Cost-of-illness studies of dementia: a systematic review focusing on stage dependency of costs

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 structure in specialist mental healthcare: what are the main drivers of the most expensive episodes?

BACKGROUND

Mental disorders are one of the costliest conditions to treat in Norway, and research into the costs of specialist mental healthcare are needed. The purpose of this article is to present a cost structure and to investigate the variables that have the greatest impact on high-cost episodes.

METHODS

Patient-level cost data and clinic information during 2018-2021 were analyzed (N = 180,220). Cost structure was examined using two accounting approaches. A generalized linear model was used to explain major cost drivers of the 1%, 5%, and 10% most expensive episodes, adjusting for patients' demographic characteristics [gender, age], clinical factors [length of stay (LOS), admission type, care type, diagnosis], and administrative information [number of planned consultations, first hospital visits, interval between two hospital episode].

RESULTS

One percent of episodes utilized 57% of total resources. Labor costs accounted for 87% of total costs. The more expensive an episode was, the greater the ratio of the inpatient (ward) cost was. Among the top-10%, 5%, and 1% most expensive groups, ward costs accounted for, respectively, 89%, 93%, and 99% of the total cost, whereas the overall average was 67%. Longer LOS, ambulatory services, surgical interventions, organic disorders, and schizophrenia were identified as the major cost drivers of the total cost, in general. In particular, LOS, ambulatory services, and schizophrenia were the factors that increased costs in expensive subgroups. The "first hospital visit" and "a very short hospital re-visit" were associated with a cost increase, whereas "the number of planned consultations" was associated with a cost decrease.

CONCLUSIONS

The specialist mental healthcare division has a unique cost structure. Given that resources are utilized intensively at the early stage of care, improving the initial flow of hospital care can contribute to efficient resource utilization. Our study found empirical evidence that planned outpatient consultations may be associated with a reduced health care burden in the long-term.

Projections of costs and quality adjusted life years lost due to dementia from 2020 to 2050: A population-based microsimulation study

INTRODUCTION

Efficient healthcare planning requires reliable projections of the future increase in costs and quality-adjusted life years (QALYs) lost due to dementia.

METHODS

We used the microsimulation model MISCAN-Dementia to simulate life histories and dementia occurrence using population-based Rotterdam Study data and nationwide birth cohort demographics. We estimated costs and QALYs lost in the Netherlands from 2020 to 2050, incorporating literature estimates of cost and utility for patients and caregivers by dementia severity and care setting.

RESULTS

Societal costs and QALYs lost due to dementia are estimated to double between 2020 and 2050. Costs are incurred predominantly through institutional (34%), formal home (31%), and informal home care (20%). Lost QALYs are mostly due to shortened life expectancy (67%) and, to a lesser extent, quality of life with severe dementia (14%).

DISCUSSION

To limit healthcare costs and quality of life losses due to dementia, interventions are needed that slow symptom progression and reduce care dependency.

Cost-utility analysis of a multispecialty interprofessional team dementia care model in Ontario, Canada

OBJECTIVES

To examine the cost-effectiveness of Multi-specialty INterprofessional Team (MINT) Memory Clinic care in comparison to the provision of usual care.

DESIGN

Using a Markov-based state transition model, we performed a cost-utility (costs and quality-adjusted life years, QALY) analysis of MINT Memory Clinic care and usual care not involving MINT Memory Clinics.

SETTING

A primary care-based Memory Clinic in Ontario, Canada.

PARTICIPANTS

The analysis included data from a sample of 229 patients assessed in the MINT Memory Clinic between January 2019 and January 2021.

PRIMARY OUTCOME MEASURES

Effectiveness as measured in QALY, costs (in Canadian dollars) and the incremental cost-effectiveness ratio calculated as the incremental cost per QALY gained between MINT Memory Clinics versus usual care.

RESULTS

MINT Memory Clinics were found to be less expensive ($C51 496 (95% Crl $C4806 to $C119 367) while slightly improving quality of life (+0.43 (95 Crl 0.01 to 1.24) QALY) compared with usual care. The probabilistic analysis showed that MINT Memory Clinics were the superior treatment compared with usual care 98% of the time. Variation in age was found to have the greatest impact on cost-effectiveness as patients may benefit from the MINT Memory Clinics more if they receive care beginning at a younger age.

CONCLUSION

Multispecialty interprofessional memory clinic care is less costly and more effective compared with usual care and early access to care significantly reduces care costs over time. The results of this economic evaluation can inform decision-making and improvements to health system design, resource allocation and care experience for persons living with dementia. Specifically, widespread scaling of MINT Memory Clinics into existing primary care systems may assist with improving quality and access to memory care services while decreasing the growing economic and social burden of dementia.

Progressive supranuclear palsy's economical burden: the use and costs of healthcare resources in a large health provider in Israel

BACKGROUND

Progressive supranuclear palsy (PSP) is a rare and fatal neurodegenerative movement disorder with no disease modifying therapy currently available. Data on the costs associated with PSP are scarce. This study aims to assess the direct medical expenditure of patients with PSP (PwPSP) throughout disease course.

METHODS

This retrospective cohort study is based on the data of a large state-mandated health provider in Israel. We identified PwPSP who were initially diagnosed between 2000 and 2017. Each PwPSP was randomly matched to three health-plan members without PSP by birth-year, sex, and socioeconomic status. Healthcare resources' utilization and related costs were assessed.

RESULTS

We identified 88 eligible PwPSP and 264 people in the reference group; mean age at diagnosis was 72.6 years (SD = 8.4) and 53.4% were female. The annual direct costs of PwPSP have risen over time, reaching US$ 21,637 in the fifth year and US$ 36,693 in the tenth year of follow-up vs US$ 8910 in the year prior diagnosis. Compared to people without PSP, PwPSP had substantially higher medical expenditure during the years prior- and post-index date.

CONCLUSION

The present study demonstrates higher economic burden, which increases with time, in PwPSP as compared to those without.

Healthcare Costs in the Year Before and After Alzheimer's Disease Diagnosis: A Danish Register-Based Matched Cohort Study

BACKGROUND

Alzheimer's disease (AD) carries a significant economic burden, with costs peaking around the time of diagnosis. However, the cost of diagnosis, including the time leading up to it, has not been studied thoroughly. Furthermore, regionalized healthcare structure could result in differences in the pre-diagnostic costs for people with suspected AD.

OBJECTIVE

This study set out to estimate the excess healthcare costs before and after AD diagnosis compared to a matched non-AD population and to investigate regional variation in AD healthcare costs in Denmark.

METHODS

We used a register-based cohort of 25,523 matched pairs of new cases of AD and non-AD controls. The healthcare costs included costs on medication, and inpatient-, outpatient-, and primary care visits. Generalized estimating equations were employed to estimate the excess healthcare cost attributable to diagnosing AD, and the variation in costs across regions.

RESULTS

Mean excess costs attributable to AD were € 3,284 and € 6,173 in the year before and after diagnosis, respectively. Regional differences in healthcare costs were identified in both the AD and control groups and were more pronounced in patients with AD (PwAD). The variation over time in regional inequality between PwAD and their controls was identified.

CONCLUSION

PwAD incur higher healthcare costs across all cost categories in the year before and after diagnosis. Regional differences in healthcare utilization by PwAD may reveal potential variation in access to healthcare. These findings suggest that a more standardized and targeted diagnostic process may help reduce costs and variation in access to healthcare.

The effects of herbal medicine (Jujadokseo-hwan) on quality of life in patients with mild cognitive impairment: Cost-effectiveness analysis alongside randomized controlled trial

Background

Mild cognitive impairment (MCI), the early stage of dementia, requires effective intervention for symptom management and improving patients' quality of life (QoL). Jujadokseo-hwan (JDH) is a Korean herbal medicine prescription used to improve MCI symptoms, such as memory deficit. This study evaluates the improvement in QoL through JDH. Alongside a clinical trial, it estimates the cost-effectiveness of JDH, compared to placebo, for MCI over 24 weeks.

Methods

Changes in QoL were measured using the EuroQol-5 Dimensions (EQ-5D) and Korean version QoL-Alzheimer's Disease (KQOL-AD). Direct medical and non-medical costs were surveyed and incremental cost-effectiveness ratios (ICER) per QALY for JDH were produced.

Results

In total, 64 patients were included in the economic evaluation (n = 35 in JDH, n = 29 in placebo). In the JDH group, EQ-5D and KQOL-AD improved by 0.020 (p = .318) and 3.40 (p = .011) over 24 weeks, respectively. In the placebo group, they increased by 0.001 (p=.920) and 1.07 (p=.130), respectively. The ICER was KRW 76,400,000 per QALY and KRW 108,000 per KQOL-AD for JDH, compared to the placebo group.

Conclusion

JDH is not considered a cost-effective treatment option compared with placebo; however, it positively affects QoL improvement in patients with MCI.

Integrated palliative homecare in advanced dementia: reduced healthcare utilisation and costs

OBJECTIVES

To determine the economic benefit of an integrated home-based palliative care programme for advanced dementia (Programme Dignity), evaluation is required. This study aimed to estimate Programme Dignity's average monthly cost from a provider's perspective; and compare healthcare utilisation and costs of programme patients with controls, accounting for enrolment duration.

METHODS

This was a retrospective cohort study. Home-dwelling patients with advanced dementia (stage 7 on the functional assessment staging in Alzheimer's disease) with a history of pneumonia, albumin <35 g/L or tube-feeding and known to be deceased were analysed (Programme Dignity=184, controls=139). One-year programme operational costs were apportioned on a per patient-month basis. Cumulative healthcare utilisation and costs were examined at 1, 3 and 6 months look-back from death. Between-group comparisons used Poisson, zero-inflated Poisson regressions and generalised linear models.

RESULTS

The average monthly programme cost was SGD$1311 (SGD-Pounds exchange rate: 0.481) per patient. Fully enrolled programme patients were less likely to visit the emergency department (incidence rate ratios (IRRs): 1 month=0.56; 3 months=0.19; 6 months=0.10; all p<0.001), be admitted to hospital (IRRs: 1 month=0.60; 3 months=0.19; 6 months=0.15; all p<0.001), had a lower cumulative length of stay (IRRs: 1 month=0.78; 3 months=0.49; 6 months=0.24; all p<0.001) and incurred lesser healthcare utilisation costs (β-coefficients: 1 month=0.70; 3 months=0.40; 6 months=0.43; all p<0.01) at all time-points examined.

CONCLUSION

Programme Dignity for advanced dementia reduces healthcare utilisation and costs. If scalable, it may benefit more patients wishing to remain at home at the end-of-life, allowing for a potentially sustainable care model to cope with rapid population ageing. It contributes to the evidence base of advanced dementia palliative care and informs healthcare policy making. Future studies should estimate informal caregiving costs for comprehensive economic evaluation.

Costs of Dementia in Low- And Middle-Income Countries: A Systematic Review

BACKGROUND

The proportion of people living with dementia in low- and middle-income countries (LMICs) is expected to reach 71% by 2050. Appraising the economic burden of the disease may contribute to strategic policy planning.

OBJECTIVE

To review studies conducted on the costs of dementia in LMICs, describe their methodology and summarize available costs estimates.

METHODS

Systematic review, including a search of health, economics, and social science bibliographic databases. No date or language restrictions were applied. All studies with a direct measure of the costs of dementia care were included.

RESULTS

Of the 6,843 publications reviewed, 17 studies from 11 LMICs were included. Costs of dementia tended to increase with the severity of the disease. Medical costs were greater in the mild stage, while social and informal care costs were highest in the moderate and severe stages. Annual cost estimates per patient ranged from PPP$131.0 to PPP$31,188.8 for medical costs; from PPP$16.1 to PPP$10,581.7 for social care services and from PPP$140.0 to PPP$25,798 for informal care. Overall, dementia care can cost from PPP$479.0 to PPP$66,143.6 per year for a single patient.

CONCLUSION

Few studies have been conducted on the costs of dementia in LMICs, and none so far in Africa. There seems to be a need to provide accurate data on the burden of disease in these countries to guide public health policies in the coming decades.

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

BACKGROUND AND OBJECTIVE

The prevalence of dementia is increasing, while new opportunities for diagnosing, treating and possibly preventing Alzheimer's disease and other dementia disorders are placing focus on the need for accurate estimates of costs in dementia. Considerable methodological heterogeneity creates challenges for synthesising the existing literature. This study aimed to estimate the costs for persons with dementia in Europe, disaggregated into cost components and informative patient subgroups.

METHODS

We conducted an updated literature review searching PubMed, Embase and Web of Science for studies published from 2008 to July 2021 reporting empirically based cost estimates for persons with dementia in European countries. We excluded highly selective or otherwise biased reports, and used a random-effects meta-analysis to produce estimates of mean costs of care across five European regions.

RESULTS

Based on 113 studies from 17 European countries, the estimated mean costs for all patients by region were highest in the British Isles (73,712 EUR), followed by the Nordics (43,767 EUR), Southern (35,866 EUR), Western (38,249 EUR), and Eastern Europe and Baltics (7938 EUR). Costs increased with disease severity, and the distribution of costs over informal and formal care followed a North-South gradient with Southern Europe being most reliant on informal care.

CONCLUSIONS

To our knowledge, this study represents the most extensive meta-analysis of the cost for persons with dementia in Europe to date. Though there is considerable heterogeneity across studies, much of this is explained by identifiable factors. Further standardisation of methodology for capturing resource utilisation data may further improve comparability of future studies. The cost estimates presented here may be of value for cost-of-illness studies and economic evaluations of novel diagnostic technologies and therapies for Alzheimer's disease.

A 14-Year Longitudinal Analysis of Healthcare Expenditure on Dementia and Related Factors (DEMENCOST Study)

BACKGROUND

The large number of dementia cases produces a great pressure on health and social care services, which requires efficient planning to meet the needs of patients through infrastructure, equipment, and financial, technical, and personal resources adjusted to their demands. Dementia analysis requires studies with a very precise patient characterization of both the disease and comorbidities present, and long-term follow-up of patients in clinical aspects and patterns of resource utilization and costs generated.

OBJECTIVE

To describe and quantify direct healthcare expenditure and its evolution from three years before and up to ten years after the diagnosis of dementia, compared to a matched group without dementia.

METHODS

Retrospective cohort design with follow-up from 6 to 14 years. We studied 996 people with dementia (PwD) and 2,998 controls matched for age, sex, and comorbidity. This paper adopts the provider's perspective as the perspective of analysis and refers to the costs actually incurred in providing the services. Aggregate costs and components per patient per year were calculated and modelled.

RESULTS

Total health expenditure increases in PwD from the year of diagnosis and in each of the following 7 years, but not thereafter. Health status and mortality are factors explaining the evolution of direct costs. Dementia alone is not a statistically significant factor in explaining differences between groups.

CONCLUSION

The incremental direct cost of dementia may not be as high or as long as studies with relatively short follow-up suggest. Dementia would have an impact on increasing disease burden and mortality.

Long-term care use among people living with dementia: a retrospective register-based study from Sweden

BACKGROUND

Although many people with dementia need progressive support during their last years of life little is known to what extent they use formal long-term care (LTC). This study investigates the use of LTC, including residential care and homecare, in the month preceding death, as well as the number of months spent in residential care, among Swedish older decedents with a dementia diagnosis, compared with those without a dementia diagnosis.

METHODOLOGY

This retrospective cohort study identified all people who died in November 2019 in Sweden aged 70 years and older (n = 6294). Dementia diagnoses were collected from the National Patient Register (before death) and the National Cause of Death Register (death certificate). The use of LTC was based on the Social Services Register and sociodemographic factors were provided by Statistics Sweden. We performed regression models (multinomial and linear logistic regression models) to examine the association between the utilization of LTC and the independent variables.

RESULTS

Not only dementia diagnosis but also time spent with the diagnosis was crucial for the use of LTC in the month preceding death, in particular residential care. Three out of four of the decedents with dementia and one fourth of those without dementia lived in a residential care facility in the month preceding death. People who were diagnosed more recently were more likely to use homecare (e.g., diagnosis for 1 year or less: home care 29%, residential care 56%), while the predicted proportion of using residential care increased substantially for those who had lived longer with a diagnosis (e.g., diagnosis for 7 + years: home care 11%, residential care 85%). On average, people with a dementia diagnosis stayed six months longer in residential care, compared with people without a diagnosis.

CONCLUSIONS

People living with dementia use more LTC and spend longer time in residential care than those without dementia. The use of LTC is primarily influenced by the time with a dementia diagnosis. Our study suggests conducting more research to investigate differences between people living with different dementia diagnoses with co-morbidities.

Formal and Informal Costs of Care for People With Dementia Who Experience a Transition to Hospital at the End of Life: A Secondary Data Analysis

OBJECTIVES

To explore formal and informal care costs in the last 3 months of life for people with dementia, and to evaluate the association between transitions to hospital and usual place of care with costs.

DESIGN

Cross-sectional study using pooled data from 3 mortality follow-back surveys.

SETTING AND PARTICIPANTS

People who died with dementia.

METHODS

The Client Service Receipt Inventory survey was used to derive formal (health, social) and informal care costs in the last 3 months of life. Generalized linear models were used to explore the association between transitions to hospital and usual place of care with formal and informal care costs.

RESULTS

A total of 146 people who died with dementia were included. The mean age was 88.1 years (SD 6.0), and 98 (67.1%) were female. The usual place of care was care home for 85 (58.2%). Sixty-five individuals (44.5%) died in a care home, and 85 (58.2%) experienced a transition to hospital in the last 3 months. The mean total costs of care in the last 3 months of life were £31,224.7 (SD 23,536.6). People with a transition to hospital had higher total costs (£33,239.2, 95% CI 28,301.8-39,037.8) than people without transition (£21,522.0, 95% CI 17,784.0-26,045.8), mainly explained by hospital costs. People whose usual place of care was care homes had lower total costs (£23,801.3, 95% CI 20,172.0-28,083.6) compared to home (£34,331.4, 95% CI 27,824.7-42,359.5), mainly explained by lower informal care costs.

CONCLUSIONS AND IMPLICATIONS

Total care costs are high among people dying with dementia, and informal care costs represent an important component of end-of-life care costs. Transitions to hospital have a large impact on total costs; preventing these transitions might reduce costs from the health care perspective, but not from patients' and families' perspectives. Access to care homes could help reduce transitions to hospital as well as reduce formal and informal care costs.

[The Cost of Early Diagnosis of Cognitive Decline in German Memory Clinics]

Dementias are expensive diseases: the net annual cost in European healthcare is about € 28.000 per case with a strong stage dependency, of which medical care accounts for about 19%. Diagnostic costs, on the other hand, account for only a small proportion of the total costs. With changes in the guidelines, biomarker tests are becoming increasingly important. At present, the concrete economic impact of biomarker-based diagnosis is largely unknown. To determine the actual costs of diagnostic procedures based on guidelines, we conducted a survey among the members of the German Memory Clinic Network (DNG). From 15 expert centres, the staff engagement time for all procedures was collected. Based on the individual engagement times of the different professions, the total of personnel costs for diagnostics was calculated using current gross personnel costs. The total sum of diagnostic costs (personnel plus procedures) was calculated for three different scenarios e. g. € 633,97 for diagnostics without biomarkers, € 1.214,90 for diagnostics with CSF biomarkers and € 4.740,58 € for diagnostics with FDG- plus Amyloid-PET. In addition, the actual diagnostic costs of the current practice in expert memory clinics were estimated, taking into account personnel costs, costs for the different procedures and the frequency of their use across all patients. This results in total average costs of € 1.394,43 per case as the mean across all centres (personnel costs € 351,72, costs for diagnostic procedures € 1.042,71). The results show that state-of-the-art diagnosis of dementia and pre-dementia states, such as mild cognitive impairment (MCI) requires financial resources, which are currently not fully reimbursed in Germany. The need for a biomarker-based etiological diagnosis of dementia and pre-dementia states will increase, due to availability of disease-modifying treatments. Therefore, the current gap of reimbursement must be filled by new models of compensation.

Perceived extrinsic barriers hinder community detection and management of mild cognitive impairment: a cross-sectional study of general practitioners in Shanghai, China

Background

General practitioners (GPs) play a critical role in community detection and management of mild cognitive impairment (MCI). Although adequate knowledge is essential, healthcare practice is shaped by intrinsic and extrinsic factors. This study aimed to test the mediating effect of perceived extrinsic barriers on the associations between knowledge, attitudes, and intended practice of GPs in community detection and management of MCI.

Methods

A cross-sectional study was conducted through an online survey of 1253 GPs sampled from 56 community health centres (CHCs) in Shanghai in 2021. Perceived extrinsic barriers were rated on a five-point Likert scale for patient engagement, working environment, and system context, respectively. A summed score was generated subsequently for each domain ranging from 0 to 100, with a higher score indicating higher barriers. The mediating effect of perceived extrinsic barriers (second-order) and the moderation effect of training on the association between MCI knowledge and practice scores, as well as the moderation effect of past experience on the association between MCI knowledge and extrinsic barriers, were tested through structural equation modelling (SEM) with a partial least square (PLS) approach.

Results

The study participants reported an average barrier score of 65.23 (SD = 13.98), 58.34 (SD = 16.95), and 60.37 (SD = 16.99) for patient engagement, working environment, and system context, respectively. Although knowledge had both direct and indirect (through attitudes) effects on intended practice, perceived extrinsic barriers negatively mediated (β = − 0.012, p = 0.025) the association between knowledge and practice. Training moderated the effect of knowledge on practice (β = − 0.066, p = 0.014).

Conclusions

Perceived extrinsic barriers have a detrimental effect on the translation of knowledge into practice for community detection and management of MCI. The effect of training on practice declines when knowledge scores become higher.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12877-022-03175-4.

Knowledge, attitudes, and practice of general practitioners toward community detection and management of mild cognitive impairment: a cross-sectional study in Shanghai, China

BACKGROUND

General practitioners (GPs) are in a unique position for community detection and management of mild cognitive impairment (MCI). However, adequate knowledge, attitudes, and practice (KAP) are prerequisites for fulfilling such a role. This study aims to assess the MCI-related KAP of GPs in Shanghai, China.

METHODS

An online survey was conducted on 1253 GPs who were recruited from 56 community health centres (CHCs) in Shanghai between April and May 2021. Knowledge (8 items), attitudes (13 items), and practice (11 items) were assessed using a scale endorsed by a panel of multidisciplinary experts. An average summed score was calculated and transformed into a score ranging from 0 to 100 for knowledge, attitudes, and practice, respectively. Adjusted odds ratios (AORs) were calculated for potential predictors of higher levels of KAP scores (with mean value as a cutoff point) through logistic modelling. The mediating role of attitudes on the association between knowledge and practice was tested using the PROCESS model 4 macro with 5000 bootstrap samples through linear regression modelling.

RESULTS

A total of 1253 GPs completed the questionnaire, with an average score of 54.51 ± 18.18, 57.31 ± 7.43, and 50.05 ± 19.80 for knowledge, attitudes, and practice, respectively. More than 12% of respondents scored zero in knowledge, 28.4% tended not to consider MCI as a disease, and 19.1% completely rejected MCI screening. Higher levels of knowledge were associated with more favourable attitudes toward community management of MCI (AOR = 1.974, p < 0.001). Higher compliance with practice guidelines was associated with both higher levels of knowledge (AOR = 1.426, p < 0.01) and more favourable attitudes (AOR = 2.095, p < 0.001). The association between knowledge and practice was partially mediated by attitudes (p < 0.001). Training was associated with higher levels of knowledge (AOR = 1.553, p < 0.01), while past experience in MCI management was associated with more favourable attitudes (AOR = 1.582, p < 0.05) and higher compliance with practice guidelines (AOR = 3.034, p < 0.001). MCI screening qualification was associated with higher compliance with practice guidelines (AOR = 2.162, p < 0.05), but less favourable attitudes (AOR = 0.452, p < 0.05).

CONCLUSION

The MCI knowledge of GPs in Shanghai is low, and is associated with less favourable attitudes toward MCI management and low compliance with practice guidelines. Attitudes mediate the association between knowledge and practice. Training is a significant predictor of knowledge. Further studies are needed to better understand how the attitudes of GPs in Shanghai are shaped by the environments in which they live and work.

The economic burden of dementia in low- and middle-income countries (LMICs): a systematic review

Introduction

More than two-thirds of people with dementia live in low- and middle-income countries (LMICs), resulting in a significant economic burden in these settings. In this systematic review, we consolidate the existing evidence on the cost of dementia in LMICs.

Methods

Six databases were searched for original research reporting on the costs associated with all-cause dementia or its subtypes in LMICs. The national-level dementia costs inflated to 2019 were expressed as percentages of each country’s gross domestic product (GDP) and summarised as the total mean percentage of GDP. The risk of bias of studies was assessed using the Larg and Moss method.

Results

We identified 14 095 articles, of which 24 studies met the eligibility criteria. Most studies had a low risk of bias. Of the 138 LMICs, data were available from 122 countries. The total annual absolute per capita cost ranged from US$590.78 for mild dementia to US$25 510.66 for severe dementia. Costs increased with the severity of dementia and the number of comorbidities. The estimated annual total national costs of dementia ranged from US$1.04 million in Vanuatu to US$195 billion in China. The average total national expenditure on dementia estimated as a proportion of GDP in LMICs was 0.45%. Indirect costs, on average, accounted for 58% of the total cost of dementia, while direct costs contributed 42%. Lack of nationally representative samples, variation in cost components, and quantification of indirect cost were the major methodological challenges identified in the existing studies.

Conclusion

The estimated costs of dementia in LMICs are lower than in high-income countries. Indirect costs contribute the most to the LMIC cost. Early detection of dementia and management of comorbidities is essential for reducing costs. The current costs are likely to be an underestimation due to limited dementia costing studies conducted in LMICs, especially in countries defined as low- income.

PROSPERO registration number

The protocol was registered in the International Prospective Register of Systematic Reviews database with registration number CRD42020191321.

Association of Serum Levels of Cystatin C and Cognition in a Cohort of Egyptian Elderly Patients with Chronic Kidney Disease

Chronic kidney disease (CKD) and dementia are common morbidities of elders. Serum cystatin C has been suggested to be an ideal marker for kidney function. The current study aimed to detect the serum levels of cystatin C in CKD patients and to correlate these levels to cognitive performance. The study involved 90 subjects aged 65 years and more, divided into two groups: Group 1: 60 patients with CKD, and Group 2: 30 control participants. Exclusion criteria included cardiac failure, hepatic failure, thyroid diseases, dialysis for more than one month, polycystic kidney disease, organ transplantation, and immunosuppressive therapy within the past six months. All participants had routine laboratory workup, serum cystatin C using enzyme-linked immunosorbent assay kits, and cognitive assessment using mini-mental state examination (MMSE). Serum cystatin level was significantly high in CKD patients while MMSE scores were significantly lower in CKD patients. A high significant negative correlation was found between serum cystatin C levels and both degree of cognitive impairment and glomerular filtration rate (GFR). Also, a significant positive correlation was found between the degree of cognitive impairment and GFR levels. Serum cystatin levels are significantly associated with cognitive impairment in CKD patients, and this correlation becomes more evident with the worsening of CKD stages. That may help in better understanding of the pathogenesis of dementia in CKD patients with the emergence of therapeutic options depending on these data.

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Medical Care and Long-Term Care Expenditures Attributable to Alzheimer's Disease Onset: Results from the LIFE Study

Background:

Alzheimer’s disease (AD) can increase both medical care and long-term care (LTC) costs, but the latter are frequently neglected in estimates of AD’s economic burden.

Objective:

To elucidate the economic burden of new AD cases in Japan by estimating patient-level medical care and LTC expenditures over 3 years using a longitudinal database.

Methods:

The study was performed using monthly claims data from residents of 6 municipalities in Japan. We identified patients with new AD diagnoses between April 2015 and March 2016 with 3 years of follow-up data. Medical care and LTC expenditures were estimated from 1 year before onset until 3 years after onset. To quantify the additional AD-attributable expenditures, AD patients were matched with non-AD controls using propensity scores, and their differences in expenditures were calculated.

Results:

After propensity score matching, the AD group and non-AD group each comprised 1748 individuals for analysis (AD group: mean age±standard deviation, 81.9±7.6 years; women, 66.0%). The total additional expenditures peaked at $1398 in the first month, followed by $1192 and $1031 in the second and third months, respectively. The additional LTC expenditures increased substantially 3 months after AD onset ($227), and gradually increased thereafter. These additional LTC expenditures eventually exceeded the additional medical care expenditures in the second year after AD onset.

Conclusion:

Although total AD-attributable expenditures peaked just after disease onset, the impact of LTC on these expenditures rose over time. Failure to include LTC expenditures would severely underestimate the economic burden of AD.

Exploring costs, cost components, and associated factors among people with dementia approaching the end of life: A systematic review

INTRODUCTION

Understanding costs of care for people dying with dementia is essential to guide service development, but information has not been systematically reviewed. We aimed to understand (1) which cost components have been measured in studies reporting the costs of care in people with dementia approaching the end of life, (2) what the costs are and how they change closer to death, and (3) which factors are associated with these costs.

METHODS

We searched the electronic databases CINAHL, Medline, Cochrane, Web of Science, EconLit, and Embase and reference lists of included studies. We included any type of study published between 1999 and 2019, in any language, reporting primary data on costs of health care in individuals with dementia approaching the end of life. Two independent reviewers screened all full-text articles. We used the Evers' Consensus on Health Economic Criteria checklist to appraise the risk of bias of included studies.

RESULTS

We identified 2843 articles after removing duplicates; 19 studies fulfilled the inclusion criteria, 16 were from the United States. Only two studies measured informal costs including out-of-pocket expenses and informal caregiving. The monthly total direct cost of care rose toward death, from $1787 to $2999 USD in the last 12 months, to $4570 to $11921 USD in the last month of life. Female sex, Black ethnicity, higher educational background, more comorbidities, and greater cognitive impairment were associated with higher costs.

DISCUSSION

Costs of dementia care rise closer to death. Informal costs of care are high but infrequently included in analyses. Research exploring the costs of care for people with dementia by proximity to death, including informal care costs and from outside the United States, is urgently needed.

Effectiveness and Safety of Acupuncture for Vascular Cognitive Impairment: A Systematic Review and Meta-Analysis

Background: Acupuncture may be a promising complementary therapy for vascular cognitive impairment (VCI) and has been extensively applied in China. However, its potential effects remain uncertain, and the clinical findings are inconsistent. This review aimed to systematically appraise the overall effectiveness and safety of acupuncture in treating VCI. Methods: To investigate the effects of acupuncture on VCI from inception to February 28, 2021 using randomized clinical trials (RCTs), seven electro-databases [Cochrane Central Register of Controlled Trials (CENTRAL), PubMed, Embase, China National Knowledge Infrastructure (CNKI), Chinese Biomedical Literature Database (CBM), VIP, and Wanfang] were searched. Two independent investigators identified the eligible RCTs and extracted data into predesigned forms. The risk of bias (ROB) within each individual trial was evaluated using the Cochrane Collaboration's tool. Meta-analyses were conducted for calculating comparative effects in the RevMan software (version 5.3). The strength of attained evidence was rated using the online GRADEpro approach. Results: A total of 48 RCTs involving 3,778 patients with VCI were included. The pooled data demonstrated that acupuncture was more beneficial for a global cognitive function [mean difference (MD) 1.86, 95% CI 1.19-2.54, p < 0.01] and activities of daily living (MD -3.08, 95% CI -4.81 to -1.35, p < 0.01) compared with western medicine (WM). The favorable results were also observed when acupuncture was combined with WM (MD 2.37, 95% CI 1.6-3.14, p < 0.01) or usual care (UC, MD 4.4, 95% CI 1.61-7.19, p = 0.002) in comparison with the corresponding control conditions. Meanwhile, the subgroup analysis did not indicate a statistical effect difference between manual acupuncture (MA) and electroacupuncture (EA) (inter-group I 2 < 50% and p > 0.1) when comparing acupuncture with WM. There were no significant differences in the occurrence of adverse events (AEs) between the acupuncture group and the control group (p > 0.05). Owing to the poor methodological quality and considerable heterogeneity among studies, the certainty of the evidence was low or very low. Conclusions: This review suggests that acupuncture as a monotherapy or an adjuvant therapy may play a positive role in improving the cognition and daily performance of VCI patients associated with few side effects. The difference in styles may not significantly influence its effectiveness. More rigorously designed and preregistered RCTs are highly desirable to verify the therapeutic benefits and determine an optimal acupuncture paradigm. The methodological and reporting quality of future researches should be enhanced by adhering to authoritative standardized statements. Systematic Review Registration: [PROSPERO], identifier [No. CRD42017071820].

Differences in Burden Severity in Adult-Child Family Caregivers and Spousal Caregivers of Persons with Dementia

Researchers are continuing to focus on the nature and sources of burden of family caregivers of persons living with dementia. Caregiving stress and burden are assessed and addressed by social workers, including at high-risk times such as hospitalization. This study tested whether adult-child family caregivers experience greater perceived burden than spousal caregivers, accounting for risks of acute stress which can accompany hospitalization for their care recipient, where social workers may be meeting with family caregivers for the first time. Family caregivers (N = 76; n = 42 adult-child; n = 34 spouse) were recruited during care-recipient clinical treatment. The settings of care included an outpatient memory care program and an inpatient geriatric psychiatry service. Results showed that adult-child caregivers reported greater burden as compared with spousal caregivers, but no differences regarding depressive symptoms, perceived stress, or grief. After controlling for demographics and location of care, being an adult-child caregiver remained a predictor of greater burden severity. Being an adult-child family caregiver may place an individual at increased risk for experiencing high burden. These findings suggest socials workers should consider how adult-child caregivers may benefit from strategies to address and reduce burden, beyond those typically offered to spousal caregivers.

Impaired Executive Function and Depression as Independent Risk Factors for Reported Delirium Symptoms: An Observational Cohort Study Over 8 Years

Background

Acute medical illnesses, surgical interventions, or admissions to hospital in older individuals are frequently associated with a delirium. In this cohort study, we investigated the impact of specific cognitive domains and depression before the occurrence of delirium symptoms in an 8-year observation of older non-hospitalized individuals.

Methods

In total, we included 807 participants (48–83 years). Deficits in specific cognitive domains were measured using the CERAD test battery, and depressive symptoms were measured using Beck Depression Inventory and the Geriatric Depression Scale (GDS) before the onset of a delirium. Delirium symptoms were retrospectively assessed by a questionnaire based on the established Nursing Delirium Screening Scale.

Results

Fifty-eight of eight hundred seven participants (7.2%) reported delirium symptoms over the 8-year course of the study. Sixty-nine percent (n = 40) of reported delirium symptoms were related to surgeries. In multivariate regression analysis, impaired executive function was an independent risk factor (p = 0.034) for the occurrence of delirium symptoms. Furthermore, age (p = 0.014), comorbidities [captured by the Charlson Comorbidity Index (CCI)] (p < 0.001), and depression (p = 0.012) were significantly associated with reported delirium symptoms.

Conclusion

Especially prior to elective surgery or medical interventions, screening for impaired executive function and depression could be helpful to identify patients who are at risk to develop delirium symptoms.

Costs and Resource Use Associated with Community-Dwelling Patients with Alzheimer's Disease in Japan: Baseline Results from the Prospective Observational GERAS-J Study

BACKGROUND

As the Japanese population ages, caring for people with Alzheimer's disease (AD) dementia is becoming a major socioeconomic issue.

OBJECTIVE

To determine the contribution of patient and caregiver costs to total societal costs associated with AD dementia.

METHODS

Baseline data was used from the longitudinal, observational GERAS-J study. Using the Mini-Mental State Examination (MMSE) score, patients routinely visiting memory clinics were stratified into three groups based on AD severity. Health care resource utilizationwas recorded using the Resource Utilization in Dementia questionnaire. Total monthly societal costs were estimated using Japan-specific unit costs of services and products (patient direct health care use, patient social care use, and informal caregiving time). Uncertainty around mean costs was estimated using bootstrapping methods.

RESULTS

Overall, 553 community-dwelling patients withADdementia (28.3% mild[MMSE21-26], 37.8% moderate[MMSE 15-20], and 34.0% moderately severe/severe [MMSE < 14]) and their caregivers were enrolled. Patient characteristics were: mean age 80.3 years, 72.7% female, and 13.6% living alone. Caregiver characteristics were: mean age 62.1 years, 70.7% female, 78.8% living with patient, 49.0% child of patient, and 39.2% sole caregiver. Total monthly societal costs of AD dementia (Japanese yen) were: 158,454 (mild), 211,301 (moderate), and 294,224 (moderately severe/severe). Informal caregiving costs comprised over 50% of total costs.

CONCLUSION

Baseline results of GERAS-J showed that total monthly societal costs associated with AD dementia increased with AD severity. Caregiver-related costs were the largest cost component. Interventions are needed to decrease informal costs and decrease caregiver burden.

Monetary value of informal caregiving in dementia from a societal perspective

BACKGROUND

Dementia is a condition which results in a high cost of care, a significant proportion of which is the cost associated with informal care. In previous studies, informal caregiving has been challenging to assess due to difficulties in estimating the true time spent on caregiving work and how to value caregivers' time. The aim of this study was to compare the costs of dementia among patients living alone and among those living with a caregiver to show the monetary value of informal caregiving from a societal perspective.

METHODS

Data from our four dementia trials using the same measures were combined, allowing the inclusion of 604 participants. Participants were followed up for 2 years or until death for their use of health and social services. Use of all services was retrieved from medical/social records. We also included the costs of lost productivity of those caregivers who were not retired.

RESULTS

The total mean cost of services and lost productivity was €22,068/person-year (pyrs). Participants living alone had a mean cost of €45,156/pyrs, whereas those living with a spouse had a mean cost of €16,416/pyrs (mean cost ratio 2.99, 95% confidence interval 2.64-3.39). Participants living alone and having <15 Mini-Mental State Examination points had higher costs than people with dementia in institutional care.

CONCLUSIONS

Detailed data of service use and characteristics of people with dementia showed that from a societal perspective, living alone is a very strong determinant of service use in dementia. Informal caregivers do invaluable work for society.

What is the societal economic cost of poor oral health among older adults in the United States? A scoping review

Objective

To assess the state of the literature in the United States quantifying the societal economic cost of poor oral health among older adults.

Background

Proponents of a Medicare dental benefit have argued that addressing the growing need for dental care among the US older adult population will decrease costs from systemic disease and other economic costs due to oral disease. However, it is unclear what the current economic burden of poor oral health among older adults is in the United States.

Methods

We conducted a scoping review examining the cost of poor oral health among older adults and identified cost components that were included in relevant studies.

Results

Other than oral cancer, no studies were found examining the economic costs of poor oral health among older adults (untreated tooth decay, gum disease, tooth loss and chronic disease/s). Only two studies examining the costs of oral cancer were found, but these studies did not assess the full economic cost of oral cancer from patient, insurer and societal perspectives.

Conclusions

Future work is needed to assess the full economic burden of poor oral health among older adults in the United States, and should leverage novel linkages between medical claims data, dental claims data and oral health outcomes data.

Valuing end-of-life care: translation and content validation of the ICECAP-SCM measure

Background

The evaluation of care strategies at the end of life is particularly important due to the globally increasing proportion of very old people in need of care. The ICECAP-Supportive Care Measure is a self-complete questionnaire developed in the UK to evaluate palliative and supportive care by measuring patient’s wellbeing in terms of ‘capability’. It is a new measure with high potential for broad and international use. The aims of this study were the translation of the ICECAP-Supportive Care Measure from English into German and the content validation of this version.

Methods

A multi-step and team-based translation process based on the TRAPD model was performed. An expert survey was carried out to assess content validity. The expert panel (n = 20) consisted of four expert groups: representative seniors aged 65+, patients aged 65+ living in residential care, patients aged 65+ receiving end-of-life care, and professionals in end-of-life care.

Results

The German version of the ICECAP-Supportive Care Measure showed an excellent content validity on both item- and scale-level. In addition, a high agreement regarding the length of the single items and the total length of the questionnaire as well as the number of answer categories was reached.

Conclusions

The German ICECAP-SCM is a valid tool to assess the quality of life at the end of life that is suitable for use in different settings. The questionnaire may be utilized in multinational clinical and economic evaluations of end-of-life care.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12904-021-00722-5.

The Evolving Role of Ophthalmology Clinics in Screening for Early Alzheimer's Disease: A Review

Alzheimer’s disease (AD) is the leading cause of dementia, which is a growing public health concern. Although there is no curative treatment for established AD, early recognition and modification of the known risk factors can reduce both severity and the rate of progression. Currently, an early diagnosis of AD is rarely achieved, as there is no screening for AD. The cognitive decline in AD is gradual and often goes unnoticed by patients and caregivers, resulting in patients presenting at later stages of the disease. Primary care physicians (general practitioners in the UK) can administer a battery of tests for patients presenting with memory problems and cognitive impairment, however final diagnosis of AD is usually made by specialised tertiary level clinics. Recent studies suggest that in AD, visuospatial difficulties develop prior to the development of memory problems and screening for visuospatial difficulties may offer a tool to screen for early stage AD. AD and cataracts share common risk and predisposing factors, and the stage of cataract presentation for intervention has shifted dramatically with early cataract referral and surgical intervention becoming the norm. This presentation offers an ideal opportunity to administer a screening test for AD, and visuospatial tools can be administered at post-operative visits by eye clinics. Abnormal findings can be communicated to primary care physicians for further follow up and assessment, or possible interventions which modify risk factors such as diabetes, hypertension and obesity can be undertaken. We propose that eye clinics and ophthalmology facilities have a role to play in the early diagnosis of AD and reducing the burdens arising from severe dementia.

Associated Factors of Total Costs of Alzheimer's Disease: A Cluster-Randomized Observational Study in China

BACKGROUND

Alzheimer's disease (AD) exerts a heavy burden on China. Substantial factors are found associated with high expenditure of AD in high-income countries. To date, few studies have been conducted in China.

OBJECTIVE

This study aimed to analyze the associated factors of the total annual costs of AD in China.

METHODS

Data were drawn from a multi-center, cross-sectional, socioeconomic study on the costs of AD conducted in China from October 2015 to March 2016. Generalized linear model (GLM) using gamma distribution with a log-link function was employed to examine the associated factors of the total cost.

RESULTS

Univariate analysis showed that the demographic and clinical characteristics of AD patients and their caregivers had a substantial impact on the total cost. In GLM analysis, age, monthly household income, AD severity, number of comorbidities, and treatment with memantine were associated with higher expenditure, while the use of a nursing home/care facility was associated with lower expenditure. The mean annual costs for patients with severe dementia were almost twice as high as those for patients with mild dementia (US$ 25,601 versus US$ 13,387, p < 0.001). The mean total cost of AD patients with at least five comorbidities (US$ 38,348) was almost three times than those with no comorbidities (US$ 13,744).

CONCLUSION

In China, AD severity and comorbidities were the most critical factors impacting the total cost. Optimizing care patterns, delaying disease progression, and managing comorbidities comprehensively could decrease the heavy burden of AD.

Caregivers' Sense of Coherence: Implications on Direct and Indirect Costs of Dementia Care

BACKGROUND

Dementia care is associated with physical, emotional, and monetary impact on the informal carers providing unpaid care. Differences in the personal characteristics of caregivers may help explain the variations in the costs of dementia care.

OBJECTIVE

The aim of this study was to analyze the effect of caregivers' sense of coherence (SOC) on direct and indirect costs in dementia care.

METHODS

A cross-sectional study was conducted in community dwelling caregivers of patients with Alzheimer's disease. Data of healthcare services were obtained from clinical registries, and information was collected from caregivers regarding their use of social care resources and time spent caregiving. The transformation of all costs into Euros was made assigning a fixed cost of 10.29 € /h and 16.24 € /h for assisting in instrumental and basic activities of daily living, respectively. Caregivers' SOC was assessed using the Orientation to Life Questionnaire (OLQ-13). Adjusted regression models were developed, with different types of costs as dependent variables.

RESULTS

A sample of 147 caregivers was recruited. The mean OLQ-13 score was 73.3 points (SD = 11.6). The regression models showed a small association between caregivers' SOC and direct costs, mainly linked to the use of social care resources (r2 = 0.429; β= -15.6 € /month), and a greater association between SOC and indirect costs (r2 = 0.562; β= -222.3 € /month).

CONCLUSION

Increasing caregivers' SOC could reduce dementia care costs by decreasing the use of social care resources and caregiving time.

Cost of care for persons with dementia: using a discrete-time Markov chain approach with administrative and clinical data from the dementia service Centres in Austria

BACKGROUND

There is growing evidence that the cost for dementia care will increase rapidly in the coming years. Therefore, the objective of this paper was to determine the economic impact of treating clients with dementia in outpatient Dementia Service Centres (DSCs) and simulate the cost progression with real clinical and cost data.

METHODS

To estimate the cost for dementia care, real administrative and clinical data from 1341 clients of the DSCs were used to approximate the total cost of non-pharmaceutical treatment and simulate the cost progression with a discrete-time Markov chain (DTMC) model. The economic simulation model takes severity and progression of dementia into account to display the cost development over a period of up to ten years.

RESULTS

Based on the administrative data, the total cost for treating these 1341 clients of the DSCs came to 67,294,910 EUR in the first year. From these costs, 74% occurred as indirect costs. Within a five-year period, these costs will increase by 7.1-fold (16.2-fold over 10 years). Further, the DTMC shows that the greatest share of the cost increase derives from the sharp increase of people with severe dementia and that the cost of severe dementia prevails the cost in later periods.

CONCLUSION

The DTMC model has shown that the cost increase of dementia care is mostly driven by the indirect cost and the increase of severity of dementia within any given year. The DTMC reveals also that the cost for mild dementia will decrease steadily over the time period of the simulation, whereas the cost for severe dementia increases sharply after running the simulation for 3 years.

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.

The Economic Impact and Health-Related Quality of Life of Spinal Muscular Atrophy. An Analysis across Europe

Background: this study aimed to estimate the economic impact and health-related quality of life (HRQOL) of patients with spinal muscular atrophy (SMA) in three European countries. It was used a cross-sectional study carried out in France, Germany, and the United Kingdom. Data were collected from July 2015 to November 2015. Healthcare costs (hospitalizations, emergencies, medical tests, drugs used, visits to general practitioners (GPs) and specialists, medical material and healthcare transport), and non-healthcare costs (social services and informal care) were identified and valued. EuroQol instruments, the Zarit interview, and the Barthel Index were also used to reflect the burden and the social impact of the disease beyond the cost of healthcare. Results: we included 86 children with SMA, 26.7% of them had Type I, and 73.3% Type II or III. The annual average cost associated with SMA reaches €54,295 in the UK, €32,042 in France and €51,983 in Germany. The direct non-healthcare costs ranged between 79–86% of the total cost and the informal care costs were the main component of these costs. Additionally, people suffering from this disease have a very low health-related quality of life, and there are large differences between countries. Conclusions: SMA has a high socioeconomic impact in terms of healthcare and social costs. It was also observed that the HRQOL of affected children was extremely reduced. The figures shown in this study may help to design more efficient and equitable policies, with special emphasis on the support provided to the families or on non-healthcare aid.

The Economic Impact and Health-Related Quality of Life of Spinal Muscular Atrophy. An Analysis across Europe

Background: this study aimed to estimate the economic impact and health-related quality of life (HRQOL) of patients with spinal muscular atrophy (SMA) in three European countries. It was used a cross-sectional study carried out in France, Germany, and the United Kingdom. Data were collected from July 2015 to November 2015. Healthcare costs (hospitalizations, emergencies, medical tests, drugs used, visits to general practitioners (GPs) and specialists, medical material and healthcare transport), and non-healthcare costs (social services and informal care) were identified and valued. EuroQol instruments, the Zarit interview, and the Barthel Index were also used to reflect the burden and the social impact of the disease beyond the cost of healthcare. Results: we included 86 children with SMA, 26.7% of them had Type I, and 73.3% Type II or III. The annual average cost associated with SMA reaches €54,295 in the UK, €32,042 in France and €51,983 in Germany. The direct non-healthcare costs ranged between 79-86% of the total cost and the informal care costs were the main component of these costs. Additionally, people suffering from this disease have a very low health-related quality of life, and there are large differences between countries. Conclusions: SMA has a high socioeconomic impact in terms of healthcare and social costs. It was also observed that the HRQOL of affected children was extremely reduced. The figures shown in this study may help to design more efficient and equitable policies, with special emphasis on the support provided to the families or on non-healthcare aid.

The Economic Impact and Health-Related Quality of Life of Spinal Muscular Atrophy. An Analysis across Europe

Background: this study aimed to estimate the economic impact and health-related quality of life (HRQOL) of patients with spinal muscular atrophy (SMA) in three European countries. It was used a cross-sectional study carried out in France, Germany, and the United Kingdom. Data were collected from July 2015 to November 2015. Healthcare costs (hospitalizations, emergencies, medical tests, drugs used, visits to general practitioners (GPs) and specialists, medical material and healthcare transport), and non-healthcare costs (social services and informal care) were identified and valued. EuroQol instruments, the Zarit interview, and the Barthel Index were also used to reflect the burden and the social impact of the disease beyond the cost of healthcare. Results: we included 86 children with SMA, 26.7% of them had Type I, and 73.3% Type II or III. The annual average cost associated with SMA reaches €54,295 in the UK, €32,042 in France and €51,983 in Germany. The direct non-healthcare costs ranged between 79-86% of the total cost and the informal care costs were the main component of these costs. Additionally, people suffering from this disease have a very low health-related quality of life, and there are large differences between countries. Conclusions: SMA has a high socioeconomic impact in terms of healthcare and social costs. It was also observed that the HRQOL of affected children was extremely reduced. The figures shown in this study may help to design more efficient and equitable policies, with special emphasis on the support provided to the families or on non-healthcare aid.

The direct cost of disability of community-dwelling older persons in Belgium

Current policies aim to promote and develop community-based support of disabled elderly persons, yet knowledge of the cost implications is insufficient. Thus, we aimed to estimate, for three disability profiles and three presence levels of the main informal carer (none, non-cohabitant, cohabitant), the cost of formal and informal support currently provided at home in Belgium. In this cross-sectional study, a sample of 5,642 disabled elderly persons living at home was established between 2010 and 2016. The administrative database of the Belgian public healthcare insurance was merged with other prospective data on social care service utilisation, informal care and disability. The total cost of formal support ranged from €725 to €1,344 (on average, per person, per month), depending on the three disability profiles identified. Twenty-five per cent of persons with the highest level of disability (important functional limitations and cognitive impairment) and helped by a cohabitant carer, had a low total cost of formal support: below €382 per month. Informal care represented the main cost component of total support costs in the three disability profiles (between 64 and 76%). To prevent the worsening of situations of disabled older persons and their informal carers, better detection of seriously disabled persons with low levels of formal support is crucial.

Factors associated with costs of care in community-dwelling persons with dementia from a third party payer and societal perspective: a cross-sectional study

Background

Besides the importance of estimating the global economic impact of care for persons with dementia, there is an emerging need to identify the key factors associated with this cost. The aim of this study was to analyze associations between the cost of care in community-dwelling persons with dementia and caregiver characteristics from both the healthcare third party payer perspective and the societal perspective.

Methods

Several characteristics based on the cross-sectional data of 355 dyads of informal caregivers and persons with dementia living in Belgium were identified to include in a log-gamma generalized linear model and were used in a multiple linear regression model with bootstrapping to test robustness.

Results

The mean monthly cost of care for a community-dwelling person with dementia was estimated at € 2339 (95% CI € 2133 – € 2545) per person from a societal perspective and at € 968 (95% CI € 825 – € 1111) per person from a third party payer viewpoint. Informal care accounted for the majority of the monthly costs from the societal perspective. Community based healthcare resource use represented the largest cost from the third party perspective. According to the regression analyses, a higher level of functional dependency of the person with dementia and a higher educational level of the caregiver were associated with a higher monthly cost from both a third party payer perspective and a societal perspective. In addition, being retired and a higher quality of life in the caregivers were associated with a lower monthly cost of care from the societal perspective.

Conclusions

Several characteristics of the caregiver and the person with dementia were associated with the monthly costs of care from a third party payer and a societal perspective. Despite the lack of clear causal relationships, the results of this study can assist policy makers in planning and financing future dementia care.

Trial registration

Clinicaltrials.gov NCT02630446, December 15, 2015.

Effects of Cystatin C on Cognitive Impairment in Older Chinese Adults

OBJECTIVE

To find a suitable dividing value to classify cystatin C and evaluate the association between cognition and levels of cystatin C.

METHODS

Using data from the China Health and Retirement Longitudinal Study, We conducted a longitudinal analysis of a prospective cohort of 6,869 middle-aged and older Chinese without cognitive impairment at baseline. Levels of cystatin C were categorized into 2 groups by method of decision tree. Logistic regression models evaluated whether cystatin C was related to cognitive impairment.

RESULTS

Respondents were categorized as lower levels of cystatin C and higher levels of cystatin C, cut-point was 1.11 mg/L. Higher levels of cystatin C was associated with the odds of cognitive impairment (OR, 1.56; 95% CI, 1.10-2.22) after multivariable adjustment. Respondents with higher levels of cystatin C had worse cognition scores.

CONCLUSIONS

We found a suitable dividing value of cystatin C in middle-aged and older Chinese.

Classification tree model of the personal economic burden of dementia care by related factors of both people with dementia and caregivers in Japan: a cross-sectional online survey

OBJECTIVE

The purpose of this study was to clarify the microlevel determinants of the economic burden of dementia care at home in Japanese community settings by classifying them into subgroups of factors related to people with dementia and their caregivers.

DESIGN

A cross-sectional online survey.

PARTICIPANTS

4313 panels of Japanese research company who fulfilled the following criteria: (1) aged 30 years or older, (2) non-professional caregiver of someone with dementia, (3) caring for only one person with dementia and (4) having no conflicts of interest with advertising or marketing research entities.

PRIMARY OUTCOME MEASURES

Informal care costs and out-of-pocket payments for long-term care (LTC) services.

RESULTS

From 4313 respondents, only 1383 caregivers in community-settings were included in this analysis. We conducted a χ² automatic interaction detection analysis to identify the factors related to each cost (informal care costs and out-of-pocket payments for LTC services) divided into subcategories. In the resultant classifications, informal care cost was mainly related to caregivers' employment status. When caregivers acquired family care leave, informal care costs were the highest. On the other hand, out-of-pocket payments for LTC were related to care-need levels and family economic status. Activities of Daily Living and Instrumental Activities of Daily Living functions such as bathing, toileting and cleaning were related to all costs.

CONCLUSION

This study clarified the difference in dementia care costs between classified subgroups by considering the combination of the situations of both people with dementia and their caregivers. Informal care costs were related to caregivers' employment and cohabitation status rather to the situations of people with dementia. On the other hand, out-of-pocket payments for LTC services were related to care-need levels and family economic status. These classifications will be useful in understanding which situation represents a greater economic burden and helpful in improving the sustainability of the dementia care system in Japan.

The costs of dementia in England

OBJECTIVES

This study measures the average per person and annual total costs of dementia in England in 2015.

METHODS/DESIGN

Up-to-date data for England were drawn from multiple sources to identify prevalence of dementia by severity, patterns of health and social care service utilisation and their unit costs, levels of unpaid care and its economic impacts, and other costs of dementia. These data were used in a refined macrosimulation model to estimate annual per-person and aggregate costs of dementia.

RESULTS

There are around 690 000 people with dementia in England, of whom 565 000 receive unpaid care or community care or live in a care home. Total annual cost of dementia in England is estimated to be £24.2 billion in 2015, of which 42% (£10.1 billion) is attributable to unpaid care. Social care costs (£10.2 billion) are three times larger than health care costs (£3.8 billion). £6.2 billion of the total social care costs are met by users themselves and their families, with £4.0 billion (39.4%) funded by government. Total annual costs of mild, moderate, and severe dementia are £3.2 billion, £6.9 billion, and £14.1 billion, respectively. Average costs of mild, moderate, and severe dementia are £24 400, £27 450, and £46 050, respectively, per person per year.

CONCLUSIONS

Dementia has huge economic impacts on people living with the illness, their carers, and society as a whole. Better support for people with dementia and their carers, as well as fair and efficient financing of social care services, are essential to address the current and future challenges of dementia.

Determinants of time to institutionalisation and related healthcare and societal costs in a community-based cohort of patients with Alzheimer's disease dementia

OBJECTIVES

To examine the costs of caring for community-dwelling patients with Alzheimer's disease (AD) dementia in relation to the time to institutionalisation.

METHODS

GERAS was a prospective, non-interventional cohort study in community-dwelling patients with AD dementia and their caregivers in three European countries. Using identified factors associated with time to institutionalisation, models were developed to estimate the time to institutionalisation for all patients. Estimates of monthly total societal costs, patient healthcare costs and total patient costs (healthcare and social care together) prior to institutionalisation were developed as a function of the time to institutionalisation.

RESULTS

Of the 1495 patients assessed at baseline, 307 (20.5%) were institutionalised over 36 months. Disease severity at baseline [based on Mini-Mental State Examination (MMSE) scores] was associated with risk of being institutionalised during follow up (p < 0.001). Having a non-spousal informal caregiver was associated with a faster time to institutionalisation (944 fewer days versus having a spousal caregiver), as was each one-point worsening in baseline score of MMSE, instrumental activities of daily living and behavioural disturbance (67, 50 and 30 fewer days, respectively). Total societal costs, total patient costs and, to a lesser extent, patient healthcare-only costs were associated with time to institutionalisation. In the 5 years pre-institutionalisation, monthly total societal costs increased by more than £1000 (€1166 equivalent for 2010) from £1900 to £3160 and monthly total patient costs almost doubled from £770 to £1529.

CONCLUSIONS

Total societal costs and total patient costs rise steeply as community-dwelling patients with AD dementia approach institutionalisation.

Refusal and resistance to care by people living with dementia being cared for within acute hospital wards: an ethnographic study

Background

The acute hospital setting has become a key site of care for people living with dementia. The Department of Health and Social Care recognises that as many as one in four acute hospital beds in the UK will be occupied by a person living with dementia at any given time. However, people living with dementia are a highly vulnerable group within the hospital setting. Following an acute admission, their functional abilities can deteriorate quickly and significantly. Detailed research is required to understand the role and needs of health-care staff caring for this patient population and to explore what constitutes ‘good care’ for people living with dementia within the acute setting.

Objectives

The focus of this study was a common but poorly understood phenomenon within the acute setting: refusal and resistance to care. Our research questions were ‘How do ward staff respond to resistance to everyday care by people living with dementia being cared for on acute hospital wards?’ and ‘What is the perspective of patients and their carers?’.

Design

This ethnography was informed by the symbolic interactionist research tradition, focusing on understanding how action and meaning are constructed within a setting. In-depth evidence-based analysis of everyday care enabled us to understand how ward staff responded to the care needs of people living with dementia and to follow the consequences of their actions.

Setting

This ethnography was carried out on 155 days (over 18 months) in 10 wards within five hospitals across England and Wales, which were purposefully selected to represent a range of hospital types, geographies and socioeconomic catchments.

Participants

In addition to general observations, 155 participants took part directly in this study, contributing to 436 ethnographic interviews. Ten detailed case studies were also undertaken with people living with dementia.

Results

We identified high levels of resistance to care among people living with dementia within acute hospital wards. Every person living with dementia observed within an acute hospital ward resisted care at some point during their admission.

Limitations

Limitations identified included the potential for the Hawthorne or researcher effect to influence data collection and establishing the generalisability of findings.

Conclusions

Ward staff typically interpreted resistance as a feature of a dementia diagnosis, which overshadowed the person. However, resistance to care was typically a response to ward organisation and delivery of care and was typically rational to that person’s present ontology and perceptions. In response, nurses and health-care assistants used multiple interactional approaches that combined highly repetitive language with a focus on completing essential care on the body, which itself had a focus on the containment and restraint of the person in their bed or at their bedside. These approaches to patient care were a response to resistance but also a trigger for resistance, creating cycles of stress for patients, families and ward staff. The findings have informed the development of simple, no-cost innovations at the interactional and organisational level. A further study is examining continence care for people living with dementia in acute hospital settings.

Funding

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

An investigation into the prevalence of cognitive impairment and the performance of older adults in Guilan province

Introduction: The escalating rate of old people with a functional impairment in Iran and the weakness of the family support due to the diminishing of family size have increased the demand for long-term care for the elderly with cognitive impairment (CI).

Objective: The purpose of this research is to explore the frequency of cognitive impairment in the elderly and its association with their daily functional impairment and disability.

Method: This is a cross-sectional and descriptive-analytic study conducted in 2016-2017. The study sample consisted of 393 elderly people who were 60 years old or older who live in of Guilan different counties. Samples were selected by using multi-stage cluster sampling. Subsequently, data were analyzed by using the Chi-square test and correlation and regression analysis conducted in SPSS 22.

Results: It was observed that 4.3, 28.6, and 37% of the subjects suffered from severe, moderate, and mild cognitive impairment, respectively. Cognitive impairment had a significant relationship with daily functioning and activities requiring special tools. Moreover, cognitive impairment in women, people with low education, and those over 70 years old was more common, and the difference between them was significant (p <0.001). Also, disability was significantly greater in the elderly with cognitive impairment.

Conclusion: Many old people need to be cared for after the appearance of cognitive impairment. Therefore, appropriate screening of cognitive impairments is conducive to early diagnosis and prevention of executive functioning problems.

Economics of dementia: A review of methods

Given the expected increase in the number of people with dementia in the coming years, it is anticipated that the resources necessary to support those with dementia will significantly increase. There will therefore likely be increased emphasis on how best to use limited resources across a number of domains including prevention, diagnosis, treatment and supporting informal caregivers. There has been increasing use of economic methods in dementia in the past number of years, in particular, cost-of-illness analysis and economic evaluation. This paper reviews the aforementioned methods and identities a number of methodological issues that require development. Addressing these methodological issues will enhance the quality of economic analysis in dementia and provide some useful insights about the best use of limited resources for dementia.

Direct health and residential care costs of people living with dementia in Australian residential aged care

OBJECTIVES

This analysis estimates the whole-of-system direct costs for people living with dementia in residential care by using a broad health and social care provision perspective and compares it to people without dementia living in residential care.

METHODS

Data were collected from 541 individuals living permanently in 17 care facilities across Australia. The annual cost of health and residential care was determined by using individual resource use data and reported by the dementia status of the individuals.

RESULTS

The average annual whole-of-system cost for people living with dementia in residential care was approximately AU$88 000 (US$ 67 100) per person in 2016. The cost of residential care constituted 93% of the total costs. The direct health care costs were comprised mainly of hospital admissions (48%), pharmaceuticals (31%) and out-of-hospital attendances (15%). While total costs were not significantly different between those with and without dementia, the cost of residential care was significantly higher and the cost of health care was significantly lower for people living with dementia.

CONCLUSION

This study provides the first estimate of the whole-of-system costs of providing health and residential care for people living with dementia in residential aged care in Australia using individual level health and social care data. This predominantly bottom-up cost estimate indicates the high cost associated with caring for people with dementia living permanently in residential care, which is underestimated when limited cost perspectives or top-down, population costing approaches are taken.

Alzheimer's disease severity and its association with patient and caregiver quality of life in Japan: results of a community-based survey

BACKGROUND

Alzheimer's disease (AD) dementia, a progressive neurodegenerative disease, exerts significant burden upon patients, caregivers, and healthcare systems globally. The current study investigated the associations between AD dementia patient disease severity and health-related quality of life (HRQoL) of both patients (proxy report) and their caregivers living in Japan, as well as caregiving-related comorbidities such as depression.

METHODS

This cross-sectional study used self-reported data from caregivers of people diagnosed with AD dementia by a healthcare provider in Japan. Caregivers were identified via online panels and invited to participate in an online survey between 2014 and 2015. Caregivers completed survey items for themselves, in addition to providing proxy measures for patients with AD dementia for whom they were caring. Patient and caregiver HRQoL was measured using the EuroQoL 5-Dimension (EQ-5D). Additional outcomes for caregivers of AD dementia patients included the Patient Health Questionnaire (PHQ-9) of depressive symptomology, as well as comorbidities experienced since initiating caregiving for their AD dementia patients. These outcomes were examined as a function of AD dementia severity, as measured by long-term care insurance (LTCI) categories. Bivariate analyses between LTCI and outcomes were conducted using independent t-tests and chi-square tests. Multivariable analyses, controlling for potential confounders, were conducted using generalized linear models (GLMs) specifying a normal distribution.

RESULTS

Across 300 caregiver respondents, multivariable results revealed that increasing AD dementia severity was significantly associated with poorer patient and caregiver EQ-5D scores and a high proportion of caregivers (30.0%) reported PHQ-9 scores indicative of major depressive disorder (MDD). The most frequent comorbidities experienced after becoming caregivers of AD dementia patients included hypertension (12.7%) and insomnia (11.0%). Depression and other comorbidities did not differ significantly by patient severity.

CONCLUSIONS

The current study provides unique insight into the specific degree of incremental burden associated with increasing AD dementia severity among patients and caregivers alike. Importantly, greater disease severity was associated with poorer quality of life among both patients and caregivers. These results suggest that earlier detection and treatment of AD dementia may provide an opportunity to reduce the burden of disease for patients, caregivers, and society at large.

The personal cost of dementia care in Japan: A comparative analysis of residence types

OBJECTIVE

We aimed to quantify the personal economic burden of dementia care in Japan according to residence type.

METHODS

A cross-sectional online survey was conducted on 3841 caregivers of people with dementia. An opportunity cost approach was used to calculate informal care costs. All costs and the observed/expected (OE) ratio of costs were adjusted using patient sex, age, and care-needs levels, and compared among the residence types.

RESULTS

The mean daily informal care time was 8.2 hours, and the mean monthly informal care costs for community-dwelling people with dementia were US$1559. The OE ratio for informal care costs in community-dwelling patients was higher than in institutionalized patients.

CONCLUSION

The inclusion of informal care costs reduced the differences in total personal costs among the residence types. The economic burden of informal care should be considered when quantifying dementia care costs.

Telephone-based Minnesota Cognitive Acuity Screen predicts time to institutionalization and homecare

ABSTRACTBackground:We assessed the ability of a telephone-administered cognitive screening test - Minnesota Cognitive Acuity Screen (MCAS) - to predict time to assisted living/nursing home placement (i.e. institutionalization) and homecare/institutionalization in healthy controls (HC), mild cognitive impairment (MCI), and Alzheimer's disease (AD).

METHODS

Participants (N = 146; HC = 37; MCI = 70; AD = 39) had baseline MCAS testing and were re-contacted over eight years for dates of starting homecare, institutionalization, and death. Occasionally, outcomes were obtained via medical records. Accounting for informative censoring due to death within a competing risks framework, Cox regression examined the associations of baseline MCAS performance with the start of (a) institutionalization and (b) homecare/institutionalization.

RESULTS

Hazard ratios (HR) captured the effect of a ten-point difference in baseline MCAS scores, corresponding to a change from the MCI/HC to AD/MCI boundaries. In unadjusted models, increased baseline cognitive impairment was associated with nearly two-fold increases in the hazard of institutionalization (HR = 1.81, 95% CI = 1.32, 2.48) and homecare/institutionalization (HR = 1.87, 95% CI = 1.44, 2.42). However, hazards were not proportional over time in models adjusting for sex. This was resolved when regressions were run for men and women separately. Both sexes showed significant increases in the hazard of institutionalization (Females: HR = 2.39, 95% CI = 1.53-3.74; Males: HR = 1.68, 95% CI = 1.02-2.76) and homecare/institutionalization (Females: HR = 2.31, 95% CI = 1.66, 3.21; Males: HR = 1.98, 95% CI = 1.32, 2.96) with increased impairment, although hazards were lower for males.

CONCLUSIONS

Telephone-administered MCAS provides useful information about the risk of needing homecare assistance or institutionalization. It may be particularly useful when office/home visits are prohibitive but cognitive monitoring is indicated.

Resource utilisation and costs in predementia and dementia: a systematic review protocol

INTRODUCTION

Dementia is the fastest growing major cause of disability globally with a mounting social and financial impact for patients and their families but also to health and social care systems. This review aims to systematically synthesise evidence on the utilisation of resources and costs incurred by patients and their caregivers and by health and social care services across the full spectrum of dementia, from its preceding preclinical stage to end of life. The main drivers of resources used and costs will also be identified.

METHODS AND ANALYSIS

A systematic literature review was conducted in MEDLINE, EMBASE, CDSR, CENTRAL, DARE, EconLit, CEA Registry, TRIP, NHS EED, SCI, RePEc and OpenGrey between January 2000 and beginning of May 2017. Two reviewers will independently assess each study for inclusion and disagreements will be resolved by a third reviewer. Data will be extracted using a predefined data extraction form following best practice. Study quality will be assessed with the Effective Public Health Practice Project quality assessment tool. The reporting of costing methodology will be assessed using the British Medical Journal checklist. A narrative synthesis of all studies will be presented for resources used and costs incurred, by level of disease severity when available. If feasible, the data will be synthesised using appropriate statistical techniques.

ETHICS AND DISSEMINATION

Included articles will be reviewed for an ethics statement. The findings of the review will be disseminated in a related peer-reviewed journal and presented at conferences. They will also contribute to the work developed in the Real World Outcomes across the Alzheimer's disease spectrum for better care: multi-modal data access platform (ROADMAP).

TRIAL REGISTRATION NUMBER

CRD42017071413.