer's Disease: A Systematic Review

OBJECTIVES

Alzheimer's disease (AD) has become one of the most prevalent neurodegenerative disorders among the elderly. The global cost of dementia is expected to reach US $2 trillion in 2030. In this systematic review, existing evidence on the cost of dementia specific to AD is appraised.

METHODS

A comprehensive search was done on 3 databases, namely PubMed, ScienceDirect, and Web of Science, to identify original cost-of-illness studies that only evaluate the economic burden of AD up to August 2022. The risk of bias in the studies was assessed using Consolidated Health Economic Evaluation Reporting Standards 2022 criteria. Cost articles without specifying etiology of AD or those in non-English were excluded.

RESULTS

Twelve of 5536 studies met the inclusion criteria. The total annual cost of AD per capita ranged from US $468.28 in mild AD to US $171 283.80 in severe AD. The cost of care raised nonlinearly with disease severity. Indirect caregiving cost represented the main contributor to societal cost in community-dwelling patients. When special caregiving accommodation was opted in daily care, it results in cost shifting from indirect cost to direct nonmedical cost. Formal caregiving accommodation caused increase in direct cost up to 67.3% of overall economic burden of the disease.

CONCLUSIONS

AD exerts a huge economic burden on patients and caregivers. Overall rise of each cost component could be anticipated with disease deterioration. Choice of special caregiving accommodation could reduce caregiver's productivity loss but increase the direct nonmedical expenditure of the disease from societal perspective.

Cost of care for Alzheimer's disease and related dementias in the United States: 2016 to 2060

Medical and long-term care for Alzheimer's disease and related dementias (ADRDs) can impose a large economic burden on individuals and societies. We estimated the per capita cost of ADRDs care in the in the United States in 2016 and projected future aggregate care costs during 2020-2060. Based on a previously published methodology, we used U.S. Health and Retirement Survey (2010-2016) longitudinal data to estimate formal and informal care costs. In 2016, the estimated per patient cost of formal care was $28,078 (95% confidence interval [CI]: $25,893-$30,433), and informal care cost valued in terms of replacement cost and forgone wages was $36,667 ($34,025-$39,473) and $15,792 ($12,980-$18,713), respectively. Aggregate formal care cost and formal plus informal care cost using replacement cost and forgone wage methods were $196 billion (95% uncertainty range [UR]: $179-$213 billion), $450 billion ($424-$478 billion), and $305 billion ($278-$333 billion), respectively, in 2020. These were projected to increase to $1.4 trillion ($837 billion-$2.2 trillion), $3.3 trillion ($1.9-$5.1 trillion), and $2.2 trillion ($1.3-$3.5 trillion), respectively, in 2060.

Home and Community-Based Service Use Varies by Health Care Team and Comorbidity Level of Veterans with Dementia

Home and community-based services (HCBSs) such as home care and adult day centers are vital to supporting adults with dementia in community settings. We investigated whether HCBS use (use of both home care and adult day, use of one service, and use of neither service) varied between adults receiving care from three types of health-care teams with case management from social workers and nurses, and by comorbidity level, using 2019 data of 143,281 patients with dementia in the Veterans Health Administration. We compared HCBS use by patients' type of case-managed team (Home-Based Primary Care, geriatrics-based primary care, and dementia-focused specialty care) to patients in none of these teams, stratified by patients' non-dementia comorbidities (<4 or ≥4). Each type of health-care team was associated with both home care and adult day services, at each level of comorbidity. Home-Based Primary Care was most consistently associated with other forms of HCBS use, followed by Dementia Clinics and geriatrics-based primary care, for patients with ≥4 non-dementia comorbidities. Our findings suggest that case management in primary and specialty care settings is a contributor to the use of critical community supports by patients with the most complex needs.

Exploring the relationship between patient-relevant outcomes and Alzheimer's disease progression assessed using the clinical dementia rating scale: a systematic literature review

Background

People with Alzheimer's disease (AD) have difficulties in performing activities of daily living (ADLs) as the disease progresses, commonly experience neuropsychiatric symptoms (NPS), and often have comorbidities such as cardiovascular disease. These factors all contribute to a requirement for care and considerable healthcare costs in AD. The Clinical Dementia Rating (CDR) scale is a widely used measure of dementia staging, but the correlations between scores on this scale and patient-/care partner-relevant outcomes have not been characterized fully. We conducted a systematic literature review to address this evidence gap.

Methods

Embase, MEDLINE, and the Cochrane Library were searched September 13, 2022, to identify published studies (no restriction by date or country) in populations with mild cognitive impairment due to AD or AD dementia. Studies of interest reported data on the relationships between CDR Global or CDR-Sum of Boxes (CDR-SB) scores and outcomes including NPS, comorbidities, ADLs, nursing home placement, healthcare costs, and resource use.

Results

Overall, 58 studies met the inclusion criteria (42 focusing on comorbidities, 14 on ADLs or dependence, five on nursing home placement, and six on economic outcomes). CDR/CDR-SB scores were correlated with the frequency of multiple NPS and with total scores on the Neuropsychiatric Inventory. For cardiovascular comorbidities, no single risk factor was consistently linked to AD progression. Increasing CDR/CDR-SB scores were correlated with decline in multiple different measures of ADLs and were also associated with nursing home placement and increasing costs of care.

Conclusion

NPS, ADLs, and costs of care are clearly linked to AD progression, as measured using CDR Global or CDR-SB scores, from the earliest stages of disease. This indicates that scores derived from the CDR are a meaningful way to describe the severity and burden of AD for patients and care partners across disease stages.

Diagnostic groups of hospital stays and outpatient visits during 10 years before Alzheimer's disease

BACKGROUND

Alzheimer's disease (AD) is a major determinant of healthcare costs and increase in the healthcare service use occur already before the AD diagnosis. However, little is known how the different diagnosis categories contribute to this increase in healthcare use. We investigated how the hospitalizations and specialized healthcare outpatient visits from different diagnosis categories, based on the International Classification of Diseases (ICD-10) chapters, contribute to increased specialized healthcare service use during ten-year period preceding AD diagnosis.

METHODS

A register-based nationwide cohort of 42,934 community-dwelling persons who received clinically verified AD diagnosis in between 2008 and 2011 in Finland and 1:1 age, sex and hospital district- matched comparison cohort were included. Hospitalizations and specialized healthcare visits were categorized by the main diagnosis, according to the ICD-10 chapters. AD and dementia were separated to their own category. The number of persons with visits and stays was calculated for every 6 months, irrespective of the frequency of visits/stays individual had during that time window. Furthermore, the relative distribution of the diagnosis categories was computed.

RESULTS

AD cohort was more likely to have visits and stays during the 10-year period (OR 1.19, 95% CI 1.17-1.21). The number of persons with visits and stays peaked in AD cohort from 1.5 years before the diagnosis when the differences in relative distribution of different diagnosis categories also became evident. The largest differences were observed for visits/stays with cognitive disorders, symptoms of unspecified diseases and psychiatric disorders diagnoses, and those with missing diagnosis codes in the last time window before AD diagnosis.

CONCLUSIONS AND IMPLICATIONS

Increased healthcare service use before AD diagnosis does not seem to arise from differences in specific diagnosis categories of ICD-10 such as diseases of the circulatory system, but from the higher frequency of visits and stays among persons with AD across diagnosis categories. Based on the relative distribution of diagnosis categories, the steep increase in healthcare service use just before and during the diagnostic process is likely due to prodromal symptoms and visits related to cognition.

Effects of Dementia on Outcomes after Cervical Spine Injuries in Elderly Patients: Evaluation of 1512 Cases in a Nationwide Multicenter Study in Japan

We aimed to retrospectively investigate the demographic characteristics and short-term outcomes of traumatic cervical spine injuries in patients with dementia. We enrolled 1512 patients aged ≥ 65 years with traumatic cervical injuries registered in a multicenter study database. Patients were divided into two groups according to the presence of dementia, and 95 patients (6.3%) had dementia. Univariate analysis revealed that the dementia group comprised patients who were older and predominantly female and had lower body mass index, higher modified 5-item frailty index (mFI-5), lower pre-injury activities of daily living (ADLs), and a larger number of comorbidities than patients without dementia. Furthermore, 61 patient pairs were selected through propensity score matching with adjustments for age, sex, pre-injury ADLs, American Spinal Injury Association Impairment Scale score at the time of injury, and the administration of surgical treatment. In the univariate analysis of the matched groups, patients with dementia had significantly lower ADLs at 6 months and a higher incidence of dysphagia up to 6 months than patients without dementia. Kaplan-Meier analysis revealed that patients with dementia had a higher mortality than those without dementia until the last follow-up. Dementia was associated with poor ADLs and higher mortality rates after traumatic cervical spine injuries in elderly patients.

Short-term associations between ambient air pollution and emergency department visits for Alzheimer's disease and related dementias

Dementia is a seriously disabling illness with substantial economic and social burdens. Alzheimer's disease and its related dementias (AD/ADRD) constitute about two-thirds of dementias. AD/ADRD patients have a high prevalence of comorbid conditions that are known to be exacerbated by exposure to ambient air pollution. Existing studies mostly focused on the long-term association between air pollution and AD/ADRD morbidity, while very few have investigated short-term associations. This study aims to estimate short-term associations between AD/ADRD emergency department (ED) visits and three common air pollutants: fine particulate matter (PM_2.5), nitrogen dioxide (NO₂), and warm-season ozone.

Methods

For the period 2005 to 2015, we analyzed over 7.5 million AD/ADRD ED visits in five US states (California, Missouri, North Carolina, New Jersey, and New York) using a time-stratified case-crossover design with conditional logistic regression. Daily estimated PM_2.5, NO_2, and warm-season ozone concentrations at 1 km spatial resolution were aggregated to the ZIP code level as exposure.

Results

The most consistent positive association was found for NO₂. Across five states, a 17.1 ppb increase in NO₂ concentration over a 4-day period was associated with a 0.61% (95% confidence interval = 0.27%, 0.95%) increase in AD/ADRD ED visits. For PM_2.5, a positive association with AD/ADRD ED visits was found only in New York (0.64%, 95% confidence interval = 0.26%, 1.01% per 6.3 µg/m³). Associations with warm-season ozone levels were null.

Conclusions

Our results suggest AD/ADRD patients are vulnerable to short-term health effects of ambient air pollution and strategies to lower exposure may reduce morbidity.

The costs of treating all-cause dementia among American Indians and Alaska native adults who access services through the Indian Health Service and Tribal health programs

INTRODUCTION

Little is known about treatment costs for American Indian and Alaska Native (AI/AN) adults with dementia who access services through the Indian Health Service (IHS) and Tribal health programs.

METHODS

We analyzed fiscal year 2013 IHS/Tribal treatment costs for AI/ANs aged 65+ years with dementia and a matched sample without dementia (n = 1842) to report actual and adjusted total treatment costs and costs by service type. Adjusted costs were estimated using multivariable regressions.

RESULTS

Mean total treatment cost for adults with dementia were $13,027, $5400 higher than for adults without dementia ($7627). The difference in adjusted total treatment costs was $2943 (95% confidence interval [CI]: $1505, $4381), the majority of which was due to the difference in hospital inpatient costs ($2902; 95% CI: $1512, $4293).

DISCUSSION

Knowing treatment costs for AI/ANs with dementia can guide enhancements to policies and services for treating dementia and effectively using health resources.

Blood and CSF Homocysteine Levels in Alzheimer's Disease: A Meta-Analysis and Meta-Regression of Case-Control Studies

OBJECTIVE

Hyperhomocysteinemia (HHcy), as an important risk factor for Alzheimer's disease (AD), would aggravate cognitive dysfunction. This study aimed to investigate whether and to what degree the homocysteine (Hcy) levels in blood and cerebrospinal fluid (CSF) were elevated in AD patients compared with healthy controls and to explore the factors related to the elevated Hcy levels in AD patients.

METHODS

PubMed and Embase databases were searched to identify eligible studies, and study quality was evaluated using the Newcastle-Ottawa Quality Assessment Scale. Ratio of mean (RoM) Hcy concentrations was used as a measure of fold-change between AD patients and healthy control subjects.

RESULTS

We identified 35 eligible studies, consisting a total of 2172 patients with AD and 2289 healthy controls. The pooled results showed that patients with AD had a significantly higher blood level of Hcy (RoM, 1.32; 95% CI, 1.25-1.40; p<0.001) than controls did, with large heterogeneity across studies (I2=81.4%, p<0.001). Hcy level in CSF did not differ significantly between patients with AD than controls (RoM, 1.12; 95% CI, 0.90-1.39, p=0.293; I2=69.4%, p=0.02). A random effects meta-regression analysis revealed that there was an inverse correlation between the blood levels of Hcy and folate (p=0.006). There was no link found between the blood levels of vitamin B12, or the Mini-Mental Status Examination scores reflecting the degree of cognitive impairment, and blood levels of Hcy.

CONCLUSION

Regardless of dementia severity, there is an approximate one-third increase in blood Hcy in AD patients, which is robustly associated with a decreased level of blood folate in AD, but not with that of blood vitamin B12 nor the degree of dementia. Future investigation on the cause-and-effect link between Hcy and folate is warranted to clarify this issue.

Artificial intelligence (AI) for home support interventions in dementia: a scoping review protocol

INTRODUCTION

Dementia has become one of the significant causes of disability and dependency among older people globally. The proportion of people with dementia who are cared for at home has soared. The rapid growth of technology and data has stimulated artificial intelligence (AI) in patients with dementia at home. However, there are still tremendous opportunities and challenges in applying AI to patients with dementia at home, and there is no systematic overview.

METHODS AND ANALYSIS

The review will adopt the Unified Theory of Acceptance and Use of Technology. This scoping review will follow the Joanna Briggs Institute scoping review methodology. The structure and content of this protocol follow the Preferred Reporting Items for Systematic reviews and Meta-analyses extension for Scoping Reviews checklist. The proposed study will consider applying AI technology for dementia patients living at home and their families. Authors will conduct systematic searches: China National Knowledge Infrastructure, Wanfang Database, China Science and Technology Journal Database, China Biology Medicine disc, PubMed, CINAHL, Web of Science Cochrane database, EBSCO, Ovid, PsycINFO, Embase. The extracted data will be processed qualitatively and described through tables. The findings are integrated by a narrative synthesis. This review aims to evaluate the nature and extent of the application of AI technology in patients with dementia at home through a systematic search of the literature.

ETHICS AND DISSEMINATION

Scoping review is an analysis of existing data and therefore does not require ethical approval. We will publish our findings in a peer-reviewed journal.Scoping review protocol registration . DOI:10.17605/OSF.IO/3NU9C.

Economic Burden of Chronic Comorbidities Among Community-Dwelling Older Adults With Dementia: A Propensity Score Matched National-Level Study

OBJECTIVE

This study examined the extent to which chronic comorbidities contribute to excess health care expenditures between older adults with dementia and propensity score (PS)-matched nondementia controls.

METHODS

This was a retrospective, cross-sectional, PS-matched case (dementia): control (nondementia) study of older adults (65 y or above) using alternative years data from pooled 2005 to 2015 Medical Expenditure Panel Surveys (MEPS). Chronic comorbidities were identified based on Clinical Classifications System or ICD-9-CM codes. Ordinary least squares regression was utilized to quantify the impact of chronic comorbidities on the excess expenditures with logarithmic transformation. Expenditures were expressed as 2019 US dollars. All analyses accounted for the complex survey design of MEPS.

RESULTS

The mean yearly home health care expenditures were particularly higher among older adults with dementia and co-occurring anemia, eye disorders, hyperlipidemia, and hypertension compared with PS-matched controls. Ordinary least squares regression models revealed that home health care expenditures were 131% higher (β=0.837, P <0.001) among older adults with dementia compared with matched nondementia controls before adjusting for chronic comorbidities. When additionally adjusting for chronic comorbidities, the percentage increase, while still significant ( P <0.001) decreased from 131% to 102%.

CONCLUSIONS

The excess home health care expenditures were partially explained by chronic comorbidities among community-dwelling older adults with dementia.

Family caregivers' perceptions and experiences of participating in the learning skills together intervention to build self-efficacy for providing complex care

The purpose of this study was to describe how an intervention to teach family caregivers of persons living with dementia to provide complex care tasks contributes to their self-efficacy. This qualitative study was embedded in a pilot study evaluating the intervention. Semi-structured interviews were conducted with 15 caregivers who had completed the intervention. Content analysis was used to analyze the data. Themes identified from the interviews were: "helpfulness of the content", "if they can do it, so can I", and "applying what I have learned". Caregivers described the helpfulness of learning from expert healthcare professionals in a supportive environment. They valued the group setting, including interacting with and learning from their peers. Caregivers demonstrated mastery of the content by applying it to their caregiving situations and sharing information with other family members. These findings provide insights into successful elements in a complex care intervention that contributed to building caregiver self-efficacy.

Themes describing social isolation in family caregivers of people living with dementia: A scoping review

INTRODUCTION

The number of people with dementia has been increasing. Evidence shows that over 16 million family caregivers provide unpaid care for people with dementia. However, family caregivers experience several challenges throughout their caregiving role, including that of social isolation. Although social isolation in people with dementia has been well documented, social isolation in their family caregivers has not received as much scholarly attention. This scoping review sought to address this dearth of research through the following research question: "What are themes, concepts, or constructs that describe social isolation of family caregivers for people living with dementia?".

METHOD

An electronic search was conducted in PubMed, PsycInfo, and Scopus, using the following Boolean search phrase: dementia AND "social isolation" AND (caregiver OR carers). Content analysis was conducted to identify relevant themes.

FINDINGS

The initial search yielded 301 studies. Through screening processes, 13 studies were eligible for review. Based on a synthesis of evidence, five themes emerged from the data: disease progression, psychological state, social networks, social supports, and technology.

DISCUSSION

This review demonstrates that caregiving is related to social isolation in family caregivers of people living with dementia. The experience of social isolation was related to the progression of dementia, psychological states, and lack of supports. In contrast, social supports, social networks, and using technology may reduce social isolation. Identifying themes provides policy and practice implications, such as using information and communication technology to create and redefine social networks.

Modifiable, Non-Modifiable, and Clinical Factors Associated with Progression of Alzheimer's Disease

There is an extensive literature relating to factors associated with the development of Alzheimer's disease (AD), but less is known about factors which may contribute to its progression. This review examined the literature with regard to 15 factors which were suggested by PubMed search to be positively associated with the cognitive and/or neuropathological progression of AD. The factors were grouped as potentially modifiable (vascular risk factors, comorbidities, malnutrition, educational level, inflammation, and oxidative stress), non-modifiable (age at clinical onset, family history of dementia, gender, Apolipoprotein E ɛ4, genetic variants, and altered gene regulation), and clinical (baseline cognitive level, neuropsychiatric symptoms, and extrapyramidal signs). Although conflicting results were found for the majority of factors, a positive association was found in nearly all studies which investigated the relationship of six factors to AD progression: malnutrition, genetic variants, altered gene regulation, baseline cognitive level, neuropsychiatric symptoms, and extrapyramidal signs. Whether these or other factors which have been suggested to be associated with AD progression actually influence the rate of decline of AD patients is unclear. Therapeutic approaches which include addressing of modifiable factors associated with AD progression should be considered.

Tip of the Iceberg: Assessing the Global Socioeconomic Costs of Alzheimer's Disease and Related Dementias and Strategic Implications for Stakeholders

While it is generally understood that Alzheimer’s disease (AD) and related dementias (ADRD) is one of the costliest diseases to society, there is widespread concern that researchers and policymakers are not comprehensively capturing and describing the full scope and magnitude of the socioeconomic burden of ADRD. This review aimed to 1) catalogue the different types of AD-related socioeconomic costs described in the literature; 2) assess the challenges and gaps of existing approaches to measuring these costs; and 3) analyze and discuss the implications for stakeholders including policymakers, healthcare systems, associations, advocacy groups, clinicians, and researchers looking to improve the ability to generate reliable data that can guide evidence-based decision making. A centrally emergent theme from this review is that it is challenging to gauge the true value of policies, programs, or interventions in the ADRD arena given the long-term, progressive nature of the disease, its insidious socioeconomic impact beyond the patient and the formal healthcare system, and the complexities and current deficiencies (in measures and real-world data) in accurately calculating the full costs to society. There is therefore an urgent need for all stakeholders to establish a common understanding of the challenges in evaluating the full cost of ADRD and define approaches that allow us to measure these costs more accurately, with a view to prioritizing evidence-based solutions to mitigate this looming public health crisis.

Health-care use and cost for multimorbid persons with dementia in the National Health and Aging Trends Study

BACKGROUND

Most persons with dementia have multiple chronic conditions; however, it is unclear whether co-existing chronic conditions contribute to health-care use and cost.

METHODS

Persons with dementia and ≥2 chronic conditions using the National Health and Aging Trends Study and Medicare claims data, 2011 to 2014.

RESULTS

Chronic kidney disease and ischemic heart disease were significantly associated with increased adjusted risk ratios of annual hospitalizations, hospitalization costs, and direct medical costs. Depression, hypertension, and stroke or transient ischemic attack were associated with direct medical and societal costs, while atrial fibrillation was associated with increased hospital and direct medical costs. No chronic condition was associated with informal care costs.

CONCLUSIONS

Among older adults with dementia, proactive and ambulatory care that includes informal caregivers along with primary and specialty providers, may offer promise to decrease use and costs for chronic kidney disease, ischemic heart disease, atrial fibrillation, depression, and hypertension.

Direct Medical Costs of Dementia With Lewy Bodies by Disease Complexity

OBJECTIVES

There is currently no accurate profile of the economic burden of dementia with Lewy bodies (DLB), particularly any examination of the direct medical costs of DLB by the number of affected clinical domains. Understanding how trends in the use of healthcare resources evolve as DLB progresses presents opportunities for the development of earlier and more appropriate interventions.

DESIGN

Retrospective study using claims data extracted from the IBM MarketScan Commercial and Medicare Supplemental database.

SETTING AND PARTICIPANTS

In total, 536 patients with DLB from the Commercial database and 5485 patients with DLB from the Medicare Supplemental database.

METHODS

Patients were grouped into disease complexity categories based on core clinical features (ie, fluctuating cognition, motor symptoms, visual hallucinations, and rapid eye movement sleep behavior disorder in addition to dementia) observed during the study period: dementia with no core features observed, dementia plus 1, 2, or ≥3 core features, respectively. Outcome measures included healthcare resource utilization and healthcare costs.

RESULTS

In both databases, total healthcare resource utilization and costs increased with number of core features. Compared with patients with no core features observed, patients in all other complexity categories had significantly higher mean medical visits and costs in both adjusted and unadjusted analyses. Fluctuating cognition was associated with the highest total costs, suggesting that this clinical feature in particular is associated with a considerable economic burden.

CONCLUSIONS AND IMPLICATIONS

Analyzing direct medical costs of DLB by disease complexity using claims data showed that a higher cost impact was associated with increasing number of clinical domains affected and with specific clinical domains, suggesting the need for both targeted and comprehensive interventions to improve the overall economic burden of DLB.

Predictors of high hospital care and medication costs and cost trajectories in community-dwellers with Alzheimer's disease

Objectives: We studied the determinants of high healthcare costs (highest decile of hospital care and medication costs) and cost trajectories among all community-dwellers with clinically verified Alzheimer's disease (AD), diagnosed during 2005-2011 in Finland (N = 70,531). Methods: The analyses were done separately for hospital care costs, medication costs and total healthcare costs that were calculated for each 6-month period from 5 years before to 3 years after AD diagnosis. Results: Total healthcare costs were driven mainly by hospital care costs. The definition of "high-cost person" was time-dependent as 63% belonged to the highest 10% at some timepoint during the study period and six distinct cost trajectories were identified. Strokes, cardiovascular diseases, fractures and mental and behavioural disorders were most strongly associated with high hospital care costs. Conclusions: Although persons with AD are often collectively considered as expensive patient group, there is large temporal and inter-individual variation in belonging to the highest decile of hospitalization and/or medication costs. It would be important to assess whether hospitalization rate could be decreased by, e.g., comprehensive outpatient care with more efficient management of comorbidities. In addition, other interventions that could decrease hospitalization rate in persons with dementia should be studied further in this context. Key messages Persons with AD had large individual fluctuation in hospital care costs and medication costs over time. Hospital care costs were considerably larger than medication costs, with fractures, cardiovascular diseases and mental and behavioural disorders being the key predictors. Antidementia medication was associated with lower hospital care costs.

Long-term medical costs of Alzheimer's disease: matched cohort analysis

OBJECTIVES

Medical costs associated with Alzheimer's disease (AD) are characterised by uncertainty and are often presented in a format unsuitable for decision modelling. We set out to estimate long-term medical costs attributable to AD compared to the general population for use in decision modelling.

METHODS

We used multiple logistic regressions to generate propensity scores to match 26,951 incident cases of AD with 26,951 people without AD, identified from Danish hospital and medication registries. Costs were available for up to 11 years for each individual, representing costs for 10 years before and 5 years after diagnosis. Generalised estimating equations were employed to investigate the effect of having AD on primary care, medication, hospital and total costs in the matched cohort. We also explored the impact of other socio-economic and demographic factors on healthcare costs.

RESULTS

We report costs by year to diagnosis, from 10 years before to 5 after. AD was associated with significantly higher costs, driven by medication and hospital costs, especially around the time of diagnosis. Mean total medical cost was €4996 higher for AD than for the control group in year of diagnosis, after which primary and hospital costs decreased to pre-diagnostic levels. AD had higher attributable primary care costs in years preceding diagnosis.

CONCLUSIONS

Reporting AD-attributable costs by year to diagnosis can be useful for use in decision modelling. Medical costs attributed to AD are driven by diagnostic procedures and medication, and the impact of AD on medical costs may not be as high or prolonged as previously suggested.

Multimorbidity and functional impairment-bidirectional interplay, synergistic effects and common pathways

This review discusses the interplay between multimorbidity (i.e. co-occurrence of more than one chronic health condition in an individual) and functional impairment (i.e. limitations in mobility, strength or cognition that may eventually hamper a person's ability to perform everyday tasks). On the one hand, diseases belonging to common patterns of multimorbidity may interact, curtailing compensatory mechanisms and resulting in physical and cognitive decline. On the other hand, physical and cognitive impairment impact the severity and burden of multimorbidity, contributing to the establishment of a vicious circle. The circle may be further exacerbated by people's reduced ability to cope with treatment and care burden and physicians' fragmented view of health problems, which cause suboptimal use of health services and reduced quality of life and survival. Thus, the synergistic effects of medical diagnoses and functional status in adults, particularly older adults, emerge as central to assessing their health and care needs. Furthermore, common pathways seem to underlie multimorbidity, functional impairment and their interplay. For example, older age, obesity, involuntary weight loss and sedentarism can accelerate damage accumulation in organs and physiological systems by fostering inflammatory status. Inappropriate use or overuse of specific medications and drug-drug and drug-disease interactions also contribute to the bidirectional association between multimorbidity and functional impairment. Additionally, psychosocial factors such as low socioeconomic status and the direct or indirect effects of negative life events, weak social networks and an external locus of control may underlie the complex interactions between multimorbidity, functional decline and negative outcomes. Identifying modifiable risk factors and pathways common to multimorbidity and functional impairment could aid in the design of interventions to delay, prevent or alleviate age-related health deterioration; this review provides an overview of knowledge gaps and future directions.

Patient-Family Agenda Setting for Primary Care Patients with Cognitive Impairment: the SAME Page Trial

BACKGROUND

Establishing priorities for discussion during time-limited primary care visits is challenging in the care of patients with cognitive impairment. These patients commonly attend primary care visits with a family companion.

OBJECTIVE

To examine whether a patient-family agenda setting intervention improves primary care visit communication for patients with cognitive impairment DESIGN: Two-group pilot randomized controlled study PARTICIPANTS: Patients aged 65 + with cognitive impairment and family companions (n = 93 dyads) and clinicians (n = 14) from two general and one geriatrics primary care clinic INTERVENTION: A self-administered paper-pencil checklist to clarify the role of the companion and establish a shared visit agenda MEASUREMENTS: Patient-centered communication (primary); verbal activity, information disclosure including discussion of memory, and visit duration (secondary), from audio recordings of visit discussion RESULTS: Dyads were randomized to usual care (n = 44) or intervention (n = 49). Intervention participants endorsed an active communication role for companions to help patients understand what the clinician says or means (90% of dyads), remind patients to ask questions or ask clinicians questions directly (84% of dyads), or listen and take notes (82% of dyads). Intervention dyads identified 4.4 health issues for the agenda on average: patients more often identified memory (59.2 versus 38.8%; p = 0.012) and mood (42.9 versus 24.5%; p = 0.013) whereas companions more often identified safety (36.7 versus 18.4%; p = 0.039) and personality/behavior change (32.7 versus 16.3%; p = 0.011). Communication was significantly more patient-centered in intervention than in control visits at general clinics (p < 0.001) and in pooled analyses (ratio of 0.86 versus 0.68; p = 0.046). At general clinics, intervention (versus control) dyads contributed more lifestyle and psychosocial talk (p < 0.001) and less biomedical talk (p < 0.001) and companions were more verbally active (p < 0.005). No intervention effects were found at the geriatrics clinic. No effect on memory discussions or visit duration was observed.

CONCLUSION

Patient-family agenda setting may improve primary care visit communication for patients with cognitive impairment.

TRIAL REGISTRATION

ClinicalTrials.gov : NCT02986958.

Lower Postsurgical Mortality for Individuals with Dementia with Better-Educated Hospital Workforce

OBJECTIVES

To investigate whether care in a hospital with more nurses holding at least a Bachelor of Science in Nursing (BSN) degree is associated with lower mortality for individuals with Alzheimer's disease and related dementias (ADRD) undergoing surgery ADRD.

DESIGN

Cross-sectional data from 2006-07 Medicare claims were linked with the Multi-State Nursing Care and Patient Safety Survey of nurses in 4 states.

SETTING

Adult, nonfederal, acute care hospitals in California, Florida, New Jersey, and Pennsylvania (N=531).

PARTICIPANTS

Medicare beneficiaries aged 65 and older with and without ADRD undergoing general, orthopedic, or vascular surgery (N=353,333; ADRD, n=46,163; no ADRD, n=307,170).

MEASUREMENTS

Thirty-day mortality and failure to rescue (death after a complication).

RESULTS

Controlling for hospital, procedure, and individual characteristics, each 10% increase in the proportion of BSN nurses was associated with 4% lower odds of death (odds ratio (OR)=0.96, 95% confidence interval (CI)=0.93-0.98) for individuals without ADRD, but 10% lower odds of death (OR=0.90, 95% CI=0.87-0.94) for those with ADRD. Each 10% increase in the proportion of nurses holding a BSN degree or higher was associated with 5% lower odds of failure to rescue (OR=0.95, 95% CI=0.92-0.98) for individuals without ADRD but 10% lower odds of failure to rescue (OR=0.90, 95% CI=0.87-0.94) for those with ADRD.

CONCLUSION

Individuals undergoing surgery who have coexisting ADRD are more likely to die within 30 days of admission and die after a complication than those without ADRD. Having more BSN nurses in the hospital improves the odds of good outcomes for all individuals and has a much greater effect in individuals with ADRD.

Donepezil may reduce the risk of comorbidities in patients with Alzheimer's disease: A large-scale matched case-control analysis in Japan

Introduction

Few studies have focused on the association between donepezil and physical comorbid conditions in Alzheimer's disease patients.

Methods

We investigated the association between donepezil prescription and the occurrences of comorbidities in Alzheimer's disease patients, by using an electronic medical records database which contains case-based information on approximately three million patients from more than 60 hospitals across Japan.

Results

Nine thousand seven hundred forty-nine patients had at least one diagnosis of Alzheimer's disease between 2001 and 2015. To test the robustness of the results, we used a risk set sampling method, and the matched cohorts based on age, sex, comorbidity level, and duration of illness consisted of 1406 cases and an equal number of controls. From the multivariate logistic regression analysis adjusted for covariance, less occurrence of physical comorbidities was associated with donepezil prescription in the matched cohort.

Discussion

Although the mechanisms are unknown, donepezil may have positive effects on both cognition and physical status.

DPP-4 inhibitors: a promising therapeutic approach against Alzheimer's disease

Alzheimer's disease (AD), the commonest cause of dementia in ageing adults, is characterized by gradual cognitive impairment and severe functional disability. Key pathophysiological hallmarks involve amyloid-β (Aβ) accumulation, tau hyper-phosphorylation and neuronal loss. Despite extensive basic and clinical investigations, the etiology of the disease remains elusive, although several risk factors have been associated with its development. Current pharmacotherapies including achetylocholinesterase inhibitors and memantine fail to halt disease progression. Interestingly, type 2 diabetes mellitus (T2DM) and AD share several common characteristics, including Aβ deposition, insulin resistance, degeneration, mitochondrial dysfunction, oxidative stress and excessive inflammation. Recent experimental and clinical evidence indicates that dipeptidyl peptidase-4 (DPP-4) inhibitors, being currently used for T2DM therapy, may also prove effective for AD treatment. They may specifically suppress Aβ accumulation, tau hyper-phosphorylation, neuroinflammation, mitochondrial dysfunction and reactive oxygen species (ROS) formation, resulting in the inhibition of cognitive impairment. In this review, we discuss the encouraging current data regarding the molecular and clinical effects of DPP-4 inhibitors in AD, highlighting the need of future studies elucidating their functional role in addressing this incurable disease.

Helping Dementia Caregivers Manage Medical Problems: Benefits of an Educational Resource

BACKGROUND/RATIONALE

Family caregivers of people with dementia must attend to medical care needs of their relative, yet few available resources address comorbidities in dementia. Consequently, caregivers feel ill-equipped when medical concerns arise. In response, an educational resource-Alzheimer's Medical Advisor ( AlzMed)-was developed in 2 forms (website and book) and evaluated.

METHODS

Family caregivers (143 website and 51 book) used an educational resource that provides information on medical problems, vital signs, pain, dehydration, and the healthcare system. Data were collected at baseline, 3 months, and 6 months regarding confidence in sign/symptom management, burden, depression, and anxiety.

RESULTS

Caregivers reported significantly improved confidence and (for website users) decreased role strain. Anxiety and depression also decreased, although not significantly. Improved confidence related to a reduction in role strain and anxiety, and care recipients did not experience adverse events.

CONCLUSION

An educational resource focusing on care of comorbid illness may benefit caregiver outcomes.

Interactive Effects of Dementia Severity and Comorbidities on Medicare Expenditures

BACKGROUND

Few studies have examined how dementia and comorbidities may interact to affect healthcare expenditures.

OBJECTIVE

To examine whether effects of dementia severity on Medicare expenditures differed for individuals with different levels of comorbidities.

METHODS

Data are drawn from the Washington Heights-Inwood Columbia Aging Project (WHICAP). Comprehensive clinical assessments of dementia severity were systematically carried out at ∼18 month intervals. Dementia severity was measured by Clinical Dementia Rating (CDR). Comorbidities were measured by a modified Elixhauser comorbidities index. Generalized linear models examined effects of dementia severity, comorbidities, and their interactions on Medicare expenditures (1999-2010).

RESULTS

At baseline, 1,280 subjects were dementia free (CDR = 0, 66.4%), 490 had very mild dementia (CDR = 0.5, 25.4%), 108 had mild dementia (CDR = 1, 5.6%), and 49 had moderate/severe dementia (CDR = 2/3, 2.5%). Average annual Medicare expenditures for individuals with moderate/severe dementia were more than twice as high as those who were dementia free (CDR = 0: $9,108, CDR = 0.5/1: $11,664, CDR≥2: $19,604, p < 0.01). Expenditures were approximately 10 times higher among those with≥3 comorbidities than among those with no comorbidities ($2,612 for those with no comorbidities, to $6,109 for those with 1, $10,656 for those with 2, and $30,244 for those with≥3 comorbidities, p < 0.001). Dementia severity was associated with higher expenditures, but comorbidities were the most important predictor of expenditures. We did not find strong interaction effects between number of comorbidities and dementia severity.

CONCLUSIONS

Increasing dementia severity and higher comorbidities are associated with higher Medicare expenditures. Care of individuals with dementia should focus on management of comorbidities.

The cost of Alzheimer's disease in China and re-estimation of costs worldwide

INTRODUCTION

The socioeconomic costs of Alzheimer's disease (AD) in China and its impact on global economic burden remain uncertain.

METHODS

We collected data from 3098 patients with AD in 81 representative centers across China and estimated AD costs for individual patient and total patients in China in 2015. Based on this data, we re-estimated the worldwide costs of AD.

RESULTS

The annual socioeconomic cost per patient was US $19,144.36, and total costs were US $167.74 billion in 2015. The annual total costs are predicted to reach US $507.49 billion in 2030 and US $1.89 trillion in 2050. Based on our results, the global estimates of costs for dementia were US $957.56 billion in 2015, and will be US $2.54 trillion in 2030, and US $9.12 trillion in 2050, much more than the predictions by the World Alzheimer Report 2015.

DISCUSSION

China bears a heavy burden of AD costs, which greatly change the estimates of AD cost worldwide.

Development and Testing of a Measure of Caregiver Confidence in Medical Sign/Symptom Management

Evaluation of efforts to support family caregivers of people with dementia in their daily medical management responsibilities requires a measure of caregiver self-efficacy (confidence). This article describes the development and psychometric properties of the Caregiver Confidence in Sign/Symptom Management (CCSM) scale, the only available instrument in this area. Measurement development included literature and expert panel review, cognitive testing, and field testing. The CCSM is a 25-item measure (α = .92) composed of confidence in relation to 4 subscales: knowledge of signs/symptoms (α = .83), management of cognitive signs/symptoms (α = .85), management of medical signs/symptoms (α = .87), and general medication management/responsiveness (α = .85), all of which relate to caregiver role strain. The CCSM is a reliable and valid instrument to assess caregiver confidence in sign/symptom management and is useful to determine caregiver needs and outcomes of related interventions. Additionally, it furthers understanding of the role of self-efficacy in caregiver quality of life.

Effects of cognition, function, and behavioral and psychological symptoms on out-of-pocket medical and nursing home expenditures and time spent caregiving for persons with dementia

INTRODUCTION

Clinical features of dementia (cognition, function, and behavioral and psychological symptoms) may differentially affect out-of-pocket medical and nursing home (NH) expenditures and informal care received (outcomes).

METHODS

We used cross-sectional data (Aging, Demographics, and Memory Study) to estimate probabilities of experiencing outcomes by clinical features. For those experiencing an outcome, we estimated effects of clinical features on the amount of the outcome.

RESULTS

No clinical feature predicted the probability of having out-of-pocket medical expenditures. For those with medical expenditures, higher cognition and poorer function were associated with more spending. Poorer function predicted having out-of-pocket NH expenditures. For those with NH expenditures, no clinical feature predicted the amount. Poorer function and a greater number of behavioral and psychological symptoms predicted the probability of receiving caregiving. For those receiving care, poorer function was associated with more caregiving.

CONCLUSIONS

Clinical features differentially impact outcomes with poorer function associated with all types of costs and caregiving received.

Direct and indirect cost of managing alzheimer's disease and related dementias in the United States

INTRODUCTION

Care of individuals with Alzheimer's Disease and Related Dementias (ADRD) poses special challenges. As the disease progresses, individuals with ADRD require increasing levels of medical care, caregiver support, and long-term care which can lead to substantial economic burden. Areas covered: In this expert review, we synthesized findings from studies of costs of ADRD in the United States that were published between January 2006 and February 2017, highlighted major sources of variation in costs, identified knowledge gaps and briefly outlined directions for future research and implications for policy and program planning. Expert commentary: A consistent finding of all studies comparing individuals with and without ADRD is that the average medical, non-medical, and indirect costs of individuals with ADRD are higher than those without ADRD, despite the differences in the methods of identifying ADRD, duration of the study, payer type and settings of study population. The economic burden of ADRD may be underestimated because many components such as direct non-medical costs for home safety modifications and adult day care services and indirect costs due to the adverse impact of ADRD on caregivers' health and productivity are not included in cost estimates.

Dementia and co-occurring chronic conditions: a systematic literature review to identify what is known and where are the gaps in the evidence?

OBJECTIVE

The challenges posed by people living with multiple chronic conditions are unique for people with dementia and other significant cognitive impairment. There have been recent calls to action to review the existing literature on co-occurring chronic conditions and dementia in order to better understand the effect of cognitive impairment on disease management, mobility, and mortality.

METHODS

This systematic literature review searched PubMed databases through 2011 (updated in 2016) using key constructs of older adults, moderate-to-severe cognitive impairment (both diagnosed and undiagnosed dementia), and chronic conditions. Reviewers assessed papers for eligibility and extracted key data from each included manuscript. An independent expert panel rated the strength and quality of evidence and prioritized gaps for future study.

RESULTS

Four thousand thirty-three articles were identified, of which 147 met criteria for review. We found that moderate-to-severe cognitive impairment increased risks of mortality, was associated with prolonged institutional stays, and decreased function in persons with multiple chronic conditions. There was no relationship between significant cognitive impairment and use of cardiovascular or hypertensive medications for persons with these comorbidities. Prioritized areas for future research include hospitalizations, disease-specific outcomes, diabetes, chronic pain, cardiovascular disease, depression, falls, stroke, and multiple chronic conditions.

CONCLUSIONS

This review summarizes that living with significant cognitive impairment or dementia negatively impacts mortality, institutionalization, and functional outcomes for people living with multiple chronic conditions. Our findings suggest that chronic-disease management interventions will need to address co-occurring cognitive impairment. Copyright © 2017 John Wiley & Sons, Ltd.

Comorbidity and polypharmacy in people with dementia: insights from a large, population-based cross-sectional analysis of primary care data

Background

The care of older people with dementia is often complicated by physical comorbidity and polypharmacy, but the extent and patterns of these have not been well described. This paper reports analysis of these factors within a large, cross-sectional primary care data set.

Methods

Data were extracted for 291,169 people aged 65 years or older registered with 314 general practices in the UK, of whom 10,258 had an electronically recorded dementia diagnosis. Differences in the number and type of 32 physical conditions and the number of repeat prescriptions in those with and without dementia were examined. Age–gender standardised rates were used to calculate odds ratios (ORs) of physical comorbidity and polypharmacy.

Results

People with dementia, after controlling for age and sex, had on average more physical conditions than controls (mean number of conditions 2.9 versus 2.4; P < 0.001) and were on more repeat medication (mean number of repeats 5.4 versus 4.2; P < 0.001). Those with dementia were more likely to have 5 or more physical conditions (age–sex standardised OR [sOR] 1.42, 95% confidence interval (CI) 1.35–1.50; P < 0.001) and were also more likely to be on 5 or more (sOR 1.46; 95% CI 1.40–1.52; P < 0.001) or 10 or more repeat prescriptions (sOR 2.01; 95% CI 1.90–2.12; P < 0.001).

Conclusions

People with dementia have a higher burden of comorbid physical disease and polypharmacy than those without dementia, even after accounting for age and sex differences. Such complex needs require an integrated response from general health professionals and multidisciplinary dementia specialists.

Medicare Expenditures Associated With Hospital and Emergency Department Use Among Beneficiaries With Dementia

Understanding expenditure patterns for hospital and emergency department (ED) use among individuals with dementia is crucial to controlling Medicare spending. We analyzed Health and Retirement Study data and Medicare claims, stratified by beneficiaries' residence and proximity to death, to estimate Medicare expenditures for all-cause and potentially avoidable hospitalizations and ED visits. Analysis was limited to the Medicare fee-for-service population age 65 and older. Compared with people without dementia, community residents with dementia had higher average expenditures for hospital and ED services; nursing home residents with dementia had lower average expenditures for all-cause hospitalizations. Decedents with dementia had lower expenditures than those without dementia in the last year of life. Medicare expenditures for individuals with and without dementia vary by residential setting and proximity to death. Results highlight the importance of addressing the needs specific to the population with dementia. There are many initiatives to reduce hospital admissions, but few focus on people with dementia.

Patterns of health service use in community living older adults with dementia and comorbid conditions: a population-based retrospective cohort study in Ontario, Canada

Background

Patients with dementia have increased healthcare utilization and often have comorbid chronic conditions. It is not clear if the increase in utilization is driven by dementia, the comorbidities or both. The objective of this study was to describe the number and types of comorbid conditions in a population-based cohort of older adults with dementia and how the level of comorbidity impacts dementia-related and non-dementia-related health service utilization.

Methods

This study is a retrospective cohort study using multiple linked administrative databases to examine health service utilization and costs of 100,630 community-living older adults living with pre-existing dementia in Ontario, Canada. Comorbid conditions and health service utilization were measured using administrative data (physician visits, emergency department visits, hospitalizations, and homecare contacts).

Results

Nearly all, 96.3 %, had at least one comorbid condition, while 18.4 % had five or more comorbid conditions. The most common comorbid conditions were hypertension (77.8 %), and arthritis (66.2 %). All types of utilization increased consistently with the number of comorbid conditions. The average number of dementia-related services tended to be similar across all levels of comorbidity while the average number of non-dementia related visits tended to increase with the level of comorbidity.

Conclusions

Comorbidities in community-living older adults with dementia are common and account for a substantial proportion of health service use and costs in this population. Our results suggest that comprehensive programs that take a holistic view to identify the needs of patients in the context of other comorbidities are required for persons with dementia living in the community.

Electronic supplementary material

The online version of this article (doi:10.1186/s12877-016-0351-x) contains supplementary material, which is available to authorized users.

Cohort Study on Predictors of Need for Nursing Care in Alzheimer's Disease: An Analysis of Healthcare Data

BACKGROUND

The individual and societal burden of Alzheimer's disease (AD) is substantial. Identifying relevant factors deteriorating AD and inducing need for nursing care would be of high relevance for healthcare planning.

OBJECTIVE

The main objective of this study was the identification of predictors of first assignment of a level of long-term care in AD, used as an approximation for disease progression.

METHODS

In a retrospective cohort study using data from a large German statutory health and long-term care insurance (SHI) company, co-morbidities and drug exposure were evaluated with respect to their predictive value for disease progression (first day the amount of daily nursing care exceeded 1.5 hours). Time to disease progression was modeled using COX-proportional hazard regression with stepwise selection of predictor variables.

RESULTS

The risk of nursing care need increased substantially with increasing age. Number of hospitalizations and number of different drugs used were significant indicators for progression, whereas outpatient visits were associated with a reduced need for care. Gender did not indicate significant influence on progression. Malignant neoplasms of ill-defined, secondary, and unspecified sites, malnutrition, renal failure, and injuries increased the risk of need for nursing care most significantly. Among prescribed drugs, significant increased risks were associated with drugs used in diabetes, preparations for treatment of wounds and ulcers, antiseptics and disinfectants, and analgesics.

CONCLUSIONS

Physical comorbidities are relevant contributors to an increase in need for nursing care. Some medical predicting conditions may be linked to cognition, while others may be directly linked to demand for care. AD patients with these comorbidities should be monitored with special attention, as they may be under an increased risk of care dependency.

Comorbidity and dementia: a mixed-method study on improving health care for people with dementia (CoDem)

Background

Among people living with dementia (PLWD) there is a high prevalence of comorbid medical conditions but little is known about the effects of comorbidity on processes and quality of care and patient needs or how services are adapting to address the particular needs of this population.

Objectives

To explore the impact of dementia on access to non-dementia services and identify ways of improving the integration of services for this population.

Design

We undertook a scoping review, cross-sectional analysis of a population cohort database, interviews with PLWD and comorbidity and their family carers and focus groups or interviews with health-care professionals (HCPs). We focused specifically on three conditions: diabetes, stroke and vision impairment (VI). The analysis was informed by theories of continuity of care and access to care.

Participants

The study included 28 community-dwelling PLWD with one of our target comorbidities, 33 family carers and 56 HCPs specialising in diabetes, stroke, VI or primary care.

Results

The scoping review (n = 76 studies or reports) found a lack of continuity in health-care systems for PLWD and comorbidity, with little integration or communication between different teams and specialities. PLWD had poorer access to services than those without dementia. Analysis of a population cohort database found that 17% of PLWD had diabetes, 18% had had a stroke and 17% had some form of VI. There has been an increase in the use of unpaid care for PLWD and comorbidity over the last decade. Our qualitative data supported the findings of the scoping review: communication was often poor, with an absence of a standardised approach to sharing information about a person’s dementia and how it might affect the management of other conditions. Although HCPs acknowledged the vital role that family carers play in managing health-care conditions of PLWD and facilitating continuity and access to care, this recognition did not translate into their routine involvement in appointments or decision-making about their family member. Although we found examples of good practice, these tended to be about the behaviour of individual practitioners rather than system-based approaches; current systems may unintentionally block access to care for PLWD. Pathways and guidelines for our three target conditions do not address the possibility of a dementia diagnosis or provide decision-making support for practitioners trying to weigh up the risks and benefits of treatment for PLWD.

Conclusions

Significant numbers of PLWD have comorbid conditions such as stroke, diabetes and VI. The presence of dementia complicates the delivery of health and social care and magnifies the difficulties that people with long-term conditions experience. Key elements of good care for PLWD and comorbidity include having the PLWD and family carer at the centre, flexibility around processes and good communication which ensures that all services are aware when someone has a diagnosis of dementia. The impact of a diagnosis of dementia on pre-existing conditions should be incorporated into guidelines and care planning. Future work needs to focus on the development and evaluation of interventions to improve continuity of care and access to services for PLWD with comorbidity.

Funding

The National Institute for Health Research Health Services and Delivery Research programme.

Severe potential drug-drug interactions in older adults with dementia and associated factors

OBJECTIVE

To identify the main severe potential drug-drug interactions in older adults with dementia and to examine the factors associated with these interactions.

METHOD

This was a cross-sectional study. The enrolled patients were selected from six geriatrics clinics of tertiary care hospitals across Mexico City. The patients had received a clinical diagnosis of dementia based on the current standards and were further divided into the following two groups: those with severe drug-drug interactions (contraindicated/severe) (n=64) and those with non-severe drug-drug interactions (moderate/minor/absent) (n=117). Additional socio-demographic, clinical and caregiver data were included. Potential drug-drug interactions were identified using Micromedex Drug Reax 2.0® database.

RESULTS

A total of 181 patients were enrolled, including 57 men (31.5%) and 124 women (68.5%) with a mean age of 80.11±8.28 years. One hundred and seven (59.1%) patients in our population had potential drug-drug interactions, of which 64 (59.81%) were severe/contraindicated. The main severe potential drug-drug interactions were caused by the combinations citalopram/anti-platelet (11.6%), clopidogrel/omeprazole (6.1%), and clopidogrel/aspirin (5.5%). Depression, the use of a higher number of medications, dementia severity and caregiver burden were the most significant factors associated with severe potential drug-drug interactions.

CONCLUSIONS

Older people with dementia experience many severe potential drug-drug interactions. Anti-depressants, antiplatelets, anti-psychotics and omeprazole were the drugs most commonly involved in these interactions. Despite their frequent use, anti-dementia drugs were not involved in severe potential drug-drug interactions. The number and type of medications taken, dementia severity and depression in patients in addition to caregiver burden should be considered to avoid possible drug interactions in this population.

Methodological challenges in assessing the impact of comorbidities on costs in Alzheimer's disease clinical trials

BACKGROUND

Alzheimer's disease (AD) is associated with considerable costs and has a significant impact on health and social care systems.

OBJECTIVE

This study assessed whether baseline comorbidities present in 2,594 patients with AD participating in two semagacestat randomized placebo-controlled trials (RCTs) would significantly impact overall costs.

METHODS

Resource utilization was captured using the Resource Utilization in Dementia Scale-Lite. Comorbidities and concomitant medications were tabulated via patient and caregiver reports. Only baseline data were analyzed. Direct and indirect costs per month were calculated per patient. The relationship between cost and explanatory variables was explored in a regression model.

RESULTS

The baseline monthly cost of care in this RCT population was £1,147 ± 2,483, with informal care costs accounting for 75% of costs. Gender, age, and functional status were significant predictors of costs (p ≤ 0.0001). The cost ratio was not impacted when the number of comorbidities was added to the model (cost ratio = 0.95; 95% CI 0.91-0.99) or when combined with the number of concomitant medications (cost ratio = 0.97; 95% CI 0.95-1.00). Inconsistent findings related to the impact of individual comorbidities on costs were noted in sensitivity analyses.

CONCLUSIONS

The number of comorbidities, alone or when combined with concomitant medications, did not impact baseline costs of care, perhaps because RCTs often enroll less severely ill and more medically stable patients. However, higher costs were consistently associated with greater functional impairment similar to non-RCT databases. Supplemental sources (e.g., claims databases) are likely needed to better estimate the effects of disease and treatment on costs of illness captured in RCTs for AD.

Comorbidity and dementia: a scoping review of the literature

BACKGROUND

Evidence suggests that amongst people with dementia there is a high prevalence of comorbid medical conditions and related complaints. The presence of dementia may complicate clinical care for other conditions and undermine a patient's ability to manage a chronic condition. The aim of this study was to scope the extent, range and nature of research activity around dementia and comorbidity.

METHODS

We undertook a scoping review including all types of research relating to the prevalence of comorbidities in people with dementia; current systems, structures and other issues relating to service organisation and delivery; patient and carer experiences; and the experiences and attitudes of service providers. We searched AMED, Cochrane Library, CINAHL, PubMed, NHS Evidence, Scopus, Google Scholar (searched 2012, Pubmed updated 2013), checked reference lists and performed citation searches on PubMed and Google Scholar (ongoing to February 2014).

RESULTS

We included 54 primary studies, eight reviews and three guidelines. Much of the available literature relates to the prevalence of comorbidities in people with dementia or issues around quality of care. Less is known about service organisation and delivery or the views and experiences of people with dementia and their family carers. There is some evidence that people with dementia did not have the same access to treatment and monitoring for conditions such as visual impairment and diabetes as those with similar comorbidities but without dementia.

CONCLUSIONS

The prevalence of comorbid conditions in people with dementia is high. Whilst current evidence suggests that people with dementia may have poorer access to services the reasons for this are not clear. There is a need for more research looking at the ways in which having dementia impacts on clinical care for other conditions and how the process of care and different services are adapting to the needs of people with dementia and comorbidity. People with dementia should be included in the debate about the management of comorbidities in older populations and there needs to be greater consideration given to including them in studies that focus on age-related healthcare issues.

Existing data sets to support studies of dementia or significant cognitive impairment and comorbid chronic conditions

BACKGROUND

Dementia or other significant cognitive impairment (SCI) are often comorbid with other chronic diseases. To promote collaborative research on the intersection of these conditions, we compiled a systematic inventory of major data resources.

METHODS

Large data sets measuring dementia and/or cognition and chronic conditions in adults were included in the inventory. Key features of the resources were abstracted including region, participant sociodemographic characteristics, study design, sample size, accessibility, and available measures of dementia and/or cognition and comorbidities.

RESULTS

117 study data sets were identified; 53% included clinical diagnoses of dementia along with valid and reliable measures of cognition. Most (79%) used longitudinal cohort designs and 41% had sample sizes greater than 5000. Approximately 47% were European-based, 40% were US-based, and 11% were based in other countries.

CONCLUSIONS

Many high-quality data sets exist to support collaborative studies of the effects of dementia or SCI on chronic conditions and to inform the development of evidence-based disease management programs.

Deaths in the United States among persons with Alzheimer's disease (2010-2050)

BACKGROUND

Alzheimer's disease (AD) profoundly affects the end-of-life experience. Yet, counts of deaths attributable to AD understate this burden of AD in the population. Therefore, we estimated the annual number of deaths in the United States among older adults with AD from 2010 to 2050.

METHODS

We calculated probabilities of AD incidence and mortality from a longitudinal population-based study of 10,802 participants. From this population, 1913 previously disease-free individuals, selected via stratified random sampling, underwent 2577 detailed clinical evaluations. Over the course of follow-up, 990 participants died. We computed age-, sex-, race-, and education-specific AD incidences and education-adjusted AD mortality proportions specific to age, sex, and race group. We then combined these probabilities with US-wide census, education, and mortality data.

RESULTS

In 2010, approximately 600,000 deaths occurred among individuals aged 65 years or older with AD, comprising 32% of all older adult deaths. By 2050, this number is projected to be 1.6 million, 43% of all older adult deaths.

CONCLUSION

Individuals with AD comprise a substantial number of older adult deaths in the United States, a number expected to rise considerably in coming decades.

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.

The clinical and economic burden of newly diagnosed Alzheimer's disease in a medicare advantage population

BACKGROUND/RATIONALE

Alzheimer's disease (AD) represents a serious public health issue affecting approximately 5.4 million individuals in the United States and is projected to affect up to 16 million by 2050. This study examined health care resource utilization (HCRU), costs, and comorbidity burden immediately preceding new diagnosis of AD and 2 years after diagnosis.

METHODS

This study utilized a claims-based, retrospective cohort design. Medicare Advantage members newly diagnosed with AD (n = 3374) were compared to matched non-AD controls (n = 6748). All patients with AD were required to have 12 months of continuous enrollment prior to AD diagnosis (International Classification of Diseases, Clinical Modification [ICD-9] 331.0), during which time no diagnosis of AD, a related dementia, or an AD medication was observed. Non-AD controls demonstrated no diagnosis of AD, a related dementia, or a prescription claim for an AD medication treatment during their health plan enrollment. Medical and pharmacy claims data were used to measure HCRU, costs, and comorbidity burden over a period of 36 months (12 months pre-diagnosis and 24 months post-diagnosis).

RESULTS

The HCRU and costs were greater for AD members during the year prior to diagnosis and during postdiagnosis years 1 and 2 compared to controls. The AD members also displayed greater comorbidity than their non-AD counterparts during postdiagnosis years 1 and 2, as measured by 2 different comorbidity indices.

CONCLUSIONS

Members newly diagnosed with AD demonstrated greater HCRU, health care costs, and comorbidity burden compared to matched non-AD controls.

Dementia care costs and outcomes: a systematic review

OBJECTIVE

We reviewed evidence on the cost-effectiveness of prevention, care and treatment strategies in relation to dementia.

METHODS

We performed a systematic review of available literature on economic evaluations of dementia care, searching key databases and websites in medicine, social care and economics. Literature reviews were privileged, and other study designs were included only to fill gaps in the evidence base. Narrative analysis was used to synthesise the results.

RESULTS

We identified 56 literature reviews and 29 single studies offering economic evidence on dementia care. There is more cost-effectiveness evidence on pharmacological therapies than other interventions. Acetylcholinesterase inhibitors for mild-to-moderate disease and memantine for moderate-to-severe disease were found to be cost-effective. Regarding non-pharmacological treatments, cognitive stimulation therapy, tailored activity programme and occupational therapy were found to be more cost-effective than usual care. There was some evidence to suggest that respite care in day settings and psychosocial interventions for carers could be cost-effective. Coordinated care management and personal budgets held by carers have also demonstrated cost-effectiveness in some studies.

CONCLUSION

Five barriers to achieving better value for money in dementia care were identified: the scarcity and low methodological quality of available studies, the difficulty of generalising from available evidence, the narrowness of cost measures, a reluctance to implement evidence and the poor coordination of health and social care provision and financing.