Family caregiving in the community up to 8-years after onset of dementia

The CareVirtue Digital Journal for Family and Friend Caregivers of People Living With Alzheimer Disease and Related Dementias: Exploratory Topic Modeling and User Engagement Study

BACKGROUND

As Alzheimer disease (AD) and AD-related dementias (ADRD) progress, individuals increasingly require assistance from unpaid, informal caregivers to support them in activities of daily living. These caregivers may experience high levels of financial, mental, and physical strain associated with providing care. CareVirtue is a web-based tool created to connect and support multiple individuals across a care network to coordinate care activities and share important information, thereby reducing care burden.

OBJECTIVE

This study aims to use a computational informatics approach to thematically analyze open text written by AD/ADRD caregivers in the CareVirtue platform. We then explore relationships between identified themes and use patterns.

METHODS

We analyzed journal posts (n=1555 posts; 170,212 words) generated by 51 unique users of the CareVirtue platform. Latent themes were identified using a neural network approach to topic modeling. We calculated a sentiment score for each post using the Valence Aware Dictionary and Sentiment Reasoner. We then examined relationships between identified topics; semantic sentiment; and use-related data, including post word count and self-reported mood.

RESULTS

We identified 5 primary topics in users' journal posts, including descriptions of specific events, professional and medical care, routine daily activities, nighttime symptoms, and bathroom/toileting issues. This 5-topic model demonstrated adequate fit to the data, having the highest coherence score (0.41) among those tested. We observed group differences across these topics in both word count and semantic sentiment. Further, posts made in the evening were both longer and more semantically positive than other times of the day.

CONCLUSIONS

Users of the CareVirtue platform journaled about a variety of different topics, including generalized experiences and specific behavioral symptomology of AD/ADRD, suggesting a desire to record and share broadly across the care network. Posts were the most positive in the early evening when the tool was used habitually, rather than when writing about acute events or symptomology. We discuss the value of embedding informatics-based tools into digital interventions to facilitate real-time content delivery.

Sentiment Dynamics Among Informal Caregivers in Web-Based Alzheimer Communities: Systematic Analysis of Emotional Support and Interaction Patterns

BACKGROUND

Alzheimer disease and related dementias (ADRD) are a growing global health challenge. ADRD place significant physical, emotional, and financial burdens on informal caregivers and negatively affects their well-being. Web-based social media platforms have emerged as valuable sources of peer support for these caregivers. However, there has been limited investigation into how web-based peer support might influence their mental well-being.

OBJECTIVE

This study aims to examine the dynamics of sentiment scores, a major indicator of mental well-being, among informal ADRD caregivers, specifically how their sentiment changes as they participate in caregiving experience discussions within 2 ADRD web-based communities.

METHODS

We collected data from 2 large web-based ADRD caregiving communities, ALZConnected (from November 2011 to August 2022) and TalkingPoint (from March 2003 to November 2022). Using the Valence Aware Dictionary for Sentiment Reasoning and Linguistic Inquiry and Word Count, we calculated sentiment scores for each post and evaluated how the initial sentiment score of a topic initiator evolves within a discussion thread. Structured topic modeling and regression analysis were used to identify the primary topics consistently associated with sentiment changes within these threads. We investigated longitudinal sentiment trends to identify patterns of sentimental stability or enhancement due to prolonged engagement in web-based communities by plotting linear interpolation lines of the sentiment values of each individual user.

RESULTS

The ALZConnected dataset comprised 532,992 posts, consisting of 57,641 topic threads and 475,351 comments. The TalkingPoint dataset was composed of 846,344 posts, consisting of 81,068 topic threads and 765,276 comments. Our research revealed that topic initiators experienced a notable increase in sentiment as they engaged in subsequent discussions within their threads, with a significant uptick in positivity in the short term. This phenomenon is part of a broader trend of steadily rising positive sentiment among ADRD caregivers. Using structured topic modeling, we cataloged a diverse range of topics that included both emotional aspects, such as family emotions, and practical concerns, such as diagnosis and treatment and everyday care practices. We observed that sentiment scores were positively aligned with discussions about family and daily routines life (coefficient=3.53; P<.001), while topics related to illness (coefficient=-1.37; P<.001) and caregiving facilities (coefficient=-1.98; P<.001) tended to correlate with lower sentiment scores. This evidence highlights the significant impact that both the time of participation and the posting content have on the sentiment changes of caregivers.

CONCLUSIONS

This study identifies sentiment changes among informal ADRD caregivers through their interactions in 2 extensive web-based communities. These findings emphasize the importance of early emotional support within a topic thread and demonstrate a predominantly positive sentiment in these communities over time. These further highlight the value of web-based peer support and its potential to enhance the emotional well-being of informal ADRD caregivers.

Association of Caregiving Receipt With Mental Health Utilization in a National Cohort of Older Adults

OBJECTIVE

There exist significant age disparities in mental health (MH) utilization, such that older adults, including older veterans, are much less likely to use MH services. In-home caregivers represent a novel, yet understudied, pathway to increase appropriate utilization. We sought to examine the association between receiving caregiving assistance and MH utilization and test moderation effects of cognitive status and depression severity in a sample of older veterans.

METHODS

Cross-sectional, mixed effects logistic regression with moderation analyses was used with a unique data resource combining survey data from the 2000-2012 U.S. Health and Retirement Study with Veterans Affairs (VA) healthcare administrative records. The analytic sample included N=1,957 Community-dwelling veterans (mean age 68.2 [9.7]), primarily male (96.5%) and non-Hispanic white (77.0%). Measures included MH utilization extracted from VA records or self-report; CESD-8 for depressive symptoms; and the Langa-Weir cognitive status classification using the modified TICS.

RESULTS

After accounting for demographics, spousal caregiver availability, health factors, and socioeconomic status, caregiving receipt was associated with two-fold odds of MH utilization, compared to receiving no assistance (8,839 person-year observations; OR = 2.02; 95% CI 1.54-2.65) and remained similar following VA policy changes to enhance MH access. Exploratory analyses revealed that categories of cognition and depressive symptoms may moderate the association.

CONCLUSION

Receipt of any in-home caregiving is associated with increased likelihood of MH use by older adults. Caregivers may represent an underutilized resource to reduce age-related mental health access disparities.

Care Partner Burden and Support Services in Dementia

OBJECTIVE

Informal care partners are essential to the care of people living with dementia, but they often experience significant burden and receive minimal training, support, and resources. This article provides an overview of care partner experiences, factors contributing to burden, and methods for reducing burden of caregiving in dementia.

LATEST DEVELOPMENTS

The US Department of Health and Human Services National Plan to Address Alzheimer's Disease and the World Health Organization Global Action Plan for dementia have identified support for dementia care partners as a top priority for research and policy in recognition of care partners' instrumental but underresourced role in dementia care. The psychological, financial, social, and physical costs of caregiving, particularly without necessary knowledge, skills, and resources, can lead to care partner burden. Reassuringly, multicomponent interventions can mitigate burden and other negative consequences of caregiving, especially when they are theoretically grounded, inclusive, and culturally relevant.

ESSENTIAL POINTS

Health care providers play a vital role in the early identification of care partner burden through brief, regular assessments. With earlier identification and subsequent intervention (eg, education, skills-based training, local and national resources), the experience of burden and negative health outcomes can be mitigated and quality of life for people living with dementia and their care partners can be improved.

Ascertaining Out-of-Pocket Costs of Dementia Care: Feasibility Study of a Web-Based Weekly Survey

BACKGROUND

Caring for a family member living with dementia is costly. A major contributor to care demands, and therefore to the costs, are the behavioral symptoms of dementia. Here, we examine the feasibility of ascertaining costs related to caregiving from weekly web-based surveys collected during a telehealth-based behavioral intervention study-Support via Technology: Living and Learning with Advancing Alzheimer Disease.

OBJECTIVE

This study aims to determine the feasibility and acceptability of using a web-based weekly survey to capture real-time data on out-of-pocket caregiving expenses and time commitments associated with dementia care. To examine relationships between behavioral symptoms, care partner reactivity, burden, and out-of-pocket dementia care costs.

METHODS

Feasibility was measured by accrual, retention, and data completion by participating care partners. Behavioral symptoms, care partner reactivity, and burden were collected before and after the intervention from 13 care partners. Weekly web-based surveys queried Support via Technology: Living and Learning with Advancing Alzheimer Disease care partners about their out-of-pocket costs associated with care-related activities. The surveys included questions on out-of-pocket costs care partners incurred from hospitalizations and emergency department use, primary care provider visits, use of paid in-home care or respite services, use of prescription medications, and use of over-the-counter medications. The surveys also queried the amount of time care partners devoted to these specific care-related activities.

RESULTS

Out-of-pocket costs of dementia care were collected via a web-based weekly survey for up to 18 months. In-home assistance was the most frequently reported type of out-of-pocket care expense and the costliest. care partners who paid for in-home assistance or respite reported more behavioral and psychological symptoms of dementia behaviors, higher reactivity, and higher burden than those who did not.

CONCLUSIONS

This novel web-based weekly survey-based approach offers lessons for designing and implementing future cost-focused studies and care partner-supportive telehealth-based interventions for Alzheimer disease and related dementias (ADRD). The results correspond with the existing understanding of ADRD in that high family-related out-of-pocket costs are a typical part of the caregiving experience, and those costs likely increase with dementia severity. The results may also offer potential insights to health systems and policy makers as they seek to implement telehealth-based and related interventions that seek to better support people living with ADRD and their family care partners.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04335110; https://clinicaltrials.gov/ct2/show/NCT04335110.

Determinants of trajectories of informal caregiving in later life: evidence from England

Although the long-term consequences of informal care provision have been well investigated, few studies have examined the trajectories of informal care provision among older people and the socioeconomic, demographic, health, and family characteristics associated with them. We use data from four waves of the English Longitudinal Study of Ageing, with 6561 respondents followed for 6 years (2012/3-2018/9). We used group-based trajectory modelling to group people's provision of care over time into a finite number of distinct trajectories of caregiving. Using multinomial logistic regressions, we then investigated the characteristics associated with these trajectories. Four distinct trajectories of caregiving were identified: "stable intensive", "increasing intensive", "decreasing", and "stable no care". Results suggest that although there are socioeconomic, demographic, and health differences across the trajectories of caregiving (with younger women in good health and poorer socioeconomic status more likely to care intensively throughout), family characteristics are their main drivers. Respondents who live alone, with no children, and no parents alive are more likely to never provide care, whereas those with older parents and who live with adults in poor health are more likely to provide stable intensive care. Also, changes in family characteristics (e.g. death of parents, widowhood, or deterioration of the partner's health) are associated with trajectories representing increases or decreases in caregiving over time. Overall, trajectories of informal caregiving undertaken by older people are varied and these patterns are mostly associated with both the availability and health of family members, suggesting that need factors represent the most immediate reason for caregiving commitments.

National Estimates of Incremental Work Absenteeism Costs Associated With Adult Children of Parents With Alzheimer's Disease and Related Dementias

OBJECTIVE

More than half of primary caregivers for ADRD patients are adult children, yet there is little empirical evidence on how caring for parents with ADRD affects their employment. Using a nationally representative dataset, this study aimed to estimate incremental work absenteeism costs for adult children of parents with ADRD.

DESIGN, SETTING, AND PARTICIPANTS

The study used the data from the 2015-2021 Medical Expenditure Panel Survey (MEPS). Multivariate regressions and two-part models were employed to estimate the incremental work absenteeism costs among adult children aged 40 to 64 who had at least one parent diagnosed with ADRD, compared with those who did not have ADRD parents.

MEASUREMENTS

The incremental work absenteeism costs due to caregiving for adult children with ADRD parents was a cumulated estimation of labor productivity cost at three stages: (1) the likelihood of not working due to unemployment, (2) the likelihood of missing any workdays for caregiving, and (3) the number of workdays missed due to caregiving.

RESULTS

Adult children with ADRD parents were more likely to be unemployed (OR = 1.80, p = 0.024) and 2.95 times more likely to miss work for caregiving (p = 0.002) than those with non-ADRD parents. The difference in the number of workdays missed for caregiving between children with and without ADRD parents was not significant. The incremental effects of having ADRD parents were estimated to be $4,510.29 ($1,702.09-$6,723.69) per person per year.

CONCLUSIONS

Having ADRD parents significantly increases the chances of unemployment and missing any workdays for caregiving, leading to higher lost labor productivity costs for adult children with ADRD parents.

Cross-National Analysis of the Associations Between Familism and Self-Efficacy in Family Caregivers of People With Dementia: Effects on Burden and Depression

Objectives: To examine the cross-national associations between familism and self-efficacy dimensions, and levels of burden and depression. Methods: Sociodemographic, familism, self-efficacy, depressive symptoms, and burden variables were measured in 349 dementia family caregivers from the US and Spain. Results: US sample: greater support from family was positively related to self-efficacy for obtaining respite and self-efficacy for controlling upsetting thoughts and behaviors. Both self-efficacy constructs were negatively related to depression. Similar findings were obtained for burden. Spanish sample: higher scores on family as referents were associated with lower scores on self-efficacy for obtaining respite; lower scores on self-efficacy for obtaining respite were associated with higher depressive symptomatology. Discussion: Study findings suggest that a significant interplay exists between the various facets of familism and self-efficacy, leading to differential caregiving outcomes. Unique cultural contexts and values derived from each country may exert distinct influences on how the caregiving role is perceived and appraised.

Social Media Discourse Related to Caregiving for Older Adults Living With Alzheimer Disease and Related Dementias: Computational and Qualitative Study

BACKGROUND

In the United States, caregivers of people living with Alzheimer disease and Alzheimer disease-related dementias (AD/ADRD) provide >16 billion hours of unpaid care annually. These caregivers experience high levels of stress and burden related to the challenges associated with providing care. Social media is an emerging space for individuals to seek various forms of support.

OBJECTIVE

We aimed to explore the primary topics of conversation on the social media site Reddit related to AD/ADRD. We then aimed to explore these topics in depth, specifically examining elements of social support and behavioral symptomology discussed by users.

METHODS

We first generated an unsupervised topic model from 6563 posts made to 2 dementia-specific subreddit forums (r/Alzheimers and r/dementia). Then, we conducted a manual qualitative content analysis of a random subset of these data to further explore salient themes in the corpus.

RESULTS

The topic model with the highest overall coherence score (0.38) included 10 topics, including caregiver burden, anxiety, support-seeking, and AD/ADRD behavioral symptomology. Qualitative analyses provided added context, wherein users sought emotional and informational support for many aspects of the care experience, including assistance in making key care-related decisions. Users expressed challenging and complex emotions on Reddit, which may be taboo to express in person.

CONCLUSIONS

Reddit users seek many different forms of support, including emotional and specific informational support, from others on the internet. Users expressed a variety of concerns, challenges, and behavioral symptoms to manage as part of the care experience. The unique (ie, anonymous and moderated) nature of the forum allowed for a safe space to express emotions free from documented caregiver stigma. Additional support structures are needed to assist caregivers of people living with AD/ADRD.

2024 Alzheimer's disease facts and figures

This article describes the public health impact of Alzheimer's disease (AD), including prevalence and incidence, mortality and morbidity, use and costs of care and the ramifications of AD for family caregivers, the dementia workforce and society. The Special Report discusses the larger health care system for older adults with cognitive issues, focusing on the role of caregivers and non-physician health care professionals. An estimated 6.9 million Americans age 65 and older are living with Alzheimer's dementia today. This number could grow to 13.8 million by 2060, barring the development of medical breakthroughs to prevent or cure AD. Official AD death certificates recorded 119,399 deaths from AD in 2021. In 2020 and 2021, when COVID-19 entered the ranks of the top ten causes of death, Alzheimer's was the seventh-leading cause of death in the United States. Official counts for more recent years are still being compiled. Alzheimer's remains the fifth-leading cause of death among Americans age 65 and older. Between 2000 and 2021, deaths from stroke, heart disease and HIV decreased, whereas reported deaths from AD increased more than 140%. More than 11 million family members and other unpaid caregivers provided an estimated 18.4 billion hours of care to people with Alzheimer's or other dementias in 2023. These figures reflect a decline in the number of caregivers compared with a decade earlier, as well as an increase in the amount of care provided by each remaining caregiver. Unpaid dementia caregiving was valued at $346.6 billion in 2023. Its costs, however, extend to unpaid caregivers' increased risk for emotional distress and negative mental and physical health outcomes. Members of the paid health care and broader community-based workforce are involved in diagnosing, treating and caring for people with dementia. However, the United States faces growing shortages across different segments of the dementia care workforce due to a combination of factors, including the absolute increase in the number of people living with dementia. Therefore, targeted programs and care delivery models will be needed to attract, better train and effectively deploy health care and community-based workers to provide dementia care. Average per-person Medicare payments for services to beneficiaries age 65 and older with AD or other dementias are almost three times as great as payments for beneficiaries without these conditions, and Medicaid payments are more than 22 times as great. Total payments in 2024 for health care, long-term care and hospice services for people age 65 and older with dementia are estimated to be $360 billion. The Special Report investigates how caregivers of older adults with cognitive issues interact with the health care system and examines the role non-physician health care professionals play in facilitating clinical care and access to community-based services and supports. It includes surveys of caregivers and health care workers, focusing on their experiences, challenges, awareness and perceptions of dementia care navigation.

Determinants of Trajectories of Informal Caregiving in later life. Evidence from England

Although long-term consequences of informal care provision are well investigated, fewer studies have examined trajectories of informal care provision among older people and the socioeconomic, demographic, health, and family characteristics associated with them. We use data from four waves of the English Longitudinal Study of Ageing, with 6,561 respondents followed for 6 years (2012/3 to 2018/9). We used group-based trajectory modelling to group people's provision of care over time into a finite number of distinct trajectories of caregiving. Using multinomial logistic regressions, we then investigated characteristics associated with these trajectories. Four distinct trajectories were identified representing "stable intensive", "increasing intensive", "decreasing", and "stable no care". Results suggest that, although there are socioeconomic, demographic, and health differences across the trajectories of caregiving (with younger women in good health and poorer socioeconomic status more likely to care intensively throughout), family characteristics are their main drivers. Respondents who live alone, with no children, and no parents alive are more likely to never provide care, whereas those with older parents and who live with adults in poor health are more likely to provide stable intensive care. Also, changes in family characteristics (e.g. death of parents, widowhood, or deterioration of the partner's health) are associated with trajectories representing increases or decreases of caregiving over time. Overall, trajectories of informal caregiving undertaken by older people are varied and these patterns are mostly associated with both the availability and health of family members, suggesting that the needs factors represent the most immediate reason for caregiving commitments.

Caregiving for dementia: trends pre-post onset and predictive factors of family caregiving (2002-2018)

Persons living with Alzheimer's and other related forms of dementia rely heavily on care from family and friends for assistance with daily activities ("family care"), but little is known about care transitions over time. We analyzed data from the Health and Retirement Study to describe caregiving patterns, from 2 years before dementia onset and up to 6 years after. Using sociodemographic data from the interview prior to dementia onset, we determined if there are significant factors that predict receipt of family care at dementia onset. We found that one-third (33%) of people living with dementia were receiving help with daily activities 2 years prior to their first positive dementia screen and this increased to 60% during the first positive screen. Nearly all of those receiving assistance received family care. We found multiple significant predictors of receiving family care at onset, including race, education, access to private health insurance, number of activities of daily living that were difficult, number of chronic conditions, and already receiving help. This demonstrates potential gaps in dementia care, and which subpopulations may benefit most from targeted interventions for household members who do not have adequate caregiving resources or programs that provide additional formal care.

Burden and Depression among Empirically-Derived Subgroups of Family Caregivers for Individuals With Dementia

Dementia caregiving experiences are not universal and different factors may influence the risk for burden and depression. This study examined factors such as the relationship with the care recipient, severity of dementia, and relationship satisfaction to uncover different types of caregiver burden profiles using baseline assessment for a telephone-based intervention study for dementia caregivers. Participants (n = 233) completed a battery of psychological and caregiving related surveys. The sample was predominantly White and female. Latent class analysis suggested four class models in subsamples of spousal caregivers and adult children caregivers. The results suggested four distinct classes among samples of spousal and adult child caregivers. Differences in burden emerged across both spouses and adult children, and differences in depression also emerged in the spousal sample. Our findings demonstrate the diversity of the caregiving experience and suggest that future psychosocial interventions may benefit from being tailored to the needs of caregiver subgroups.

Evaluating Elements of the Care Partner Experience in Individuals Who Care for People with Alzheimer's Disease Across the Severity Spectrum

INTRODUCTION

Non-professional care partners play an important and often evolving role in the care of persons living with Alzheimer's disease (PLWAD). We investigated two elements of the care partner experience, namely time and strain incurred by care partners providing care to PLWAD across the severity spectrum.

METHODS

Data gathered from the Alzheimer's Disease Patient and Caregiver Engagement (AD PACE) What Matters Most (WMM) study series were analyzed to determine how much time care partners spent providing care to PLWAD based on where the care recipients lived. Additionally, quantitative assessments of weekly hours providing care and the strain experienced by care partners were conducted using the UsAgainstAlzheimer's A-LIST Insights Series survey, which included the Modified Caregiver Strain Index (MCSI). Finally, a targeted literature review was conducted to contextualize findings and characterize the existing literature landscape.

RESULTS

Care partners in the AD PACE WMM studies (n = 139) spent significantly more hours providing care for recipients who lived with someone (mean ± standard deviation [SD], 57.3 ± 44.3 h/week) than for recipients who lived alone (26.0 ± 12.0 h/week) (P = 0.0096) or lived in assisted living/nursing home (23.6 ± 14.4 h/week) (P = 0.0002). In the A-LIST Insights Series survey, care partners provided an overall mean (± SD) 58.1 ± 53.0 h of direct care each week, with caregiving hours increasing with increasing severity of AD/AD-related dementias (AD/ADRD). Additionally, care partners for recipients with mild (n = 14), moderate (n = 111), and severe AD/ADRD (n = 91) had overall mean MCSI scores of 9.0 ± 3.8 (range 2-14), 13.3 ± 4.8 (range 4-23), and 17.5 ± 5.3 (range 4-26), respectively, with higher scores suggesting greater care partner strain.

CONCLUSIONS

Persons living with AD require increasing levels of care along the spectrum of disease, and even individuals with early disease need care from partners. Early interventions that slow progression of AD and programs that improve family function may have beneficial impact on the experiences of care partners for recipients with mild, moderate, or severe AD.

Risk of dementia among veterans experiencing homelessness and housing instability

BACKGROUND

In the United States, nearly 85,000 Veterans experienced homelessness during 2020, and thousands more are experiencing housing instability, representing a significant proportion of the population.1 Many Veterans experiencing homelessness are aging and have complex co-occurring medical, psychiatric, and substance use disorders. Homelessness and older age put Veterans at greater risk for age-related disorders, including Alzheimer's disease and related dementias (ADRD).

METHODS

We examined the rate of ADRD diagnosis for Veterans experiencing homelessness and housing instability compared to a matched cohort of stably housed Veterans over a nine-year period using cox proportional hazard models.

RESULTS

In the matched cohort, 95% (n = 88,811) of Veterans were men, and 67% (n = 59,443) were White and were on average 63 years old (SD = 10.8). Veterans with housing instability had a higher hazard of 1.53 (95% confidence interval (CI) 1.50, 1.59) for ADRD compared to Veterans without housing instability.

CONCLUSIONS

Veterans experiencing housing instability have a substantially higher risk of receiving an ADRD diagnosis than a matched cohort of stably housed Veterans. Health systems and providers should consider cognitive screening among people experiencing housing insecurity. Existing permanent supportive housing programs should consider approaches to modify wraparound services to support Veterans experiencing ADRD.

Caring for Dementia Caregivers: Psychosocial Factors Related to Engagement in Self-Care Activities

Caregivers often prioritize the needs of the care recipient and neglect their own health needs. It is imperative to understand the factors related to their self-care practices and engagement in self-care activities. The present study examined the extent to which dementia caregivers engaged in self-care activities, how this varied depending on caregiver characteristics, and whether self-care engagement mediated the relationship between social support and caregiver outcomes. The study utilized baseline data from a diverse sample of dementia caregivers (N = 243) who participated in a randomized trial evaluating a psychosocial technology-based caregiver intervention. Results showed that the dementia caregivers engaged in low levels of self-care activities and that their engagement varied based on the caregivers' background characteristics (age, gender, race/ethnicity, relationship to the care recipient, and employment status). Less caregiver involvement (e.g., less ADL/IADL help provided and more caregiver preparedness) and more social support predicted higher self-care activity engagement. Self-care activity engagement served as a mediator, such that more social support predicted more self-care activities, which, in turn, were associated with more positive perceptions of caregiving and less caregiver burden and depression. The findings suggest a need for interventions that promote self-care engagement among dementia caregivers and underscore the importance of social support and caregiver preparedness to caregivers' well-being.

Cost effectiveness of non-drug interventions that reduce nursing home admissions for people living with dementia

INTRODUCTION

Six million Americans live with Alzheimer's disease and Alzheimer's disease and related dementias (AD/ADRD), a major health-care cost driver. We evaluated the cost effectiveness of non-pharmacologic interventions that reduce nursing home admissions for people living with AD/ADRD.

METHODS

We used a person-level microsimulation to model the hazard ratios (HR) on nursing home admission for four evidence-based interventions compared to usual care: Maximizing Independence at Home (MIND), NYU Caregiver (NYU); Alzheimer's and Dementia Care (ADC); and Adult Day Service Plus (ADS Plus). We evaluated societal costs, quality-adjusted life years and incremental cost-effectiveness ratios.

RESULTS

All four interventions cost less and are more effective (i.e., cost savings) than usual care from a societal perspective. Results did not materially change in 1-way, 2-way, structural, and probabilistic sensitivity analyses.

CONCLUSION

Dementia-care interventions that reduce nursing home admissions save societal costs compared to usual care. Policies should incentivize providers and health systems to implement non-pharmacologic interventions.

The Effects of Increasing State Minimum Wage on Family and Paid Caregiving

Older adults may receive either or a combination of unpaid family/friend and paid caregiving. The consumption of family/friend and paid caregiving may be sensitive to minimum wage policies. We used data (n = 11,698 unique respondents) from the Health and Retirement Study and a difference-in-differences design to evaluate associations between increases in state minimum wage between 2010 and 2014 and family/friend and paid caregiving consumed by adults age 65+ years. We also examined responses to increases in minimum wage for respondents with dementia or Medicaid beneficiaries. People living in states that increased their minimum wage did not consume substantially different hours of family/friend, paid, or any family/friend or paid caregiving. We did not observe differential responses between increases in minimum wage and hours of family/friend or paid caregiving among people with dementia or Medicaid beneficiaries. Increases in state minimum wage were not associated with changes in caregiving consumed by adults age 65+.

2023 Alzheimer's disease facts and figures

This article describes the public health impact of Alzheimer's disease, including prevalence and incidence, mortality and morbidity, use and costs of care, and the overall impact on family caregivers, the dementia workforce and society. The Special Report examines the patient journey from awareness of cognitive changes to potential treatment with drugs that change the underlying biology of Alzheimer's. An estimated 6.7 million Americans age 65 and older are living with Alzheimer's dementia today. This number could grow to 13.8 million by 2060 barring the development of medical breakthroughs to prevent, slow or cure AD. Official death certificates recorded 121,499 deaths from AD in 2019, and Alzheimer's disease was officially listed as the sixth-leading cause of death in the United States. In 2020 and 2021, when COVID-19 entered the ranks of the top ten causes of death, Alzheimer's was the seventh-leading cause of death. Alzheimer's remains the fifth-leading cause of death among Americans age 65 and older. Between 2000 and 2019, deaths from stroke, heart disease and HIV decreased, whereas reported deaths from AD increased more than 145%. This trajectory of deaths from AD was likely exacerbated by the COVID-19 pandemic in 2020 and 2021. More than 11 million family members and other unpaid caregivers provided an estimated 18 billion hours of care to people with Alzheimer's or other dementias in 2022. These figures reflect a decline in the number of caregivers compared with a decade earlier, as well as an increase in the amount of care provided by each remaining caregiver. Unpaid dementia caregiving was valued at $339.5 billion in 2022. Its costs, however, extend to family caregivers' increased risk for emotional distress and negative mental and physical health outcomes - costs that have been aggravated by COVID-19. Members of the paid health care workforce are involved in diagnosing, treating and caring for people with dementia. In recent years, however, a shortage of such workers has developed in the United States. This shortage - brought about, in part, by COVID-19 - has occurred at a time when more members of the dementia care workforce are needed. Therefore, programs will be needed to attract workers and better train health care teams. Average per-person Medicare payments for services to beneficiaries age 65 and older with AD or other dementias are almost three times as great as payments for beneficiaries without these conditions, and Medicaid payments are more than 22 times as great. Total payments in 2023 for health care, long-term care and hospice services for people age 65 and older with dementia are estimated to be $345 billion. The Special Report examines whether there will be sufficient numbers of physician specialists to provide Alzheimer's care and treatment now that two drugs are available that change the underlying biology of Alzheimer's disease.

Caregiver training: Evidence of its effectiveness for cognitive and functional improvement in older adults

AIMS AND OBJECTIVES

The objectives of this study were to assess the benefits of a caregiver training programme on the cognitive and functional status of older adults, and to compare the effects of this programme according to type of caregiver (professional vs. family caregiver).

BACKGROUND

Due to demographic changes that have resulted in an aging population, the role of caregiver of an older adult has become very important in recent years.

DESIGN AND METHODS

The sample was composed of 160 older adults: (a) 100 received care from caregivers who had taken the three-month training programme (treatment group), of which 60 were professional caregivers and 40 were family caregivers, and (b) 60 received care from caregivers who had not taken the programme (control group). In order to evaluate programme effects on cognitive and functional status, we used both direct measures answered by the older adults (MMSE, CAPE and EuroQol) and caregiver reports (Barthel and RMPBC). We used a quasi-experimental, pre-post design. We followed SQUIRE 2.0 guidelines for reporting.

RESULTS

The results showed that older adults who were cared for by caregivers that had participated in the training programme showed gains in quality of life and cognitive ability and maintenance of functional ability. Within the treatment group, although everyone significantly improved their scores, the older adults cared for by family caregivers improved in more of the cognitive sub-items than did their peers in the professional caregiver group.

CONCLUSIONS

The data obtained show that a caregiver training programme based on cognitive stimulation produces cognitive, functional and health-related quality-of-life benefits in older adults. Furthermore, the caregivers reported increased satisfaction with their work.

RELEVANCE TO CLINICAL PRACTICE

The improvements obtained in the older adults and in caregivers show the relevance of this type of intervention when working in the clinical field of caregiving.

The HOMESIDE Music Intervention: A Training Protocol for Family Carers of People Living with Dementia

Background: The number of people living with dementia (PwD) worldwide is expected to double every 20 years. Many continue living at home, receiving support from family caregivers who may experience significant stress, simultaneously to that of the PwD. Meaningful and effective home-based interventions to support PwD and their caregivers are needed. The development of a theory- and practice-driven online home-based music intervention (MI) is delivered by credentialed music therapists, nested within the HOMESIDE RCT trial. Methods: Dyads including the PwD and their family carer are randomised to MI, reading (RI) or standard care (SC). MI aims to support health wellbeing and quality of life by training caregivers to intentionally use music (singing, instrument playing, movement/dancing, and music listening) with their family member (PwD) in daily routines. MI is underpinned by cognitive, relational, social, and psychological theories of mechanisms of change. Results: Preliminary sub-cohort results analyses show MI can be delivered and is accepted well by participants and music-therapist interventionists across five countries. Conclusions: The specialist skills of a music therapist through MI enable carers to access music when music therapists are not present, to meet carer and PwD needs. Music therapists embrace this changing professional role, observing therapeutic change for members of the dyads.

Depressive Symptoms and Caregiving Intensity Before and After Onset of Dementia in Partners: A Retrospective, Observational Study

BACKGROUND

Caring for a partner with dementia poses significant emotional burden and high care demands, but changes in impacts before and after dementia onset is unclear.

OBJECTIVE

Examine changes in depressive symptoms and hours of care provided by caregivers through the course of their partners' cognitive decline.

METHODS

Retrospective, observational study using household survey data from 2000-2016 Health and Retirement Study and count models to evaluate older individuals' (ages ≥51 y) depressive symptoms (measured using the shortened Center for Epidemiologic Studies Depression Scale) and weekly caregiving in the 10 years before and after their partners' dementia onset (identified using Telephone Interview Cognitive Status screening). Relationships were examined overall and by sex and race.

RESULTS

We identified 8298 observations for 1836 older caregivers whose partners developed dementia. From before to after partners' dementia onset, caregivers' mean (SD) depressive symptoms increased from 1.4 (1.9) to 1.9 (2.1) ( P <0.001) and weekly caregiving increased from 4.4 (19.7) to 20.8 (44.1) ( P <0.001) hours. Depressive symptoms and caregiving hours were higher for women compared with men. Depressive symptoms were higher for Blacks compared with Whites, while caregiving hours were higher for Whites. The expected count of caregivers' depressive symptoms and caregiving hours increased by 3% ( P <0.001) and 9% ( P =0.001) before partners' dementia onset and decreased by 2% ( P <0.001) and 1% ( P =0.63) following partners' dementia onset. No differences observed by sex or race.

DISCUSSION

Depressive symptoms and instrumental burdens for caregivers increase substantially before the onset of dementia in partners. Early referral to specialty services is critical.

Prevalence of Alzheimer's disease and related dementias among veterans experiencing housing insecurity

INTRODUCTION

Housing insecure veterans are aging, but the prevalence of Alzheimer's disease and related dementias (AD/ADRD) in the population is unknown.

METHODS

We calculated the prevalence of AD/ADRD diagnoses in 2018 among veterans that experienced homelessness, were at-risk for homelessness, or were stably housed. We determined acute care (emergency department, hospitalizations, psychiatric hospitalizations), and any long-term care (nursing home, and community-based) use by housing status among veterans with an AD/ADRD diagnosis.

RESULTS

The overall prevalence of AD/ADRD diagnoses for homeless, at-risk, and stably housed veterans was 3.66%, 13.48%, and 3.04%, respectively. Housing insecure veterans with AD/ADRD used more acute care, and were more likely to have a nursing home admission compared to stably housed veterans. At risk, but not homeless veterans, were more likely to use US Department of Veterans Affairs-paid home and community-based care than stably housed veterans.

DISCUSSION

The prevalence of AD/ADRD diagnoses is greater among housing insecure veterans than stably housed veterans.

Caring Together: Trajectories of Paid and Family Caregiving Support to Those Living in the Community With Dementia

OBJECTIVES

Paid caregivers (e.g., home health aides) often work with family caregivers to support persons living with dementia at home. We identify (a) unique trajectories of paid and family caregiving support among persons living with dementia with high care needs and (b) factors associated with these trajectories.

METHODS

We used group-based multiple trajectory modeling to identify distinct trajectories of paid and family caregiving hours among National Health and Aging Trends Study respondents with dementia who died or moved to a nursing home (n = 334, mean follow-up 5.5 years). We examined differences between trajectory groups and identified factors associated with group membership using generalized estimating equation modeling.

RESULTS

A 3-group model best fit our data: (a) "low/stable care" (61.3% of respondents) with stable, low/no paid care and moderate family care, (b) "increasing paid care" with increasing, moderate paid and family care, and (c) "high family care" with increasing, high family care and stable, low paid care. While both the "increasing paid care" and "high family care" groups were more functionally impaired than the "low/stable care" group, the "high family care" group was also more likely to be non-White and experience multiple medical comorbidities, depression, and social isolation.

DISCUSSION

Study findings highlight the importance of considering unique arrangements in dementia care. Receipt of paid care was not only determined by patient care needs. Creating equitable access to paid care may be a particularly important way to support both persons living with dementia and their family caregivers as care needs grow.

2022 Alzheimer's disease facts and figures

This article describes the public health impact of Alzheimer's disease (AD), including incidence and prevalence, mortality and morbidity, use and costs of care, and the overall impact on family caregivers, the dementia workforce and society. The Special Report discusses consumers' and primary care physicians' perspectives on awareness, diagnosis and treatment of mild cognitive impairment (MCI), including MCI due to Alzheimer's disease. An estimated 6.5 million Americans age 65 and older are living with Alzheimer's dementia today. This number could grow to 13.8 million by 2060 barring the development of medical breakthroughs to prevent, slow or cure AD. Official death certificates recorded 121,499 deaths from AD in 2019, the latest year for which data are available. Alzheimer's disease was officially listed as the sixth-leading cause of death in the United States in 2019 and the seventh-leading cause of death in 2020 and 2021, when COVID-19 entered the ranks of the top ten causes of death. Alzheimer's remains the fifth-leading cause of death among Americans age 65 and older. Between 2000 and 2019, deaths from stroke, heart disease and HIV decreased, whereas reported deaths from AD increased more than 145%. More than 11 million family members and other unpaid caregivers provided an estimated 16 billion hours of care to people with Alzheimer's or other dementias in 2021. These figures reflect a decline in the number of caregivers compared with a decade earlier, as well as an increase in the amount of care provided by each remaining caregiver. Unpaid dementia caregiving was valued at $271.6 billion in 2021. Its costs, however, extend to family caregivers' increased risk for emotional distress and negative mental and physical health outcomes - costs that have been aggravated by COVID-19. Members of the dementia care workforce have also been affected by COVID-19. As essential care workers, some have opted to change jobs to protect their own health and the health of their families. However, this occurs at a time when more members of the dementia care workforce are needed. Average per-person Medicare payments for services to beneficiaries age 65 and older with AD or other dementias are almost three times as great as payments for beneficiaries without these conditions, and Medicaid payments are more than 22 times as great. Total payments in 2022 for health care, long-term care and hospice services for people age 65 and older with dementia are estimated to be $321 billion. A recent survey commissioned by the Alzheimer's Association revealed several barriers to consumers' understanding of MCI. The survey showed low awareness of MCI among Americans, a reluctance among Americans to see their doctor after noticing MCI symptoms, and persistent challenges for primary care physicians in diagnosing MCI. Survey results indicate the need to improve MCI awareness and diagnosis, especially in underserved communities, and to encourage greater participation in MCI-related clinical trials.

Supporting Veterans with dementia to remain in the community: strategies used in 12 Veterans Health Administration programs

The Veterans Health Administration (VA) provides services to growing numbers of Veterans with dementIa, individuals at heightened risk for hospitalizations and nursing home placement. Beginning in 2010, the VA funded 12 innovative pilot programs to improve dementia care and help Veterans remain at home. We conducted a retrospective qualitative analysis of program materials and interviews with physicians, nurses, social workers, and other personnel (n = 33) to understand the strategies these programs adopted. Interviews were conducted every 6 months between 2010-2013 (4-5 interviews per program) and focused on factors affecting program design and implementation, challenges, and strategies to reduce hospitalizations and nursing home placements. Programs varied considerably yet shared three overarching strategies to improve dementia care: involving and supporting family caregivers; engaging interdisciplinary teams; and improving coordination with other healthcare providers. Our results highlight the importance of adapting common dementia care strategies based on the local context and needs of individuals served.

Effects of the tailored activity program (TAP) on dementia-related symptoms, health events and caregiver wellbeing: a randomized controlled trial

Background

People living with dementia (PLWD) and caregivers are adversely impacted by lack of meaningful activity leading to worse symptoms and impaired quality-of-life. There is a critical need to develop effective and well-tolerated treatments that mitigate clinical symptoms, engage PLWD and support caregiver wellbeing. We tested whether, compared to attention control, the Tailored Activity Program (TAP) reduced clinical symptoms and health-related events, and improved caregiver wellbeing, and if TAP activities were well-tolerated.

Methods

We conducted a single-blind randomized controlled trial among 250 dyads recruited from Baltimore-Washington DC (2012–2016) with a dementia diagnosis and clinically significant agitation/aggression. Dyads were randomized to TAP (n = 124) or attention control (n = 126), and interviewed at baseline, 3 (endpoint) and 6-months (follow-up) by interviewers masked to group allocation. TAP assessed PLWD abilities/interests, instructed caregivers in using prescribed activities, and provided dementia education and stress reduction techniques. Attention controls received disease education and home safety tips. Both groups had up to 8 home visits over 3-months. The primary outcome was frequency by severity scores for agitation/aggression subscales of Neuropsychiatric Inventory-Clinician using caregiver ratings. Secondary outcomes included number of instrumental (IADL) and activities of daily living (ADL) needing assistance, caregiver wellbeing, and confidence using activities. Health-related events (PLWD death, hospitalizations, caregiver hospitalization, depression) and perceived study benefits were captured over 6 months. PLWD tolerability of prescribed activities was examined.

Results

Of 250 dyads, most caregivers were female (81.2 %, n = 203), non-spouses (54.4 %, n = 136), white (59.2 %, n = 145) or African American (36.7 %, n = 90) with mean age = 65.4 (SD = 12.6). PLWD were mostly female (63.2 %, n = 158) with mean age = 81.4 (SD = 7.9), and mean MMSE = 14.3 (SD = 7.8). At 3-months, compared to controls, TAP conferred no benefit to agitation/aggression (p = 0.43, d = 0.11), but resulted in less IADL (p = 0.02, d=-0.33), and ADL (p = 0.04, d=-0.30) assistance, improved caregiver wellbeing (p = 0.01, d = 0.39), and confidence using activities (p = 0.02, d = 0.32). By 6-months, 15 PLWD in TAP had ≥ 1 health-related event versus 28 PLWD in control, demonstrating 48.8 % improvement in TAP (p = 0.03). TAP caregivers were more likely to perceive study benefits. Prescribed activities were well-tolerated.

Conclusions

Although TAP did not benefit agitation/aggression, it impacted important outcomes that matter to families warranting its use in dementia care.

Clinical trial registration

Clinicaltrials.gov # NCT01892579 at https://clinicaltrials.gov/; Date of clinical trial registration: 04/07/2013; Date first dyad enrolled: 15/11/2013.

Baby Boomers Who Provide Informal Care for People Living with Dementia in the Community

One in four Baby Boomers fills the informal caregiver role in the United States. The objectives of this study were to estimate the prevalence of Baby Boomers who are informal caregivers for people living with dementia and compare their physical and mental health status to caregivers for persons with conditions other than dementia using 2015-2018 Behavioral Risk Factor Surveillance System data (N = 10,602). We identified caregiving status (assisting a family member/friend with a long-term illness or disability in the past month, managing personal care, and not caring for a child/grandchild) and whether the care recipient's major health condition was dementia. We calculated weighted estimates and used chi-square tests and log-binomial regression for comparisons of selected characteristics. Among Baby Boomer caregivers, 15.4% were caring for someone with dementia. Dementia caregivers were more likely to be female, caring for a parent/parent-in-law, and providing care longer than caregivers for persons without dementia. After adjusting for sociodemographic and caregiving characteristics, the prevalence of fair/poor health, frequent mental distress, and chronic conditions were similar across types of caregivers. Although no differences in caregiver's physical and mental health by care recipient's dementia status were found, we should underscore the importance of maintaining Baby Boomer caregivers' health and well-being.

Incidence of Homelessness among Veterans Newly Diagnosed with Alzheimer's Disease and Related Dementias

BACKGROUND

To determine the incidence of homelessness among Veterans diagnosed with Alzheimer's disease and related dementias (ADRD).

METHODS

We used Veterans Affairs (VA) administrative records to identify Veterans with a new ADRD diagnosis anytime between 2010-2019. Among these Veterans, we calculated the incidence of homelessness, and estimated the association between demographics, comorbidities and hazard of homelessness.

RESULTS

The incidence rate of homelessness was highest for Veterans diagnosed with ADRD between 18-49 years of age (14.9 per 1,000 person-years; 95%CI: 13.6, 16.3) and lowest for Veterans diagnosed with ADRD at 90+ years (0.3 per 1,000 person-years; 95%CI: 0.2, 0.4). The adjusted hazard ratio of homelessness was higher for unmarried Veterans, and those with alcohol use disorder, substance use disorder, liver disease, depression, hypertension, lung disease, post-traumatic stress disorder and psychoses.

CONCLUSIONS

Younger age and being unmarried at the time of ADRD diagnosis are associated with a greater risk of experiencing homelessness.

A longitudinal evaluation of family caregivers' willingness to pay for an in-home nonpharmacologic intervention for people living with dementia: results from a randomized trial

OBJECTIVE

To determine the willingness-to-pay (WTP) of family caregivers to learn care strategies for persons living with dementia (PLwD).

DESIGN

Randomized clinical trial.

SETTING

Community-dwelling PLwD and their caregivers (dyads) in Maryland and Washington, DC.

PARTICIPANTS

250 dyads.

INTERVENTION

Tailored Activity Program (TAP) compared to attention control. TAP provides activities tailored to the PLwD and instructs caregivers in their use.

MEASUREMENT

At baseline, 3 and 6 months, caregivers were asked their WTP per session for an 8-session 3-month in-home nonpharmacologic intervention to address behavioral symptoms and functional dependence.

RESULTS

At baseline, 3 and 6 months, caregivers assigned to TAP were willing to pay $26.10/session (95%CI:$20.42, $33.00), $28.70 (95%CI:$19.73, $39.30), and $22.79 (95%CI: $16.64, $30.09), respectively; attention control caregivers were willing to pay $37.90/session (95%CI: $27.10, $52.02), $30.92 (95%CI: $23.44, $40.94), $27.44 (95%CI: $20.82, $35.34), respectively. The difference in baseline to 3 and 6 months change in WTP between TAP and the attention control was $9.58 (95%CI: -$5.00, $25.47) and $7.15 (95%CI: -$5.72, $21.81). The difference between TAP and attention control in change in the proportion of caregivers willing to pay something from baseline to 3 and 6 months was -12% (95%CI: -28%, -5%) and -7% (95%CI:-25%, -11%), respectively. The difference in change in WTP, among caregivers willing to pay something, between TAP and attention control from baseline to 3 and 6 months was $17.93 (95%CI: $0.22, $38.30) and $11.81 (95%CI: -$2.57, $28.17).

CONCLUSIONS

Family caregivers are willing to pay more for an intervention immediately following participation in a program similar to which they were asked to value.

2021 Alzheimer's disease facts and figures

This article describes the public health impact of Alzheimer's disease (AD), including incidence and prevalence, mortality and morbidity, use and costs of care, and the overall impact on caregivers and society. The Special Report discusses the challenges of providing equitable health care for people with dementia in the United States. An estimated 6.2 million Americans age 65 and older are living with Alzheimer's dementia today. This number could grow to 13.8 million by 2060 barring the development of medical breakthroughs to prevent, slow or cure AD. Official death certificates recorded 121,499 deaths from AD in 2019, the latest year for which data are available, making Alzheimer's the sixth-leading cause of death in the United States and the fifth-leading cause of death among Americans age 65 and older. Between 2000 and 2019, deaths from stroke, heart disease and HIV decreased, whereas reported deaths from AD increased more than 145%. This trajectory of deaths from AD was likely exacerbated in 2020 by the COVID-19 pandemic. More than 11 million family members and other unpaid caregivers provided an estimated 15.3 billion hours of care to people with Alzheimer's or other dementias in 2020. These figures reflect a decline in the number of caregivers compared with a decade earlier, as well as an increase in the amount of care provided by each remaining caregiver. Unpaid dementia caregiving was valued at $256.7 billion in 2020. Its costs, however, extend to family caregivers' increased risk for emotional distress and negative mental and physical health outcomes - costs that have been aggravated by COVID-19. Average per-person Medicare payments for services to beneficiaries age 65 and older with AD or other dementias are more than three times as great as payments for beneficiaries without these conditions, and Medicaid payments are more than 23 times as great. Total payments in 2021 for health care, long-term care and hospice services for people age 65 and older with dementia are estimated to be $355 billion. Despite years of efforts to make health care more equitable in the United States, racial and ethnic disparities remain - both in terms of health disparities, which involve differences in the burden of illness, and health care disparities, which involve differences in the ability to use health care services. Blacks, Hispanics, Asian Americans and Native Americans continue to have a higher burden of illness and lower access to health care compared with Whites. Such disparities, which have become more apparent during COVID-19, extend to dementia care. Surveys commissioned by the Alzheimer's Association recently shed new light on the role of discrimination in dementia care, the varying levels of trust between racial and ethnic groups in medical research, and the differences between groups in their levels of concern about and awareness of Alzheimer's disease. These findings emphasize the need to increase racial and ethnic diversity in both the dementia care workforce and in Alzheimer's clinical trials.

Socioeconomic Costs of Dementia Based on Utilization of Health Care and Long-Term-Care Services: A Retrospective Cohort Study

This study examined the socioeconomic costs of dementia based on the utilization of healthcare and long-term care services in South Korea. Using 2016 data from two national insurance databases and a survey study, persons with dementia were categorized into six groups based on healthcare and long-term care services used: long-term care insurance users with home- and community-based services (n = 93,346), nursing home services (n = 69,895), and combined services (n = 16,068); and long-term care insurance non-users cared for by family at home (n = 192,713), living alone (n = 19,526), and admitted to long-term-care hospitals (n = 65,976). Their direct and indirect costs were estimated. The total socioeconomic cost of dementia was an estimated US$10.9 billion for 457,524 participants in 2016 (US$23,877 per person). Among the six groups, the annual per-person socioeconomic cost of dementia was lowest for long-term care insurance users who received home- and community-based services (US$21,391). It was highest for long-term care insurance non-users admitted to long-term care hospitals (US$26,978). Effective strategies are necessary to promote long-term care insurance with home- and community-based services to enable persons with dementia to remain in their communities as long as possible while receiving cost-efficient, quality care.

Assessment of Rural-Urban Differences in Health Care Use and Survival Among Medicare Beneficiaries With Alzheimer Disease and Related Dementia

IMPORTANCE

There is poor understanding as to how survival and health care use varies among older adults living with Alzheimer disease and related dementia (ADRD) in rural vs urban areas of the United States.

OBJECTIVE

To describe survival and trajectories of hospital, hospice, nursing home, and home health care use among rural and urban Medicare beneficiaries with ADRD in the 6 years after diagnosis.

DESIGN, SETTING, AND PARTICIPANTS

This retrospective cohort study linked Medicare claims data from January 1, 2009, to December 31, 2016, with nursing home and home health assessment data from all US counties. A total of 555 333 Medicare fee-for-service beneficiaries newly diagnosed with ADRD in 2010 were included. A total of 424 561 individuals (76.5%) resided in metropolitan counties, 75 001 (13.5%) in micropolitan counties, and 55 771 (10.0%) in rural counties.

EXPOSURES

Rurality of beneficiary's county of residence.

MAIN OUTCOMES AND MEASURES

Number of days survived after initial ADRD diagnosis; percent of survived days per month spent in the hospital, hospice nursing home, community with home health care services, and community without home health care services.

RESULTS

A total of 555 333 Medicare beneficiaries (mean [SD] age, 82.0 [7.5] years; 345 294 women [62.2%]; 480 286 White [86.5%]) were evaluated. Compared with metropolitan county residents, rural beneficiaries were younger (mean [SD] age, 81.6 [7.6] vs 82.1 [7.5] years), were less likely to be women (34 100 [61.1%] vs 264 688 [62.3%]), were more likely to be White (50 886 [91.2%] vs 361 205 [85.1%]) and Medicaid-eligible (14 264 [25.6%] vs 71 656 [16.9%]), and had fewer preexisting chronic conditions (mean [SD], 6.9 [2.8] vs 7.4 [2.9]). Medicare beneficiaries residing in metropolitan counties survived a mean (SD) of 1183.5 (826.0) days after diagnosis. Adjusting for individual demographic and clinical characteristics, rural and micropolitan county residents survived approximately 1.5 months less than metropolitan residents. The adjusted share of survived days spent in nursing homes was 5.7 (95% CI, 4.0-7.5) percentage points higher for rural vs metropolitan residents. The adjusted share of days in hospitals was 0.7 (95% CI, -0.9 to -0.4) percentage points lower, and the share of days in community without home health care was 4.6 (95% CI, -6.1 to -3.1) percentage points lower for rural vs metropolitan county residents. There were no statistically significant differences in home health or hospice use. Similar patterns were found for micropolitan vs metropolitan residents as for rural vs metropolitan residents, although the magnitude of the differences were smaller. Differences in time spent in community and nursing homes between rural vs metropolitan beneficiaries became more pronounced with further time from diagnosis.

CONCLUSIONS AND RELEVANCE

Study results suggest that, after diagnosis, rural Medicare beneficiaries with ADRD spend more time in nursing homes and less time in the community, receive less home health care, and have shorter survival than their urban counterparts.