Estimating the relationship between disease progression and cost of care in dementia

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.

International depiction of the cost of functional independence limitations among older adults living in the community: a systematic review and cost-of-impairment study

BACKGROUND

Functional independence limitations restrict older adult self-sufficiency and can reduce quality of life. This systematic review and cost of impairment study examined the costs of functional independence limitations among community dwelling older adults to society, the health care system, and the person.

METHODS

Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines this systematic review included community dwelling older adults aged 60 years and older with functional independence limitations. Databases (Cochrane Database of Systematic Reviews, EconLit, NHS EED, Embase, CINAHL, AgeLine, and MEDLINE) were searched between 1990 and June 2020. Two reviewers extracted information on study characteristics and cost outcomes including mean annual costs of functional independence limitations per person for each cost perspective (2020 US prices). Quality was assessed using the Consolidated Health Economic Evaluation Reporting Standards (CHEERS) checklist.

RESULTS

85 studies were included. The mean annual total costs per person (2020 US prices) were: $27,380.74 (95% CI: [$4075.53, $50,685.96]) for societal, $24,195.52 (95% CI: [$9679.77, $38,711.27]) for health care system, and $7455.49 (95% CI: [$2271.45, $12,639.53]) for personal. Individuals with cognitive markers of functional independence limitations accounts for the largest mean costs per person across all perspectives. Variations across studies included: cost perspective, measures quantifying functional independence limitations, cost items reported, and time horizon.

CONCLUSIONS

This study sheds light on the importance of targeting cognitive markers of functional independence limitations as they accounted for the greatest costs across all economic perspectives.

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.

Distress in neurocognitive disorders due to Alzheimer's disease and stroke

Patients with neurocognitive disorders experience subjectively the concept of quality of life; this is the reason why researchers avoid approaching this concept and prefer to focus attention on the emotional profile of the caregivers. Many studies highlight the efforts both emotional and financial made by caregivers in case of patients diagnosed with neurocognitive disorders. The present study shows the differences between the patients diagnosed with neurocognitive disorder due to Alzheimer's disease and patients diagnosed with stroke, as well as the Romanian norms for the short form of Geriatric Depression Scale. The study group consisted of the clinical population (N=45), selected according to the inclusion/exclusion criteria, following the principles of Helsinki Declaration for Ethical Medical Research. The study was conducted at the Neuropsychiatry section of the Municipal Clinical Hospital, Dr Gavril Curteanu, Oradea, Romania. The results showed significant differences between the two types of patients in terms of quality of life, t(43)=-7.99, P=0.001, affective distress, t(43)=5.10, P=0.001 and perceived stress, t(43)=3.81, P=0.001. The internal consistency of the scale is high, the coefficient KR-20 being 0.86.

Healthcare utilization and monetary costs associated with agitation in UK care home residents with advanced dementia: a prospective cohort study

OBJECTIVE

Nearly half of care home residents with advanced dementia have clinically significant agitation. Little is known about costs associated with these symptoms toward the end of life. We calculated monetary costs associated with agitation from UK National Health Service, personal social services, and societal perspectives.

DESIGN

Prospective cohort study.

SETTING

Thirteen nursing homes in London and the southeast of England.

PARTICIPANTS

Seventy-nine people with advanced dementia (Functional Assessment Staging Tool grade 6e and above) residing in nursing homes, and thirty-five of their informal carers.

MEASUREMENTS

Data collected at study entry and monthly for up to 9 months, extrapolated for expression per annum. Agitation was assessed using the Cohen-Mansfield Agitation Inventory (CMAI). Health and social care costs of residing in care homes, and costs of contacts with health and social care services were calculated from national unit costs; for a societal perspective, costs of providing informal care were estimated using the resource utilization in dementia (RUD)-Lite scale.

RESULTS

After adjustment, health and social care costs, and costs of providing informal care varied significantly by level of agitation as death approached, from £23,000 over a 1-year period with no agitation symptoms (CMAI agitation score 0-10) to £45,000 at the most severe level (CMAI agitation score >100). On average, agitation accounted for 30% of health and social care costs. Informal care costs were substantial, constituting 29% of total costs.

CONCLUSIONS

With the increasing prevalence of dementia, costs of care will impact on healthcare and social services systems, as well as informal carers. Agitation is a key driver of these costs in people with advanced dementia presenting complex challenges for symptom management, service planners, and providers.

[Alzheimer's disease and the quality of life of the informal caregiver]

BACKGROUND

Along with an ageing population, a higher incidence of chronic diseases leads to increasingly complex health profiles. The relationship between survival, dependence, and social and demographic trends affecting caregiving, has led to an increase in the negative consequences associated with care provision. In this context, an assessment needs to be made on the impact that caregiving has on the well-being of the caregivers. The main aim of this article is to study the factors that determine the Quality of Life (QoL) of those who provide informal care to people suffering from Alzheimer's disease (AD).

METHODS

A total of 175 caregivers of people with AD were recruited through the Galician Association for Relatives with Alzheimer. These caregivers completed a questionnaire (EQ-5D) that gathered sociodemographic and health variables, QoL, and care characteristics. Multiple regression models were calculated to explain the QoL of the caregivers.

RESULTS

Of the five dimensions that the EQ-5D used to describe health, anxiety/depression was the one that concerned the largest percentage of caregivers who declared the highest levels of severity. The key variables for explaining QoL are those related to caregiver health status, periods of rest during caregiving, and the presence of a second caregiver.

CONCLUSIONS

Maintaining a minimal QoL among the caregivers not only has repercussions on the caregivers themselves, but also has an impact on those receiving care and the entire health system, which would have to find replacements for those informal caregivers.

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.

Potential cost savings to be made by slowing cognitive decline in mild Alzheimer's disease dementia using a model derived from the UK GERAS observational study

Background

Given the high costs associated with the care of those with Alzheimer’s disease (AD) dementia, we examined the likely impact of a reduction in the rate of cognitive decline upon cost outcomes associated with this disease.

Methods

Using the group of patients with mild AD dementia from the GERAS study, generalised linear modelling (GLM) was used to explore the relationship between change in cognition as measured using the Mini-Mental State Examination (MMSE) and UK overall costs (health care and social care costs, and total societal costs) associated with AD dementia.

Results

A total of 200 patients with mild AD dementia were identified. Least squares mean (LSM) ± standard error (SE) reduction in MMSE score was 3.6 ± 0.4 points over 18 months. Using GLM it was possible to calculate that this worsening in cognition was associated with an 8.7% increase in total societal costs, equating to an increase of approximately £2200 per patient over an 18-month period. If the rate of decline in cognition was reduced by 30% or 50%, the associated savings in total societal costs over 18 months would be approximately £670 and £1100, respectively, of which only £110 and £180, respectively, could be attributed to a saving of health care costs.

Conclusion

This study demonstrates that there are potential savings to be made in the care of patients with AD dementia through reducing the rate of cognitive decline. A reduction in wider societal costs is likely to be the main contributor to these potential savings, and need to be further evaluated when intervention costs and cost offsets can be measured.

The cost of care homes for people with dementia in England: a modelling approach

OBJECTIVES

To examine the cost of care for people with dementia in institutional care settings, to understand the major cost drivers and to highlight opportunities for service development.

METHODS

Data on 277 residents with dementia in 16 UK residential or nursing homes were collected. We estimated care and support costs and fitted models to the data. Sensitivity analyses were also conducted.

RESULTS

Care home residents cost £792 weekly: 95% of the costs accounted for by direct fees. Hospital contacts contributed the largest proportion of the additional costs. Having an established diagnosis of dementia (b = 0.070; p < 0.05) was associated with higher costs. No association was found between cost and needs (b = -0.002; p = 0.818).

CONCLUSION

The absence of an association between cost and needs emphasizes the importance of a more needs-based costing system which could result in clinical and economic advantages. Copyright © 2016 John Wiley & Sons, Ltd.

Disease Progression in Mild Dementia due to Alzheimer Disease in an 18-Month Observational Study (GERAS): The Impact on Costs and Caregiver Outcomes

Background/Aims

We assessed whether cognitive and functional decline in community-dwelling patients with mild Alzheimer disease (AD) dementia were associated with increased societal costs and caregiver burden and time outcomes.

Methods

Cognitive decline was defined as a ≥3-point reduction in the Mini-Mental State Examination and functional decline as a decrease in the ability to perform one or more basic items of the Alzheimer's Disease Cooperative Study Activities of Daily Living Inventory (ADCS-ADL) or ≥20% of instrumental ADL items. Total societal costs were estimated from resource use and caregiver hours using 2010 costs. Caregiver burden was assessed using the Zarit Burden Interview (ZBI); caregiver supervision and total hours were collected.

Results

Of 566 patients with mild AD enrolled in the GERAS study, 494 were suitable for the current analysis. Mean monthly total societal costs were greater for patients showing functional (+61%) or cognitive decline (+27%) compared with those without decline. In relation to a typical mean monthly cost of approximately EUR 1,400 at baseline, this translated into increases over 18 months to EUR 2,254 and 1,778 for patients with functional and cognitive decline, respectively. The number of patients requiring supervision doubled among patients showing functional or cognitive decline compared with those not showing decline, while caregiver total time increased by 70 and 33%, respectively and ZBI total score by 5.3 and 3.4 points, respectively.

Conclusion

Cognitive and, more notably, functional decline were associated with increases in costs and caregiver outcomes in patients with mild AD dementia.

The effectiveness of reality orientation in the treatment of Alzheimer's disease

Alzheimer's disease (AD) is the most frequent cause of dementia. This work aims to assess the effectiveness of reality orientation (RO), a traditional, extensively documented cognitive enhancement technique, when combined with acetylcholinesterase inhibitors in the treatment of AD. Fourteen patients with AD having mild to moderate dementia receiving standard treatment with donepezil were randomly assigned to control and treatment groups. Patients in the treatment group were submitted to weekly RO sessions for 6 months. Cognitive outcomes were assessed based on scores in the Consortium to Establish a Registry for Alzheimer's Disease (CERAD) neuropsychological battery and the Clock Drawing Test (CDT). Mean CERAD neuropsychological battery, Mini-Mental State Examination (MMSE), and CDT scores improved in the treatment group and worsened in the control group. A number of CERAD neuropsychological battery and MMSE scores were statistically significant. Our findings suggest that RO is a valuable long-term complementary intervention for dementia in AD.

Longitudinal costs of caring for people with Alzheimer's disease

BACKGROUND

There has been an increasing interest in the relationship between severity of disease and costs in the care of people with dementia. Much of the current evidence is based on cross-sectional data, suggesting the need to examine trends over time for this important and growing cohort of the population.

METHODS

This paper estimates resource use and costs of care based on longitudinal data for 72 people with dementia in Ireland. Data were collected from the Enhancing Care in Alzheimer's Disease (ECAD) study at two time points: baseline and follow-up, two years later. Patients' dependence on others was measured using the Dependence Scale (DS), while patient function was measured using the Disability Assessment for Dementia (DAD) scale. Univariate and multivariate analysis were used to explore the effects of a range of variables on formal and informal care costs.

RESULTS

Total costs of formal and informal care over six months rose from €9,266 (Standard Deviation (SD): 12,947) per patient at baseline to €21,266 (SD: 26,883) at follow-up, two years later. This constituted a statistically significant (p = 0.0014) increase in costs over time, driven primarily by an increase in estimated informal care costs. In the multivariate analysis, a one-point increase in the DS score, that is a one-unit increase in patient's dependence on others, was associated with a 19% increase in total costs (p = 0.0610).

CONCLUSIONS

Higher levels of dependence in people with Alzheimer's disease are significantly associated with increased costs of informal care as the disease progresses. Formal care services did not respond to increased dependence in people with dementia, leaving it to families to fill the caring gap, mainly through increased supervision with the progress of disease.

Service utilisation and family support of people with dementia: a cohort study in England

OBJECTIVES

This study aimed to compare costs of caring for people with dementia in domiciliary and residential settings, central England.

METHODS

A cohort of people with dementia was recruited during a hospital stay 2008-2010. Data were collected by interview at baseline, and 6- and 12-month follow-up, covering living situation (own home with or without co-resident carer, care home); cognition, health status and functioning of person with dementia; carer stress; utilisation of health and social services; and informal (unpaid) caring input. Costs of formal services and informal caring (replacement cost method) were calculated. Costs of residential and domiciliary care packages were compared.

RESULTS

Data for 109 people with dementia were collected at baseline; 95 (87.2%) entered hospital from their own homes. By 12 months, 40 (36.7%) had died and 85% of the survivors were living in care homes. Over one-half of people with dementia reported social care packages at baseline; those living alone had larger packages than those living with others. Median caring time for co-resident carers was 400 min/day and 10 h/week for non co-resident carers. Residential care was more costly than domiciliary social care for most people. When the value of informal caring was included, the total cost of domiciliary care was higher than residential care, but not significantly so. Carer stress reduced significantly after the person with dementia entered a care home.

CONCLUSIONS

Caring for people with dementia at home may be more expensive, and more stressful for carers, than care in residential settings.

Transitions between care settings in dementia: are they relevant in economic terms?

OBJECTIVES

This study was performed to assess the economic effect of interventions affecting transitions between dementia care settings in Germany.

METHODS

A Markov-model that models the course of dementia with respect to typical care setting transitions was derived. Model data and parameters were retrieved by literature reviews. A deterministic and probabilistic sensitivity analysis was conducted to account for parameter uncertainty.

RESULTS

In the base case, the expected present value of remaining lifetime costs is €25,326 for each cohort member. As a function of effectiveness, pharmaceutical interventions may reduce the costs by 2% to 13% and psychosocial interventions come with savings of 1% to 10%. A structural intervention-promoting group living as a substitute for nursing home care increases costs by 2% to 8%. Sensitivity analyses indicate high variance and variability of results, as well as valuation of informal care being a crucial parameter.

CONCLUSIONS

There are economic benefits of delayed transitions to institutional settings, especially from the viewpoint of statutory care insurances, but these do unlikely exceed intervention costs. Thus, further intervention effects should be considered. Ultimately, concentrating research on preventive and protective factors of dementia could lead to an efficient intervention from every perspective.

Dependence in Alzheimer's disease and service use costs, quality of life, and caregiver burden: the DADE study

BACKGROUND

Most models determining how patient and caregiver characteristics and costs change with Alzheimer's disease (AD) progression focus on one aspect, for example, cognition. AD is inadequately defined by a single domain; tracking progression by focusing on a single aspect may mean other important aspects are insufficiently addressed. Dependence has been proposed as a better marker for following disease progression.

METHODS

This was a cross-sectional observational study (18 UK sites). Two hundred forty-nine community or institutionalized patients, with possible/probable AD, Mini-Mental State Examination (3-26), and a knowledgeable informant participated.

RESULTS

Significant associations noted between dependence (Dependence Scale [DS]) and clinical measures of severity (cognition, function, and behavior). Bivariate and multivariate models demonstrated significant associations between DS and service use cost, patient quality of life, and caregiver perceived burden.

CONCLUSION

The construct of dependence may help to translate the combined impact of changes in cognition, function, and behavior into a more readily interpretable form. The DS is useful for assessing patients with AD in clinical trials/research.

A 12-month follow-up study of people with dementia referred to general hospital liaison psychiatry services

BACKGROUND

new services for patients with dementia in general hospitals are being widely developed. Little is known of outcomes after hospital for such patients.

OBJECTIVE

to establish outcomes for patients with dementia referred to general hospital psychiatric services.

DESIGN

prospective cohort study.

SETTING

two UK general hospitals.

SUBJECTS

referrals with dementia to liaison psychiatric services.

METHOD

eligible referrals (n = 112), and their carers, were assessed during admission, and at 6 and 12 months, using battery of health measurements.

RESULTS

mortality at 6 months was 31% and at 12 months 40%. At baseline, 13% lived in a care home, rising to 84% by 6 months. Quality of life scores remained stable over 12 months, while carer stress fell significantly. Baseline clinical and demographic variables did not predict quality of life or carer stress at 6 and 12 months.

CONCLUSIONS

dementia liaison services in general hospitals currently focus on poor outcome cases.

The size, burden and cost of disorders of the brain in the UK

AIM

The aim of this paper is to increase awareness of the prevalence and cost of psychiatric and neurological disorders (brain disorders) in the UK.

METHOD

UK data for 18 brain disorders were extracted from a systematic review of European epidemiological data and prevalence rates and the costs of each disorder were summarized (2010 values).

RESULTS

There were approximately 45 million cases of brain disorders in the UK, with a cost of €134 billion per annum. The most prevalent were headache, anxiety disorders, sleep disorders, mood disorders and somatoform disorders. However, the five most costly disorders (€ million) were: dementia: €22,164; psychotic disorders: €16,717; mood disorders: €19,238; addiction: €11,719; anxiety disorders: €11,687. Apart from psychosis, these five disorders ranked amongst those with the lowest direct medical expenditure per subject (<€3000). The approximate breakdown of costs was: 50% indirect costs, 25% direct non-medical and 25% direct healthcare costs.

DISCUSSION

The prevalence and cost of UK brain disorders is likely to increase given the ageing population. Translational neurosciences research has the potential to develop more effective treatments but is underfunded. Addressing the clinical and economic challenges posed by brain disorders requires a coordinated effort at an EU and national level to transform the current scientific, healthcare and educational agenda.

Determinants of care costs of patients with dementia or cognitive impairment

INTRODUCTION

Dementia causes a high burden on patients, caregivers, and societies. Decision analytic models to support allocation of resources are often developed making use of cost-of-illness (COI) studies. However, current COI study estimates are highly variable due to care setting and methodological issues. We aim to explore variables explaining the variation of (formal and informal) health care costs of cognitive disorders, using a broad spectrum of variables, including patient, caregiver, and social context variables.

METHODS

A bottom-up COI study design was used in which a societal viewpoint and a validated method to measure and value informal care was applied. Data were analyzed using univariate, multivariate, and forward regression analyses.

RESULTS

The average 1-year health care sector costs were &OV0556;26,140 ($34,505 or £17,775) and &OV0556;11,931 ($15,749 or £8113) for patient and family. The analyses indicated that cognitive functioning, caregiver burden, patient sex, and instrumental activities of daily living were significantly associated with care costs independently.

CONCLUSIONS

Cognitive functioning and instrumental activities of daily living are important variables to include in health care decision models. We recommend also including caregiver burden and patient sex in decision models for health policy decision makers to fully reflect the heterogeneity of the disease progression of cognitive disorders.

EVOLUTION OF A COST-UTILITY MODEL OF DONEPEZIL FOR ALZHEIMER'S DISEASE

Objectives: The aim of this study was to describe the evolution of a cost-utility model used to inform the UK National Institute for Health and Clinical Excellence's (NICE) most recent decisions on the cost-utility of drug treatments for Alzheimer's disease (AD), and to explore the impact of structural assumptions on the cost-utility results.

Methods: Changes informed by noted limitations of the decision model used in NICE's previous decisions (in 2006) were made cumulatively to the original decision model for donepezil compared with best supportive care (for patients with mild to moderate AD). Deterministic and probabilistic analyses were undertaken for each cumulative change of the model. The expected value of perfect information (EVPI) of parameter estimates and structural assumptions was also calculated.

Results: Cumulative changes to the decision model highlighted how the results of the original model (incremental cost-effectiveness ratio of £81,000 per quality-adjusted life-year gained) related to those of the new model (where donepezil was estimated to be cost-saving), mainly due to uncertainty in the incremental cost of donepezil treatment over best supportive care (ranging from -£600 to £3,000 per patient). The partial EVPI analysis reflected this finding where further information on treatment discontinuations and cost parameter estimates were shown to be valuable in terms of reducing decision uncertainty.

Conclusions: Assessing the evolution of the cost-utility model helped to identify and explore structural differences between cohort-based models and is likely to be useful for decision models in other disease areas. This approach makes the structural uncertainty explicit, forcing decision makers to address structural uncertainty in addition to parameter uncertainty.

The effects of dependence and function on costs of care for Alzheimer's disease and mild cognitive impairment in Ireland

OBJECTIVE

To explore the incremental effects of patient dependence and function on costs of care for patients with Alzheimer's disease (AD) and amnestic mild cognitive impairment (MCI) in Ireland.

METHODS

Cost analysis based on reported resource use for a cross-section of 100 community-based people with AD and MCI. Formal care included general practice visits, hospitalizations, outpatient clinic consultations, accident and emergency visits, respite care, meals on wheels services and other health and social care professional consultations. Informal care included time input provided by caregivers. Resource unit costs were applied to value formal care and the opportunity cost method was used to value informal care. Patient dependence on others was measured using the Dependence Scale and patient functional capacity using the Disability Assessment for Dementia scale. Multivariate regression analysis was used to model the cost of care.

RESULTS

Both dependence and function were independently and significantly associated with total formal and informal care cost: a one point increase in dependence was associated with a €796 increase in total cost and a one point improvement in function with a €417 reduction in total cost over 6 months. Patient function was significantly associated with formal care costs, whereas patient function and dependence were both significantly associated with informal care costs.

CONCLUSION

The costs of care for patients with AD and MCI in Ireland are substantial. Interventions that reduce patient dependence on others and functional decline may be associated with important economic benefits.

Evolution of the evidence on the effectiveness and cost-effectiveness of acetylcholinesterase inhibitors and memantine for Alzheimer's disease: systematic review and economic model

INTRODUCTION

in 2007 the National Institute of Health and Clinical Excellence (NICE) restricted the use of acetylcholinesterase inhibitors and memantine.

METHODS

we conducted a health technology assessment (HTA) of the effectiveness and cost-effectiveness of donepezil, galantamine, rivastigmine and memantine for the treatment of AD to re-consider and up-date the evidence base used to inform the 2007 NICE decision. The systematic review of effectiveness targeted randomised controlled trials. A comprehensive search, including MEDLINE, Embase and the Cochrane Library, was conducted from January 2004 to March 2010. All key review steps were done by two reviewers. Random effects meta-analysis was conducted. The cost-effectiveness was assessed using a cohort-based model with three health states: pre-institutionalised, institutionalised and dead. The perspective was NHS and Personal Social Services and the cost year 2009.

RESULTS

confidence about the size and statistical significance of the estimates of effect of galantamine, rivastigmine and memantine improved on function and global impact in particular. Cost-effectiveness also changed. For donepezil, galantamine and rivastigmine, the incremental cost per quality-adjusted life year (QALY) in 2004 was above £50,000; in 2010 the same drugs 'dominated' best supportive care (improved clinical outcome at reduced cost). This was primarily because of changes in the modelled costs of introducing the drugs. For memantine, the cost-effectiveness also improved from a range of £37-53,000 per QALY gained to a base-case of £32,000.

CONCLUSION

there has been a change in the evidence base between 2004 and 2010 consistent with the change in NICE guidance. Further evolution in cost-effectiveness estimates is possible particularly if there are changes in drug prices.

Predictors of costs of care in Alzheimer's disease: a multinational sample of 1222 patients

BACKGROUND

The costs of care for patients with Alzheimer's disease are correlated with key measures of disease severity. This relationship is important in the economic evaluation of new treatments and is used to translate treatment efficacy into effects on costs through economic modeling. We aimed to identify what measures of disease severity are the most important predictors of societal costs of care and whether their relationship differs across countries.

METHODS

Interviews were conducted with 1222 patient and caregiver pairs residing in the community or in residential care settings in Spain, Sweden, United Kingdom, and the United States. Assessments included costs of care (Resource Utilization in Dementia) and key disease severity measures: cognitive function (Mini-Mental State Examination), ability to perform Activities of Daily Living (ADL-ability, Disability Assessment for Dementia [DAD]), and behavioral symptoms (Neuropsychiatry Inventory (NPI)-severity).

RESULTS

ADL-ability was the most important predictor of societal costs of care of community-dwelling patients in all countries. A one-point decrease in DAD resulted in a 1.4% increase in costs of care in Spain, United Kingdom, and the United States on average, and a 2% increase in Sweden. This translated into a 45% increase from a standard deviation decrease in DAD on average. NPI-severity and Mini-Mental State Examination were also significant predictors but with lesser effect. Although mean costs of care differed across countries, the important predictors were the same.

CONCLUSION

ADL-ability is the most important predictor of societal costs of care in community dwellings irrespective of country and should therefore be central in the economic evaluation of Alzheimer's disease therapies.

Who pays and who benefits? How different models of shared responsibilities between formal and informal carers influence projections of costs of dementia management

Background

The few studies that have attempted to estimate the future cost of caring for people with dementia in Australia are typically based on total prevalence and the cost per patient over the average duration of illness. However, costs associated with dementia care also vary according to the length of the disease, severity of symptoms and type of care provided. This study aimed to determine more accurately the future costs of dementia management by taking these factors into consideration.

Methods

The current study estimated the prevalence of dementia in Australia (2010-2040). Data from a variety of sources was recalculated to distribute this prevalence according to the location (home/institution), care requirements (informal/formal), and dementia severity. The cost of care was attributed to redistributed prevalences and used in prediction of future costs of dementia.

Results

Our computer modeling indicates that the ratio between the prevalence of people with mild/moderate/severe dementia will change over the three decades from 2010 to 2040 from 50/30/20 to 44/32/24.

Taking into account the severity of symptoms, location of care and cost of care per hour, the current study estimates that the informal cost of care in 2010 is AU$3.2 billion and formal care at AU$5.0 billion per annum. By 2040 informal care is estimated to cost AU$11.6 billion and formal care $AU16.7 billion per annum. Interventions to slow disease progression will result in relative savings of 5% (AU$1.5 billion) per annum and interventions to delay disease onset will result in relative savings of 14% (AU$4 billion) of the cost per annum.

With no intervention, the projected combined annual cost of formal and informal care for a person with dementia in 2040 will be around AU$38,000 (in 2010 dollars). An intervention to delay progression by 2 years will see this reduced to AU$35,000.

Conclusions

These findings highlight the need to account for more than total prevalence when estimating the costs of dementia care. While the absolute values of cost of care estimates are subject to the validity and reliability of currently available data, dynamic systems modeling allows for future trends to be estimated.

Cost of disorders of the brain in Europe 2010

BACKGROUND

The spectrum of disorders of the brain is large, covering hundreds of disorders that are listed in either the mental or neurological disorder chapters of the established international diagnostic classification systems. These disorders have a high prevalence as well as short- and long-term impairments and disabilities. Therefore they are an emotional, financial and social burden to the patients, their families and their social network. In a 2005 landmark study, we estimated for the first time the annual cost of 12 major groups of disorders of the brain in Europe and gave a conservative estimate of €386 billion for the year 2004. This estimate was limited in scope and conservative due to the lack of sufficiently comprehensive epidemiological and/or economic data on several important diagnostic groups. We are now in a position to substantially improve and revise the 2004 estimates. In the present report we cover 19 major groups of disorders, 7 more than previously, of an increased range of age groups and more cost items. We therefore present much improved cost estimates. Our revised estimates also now include the new EU member states, and hence a population of 514 million people.

AIMS

To estimate the number of persons with defined disorders of the brain in Europe in 2010, the total cost per person related to each disease in terms of direct and indirect costs, and an estimate of the total cost per disorder and country.

METHODS

The best available estimates of the prevalence and cost per person for 19 groups of disorders of the brain (covering well over 100 specific disorders) were identified via a systematic review of the published literature. Together with the twelve disorders included in 2004, the following range of mental and neurologic groups of disorders is covered: addictive disorders, affective disorders, anxiety disorders, brain tumor, childhood and adolescent disorders (developmental disorders), dementia, eating disorders, epilepsy, mental retardation, migraine, multiple sclerosis, neuromuscular disorders, Parkinson's disease, personality disorders, psychotic disorders, sleep disorders, somatoform disorders, stroke, and traumatic brain injury. Epidemiologic panels were charged to complete the literature review for each disorder in order to estimate the 12-month prevalence, and health economic panels were charged to estimate best cost-estimates. A cost model was developed to combine the epidemiologic and economic data and estimate the total cost of each disorder in each of 30 European countries (EU27+Iceland, Norway and Switzerland). The cost model was populated with national statistics from Eurostat to adjust all costs to 2010 values, converting all local currencies to Euro, imputing costs for countries where no data were available, and aggregating country estimates to purchasing power parity adjusted estimates for the total cost of disorders of the brain in Europe 2010.

RESULTS

The total cost of disorders of the brain was estimated at €798 billion in 2010. Direct costs constitute the majority of costs (37% direct healthcare costs and 23% direct non-medical costs) whereas the remaining 40% were indirect costs associated with patients' production losses. On average, the estimated cost per person with a disorder of the brain in Europe ranged between €285 for headache and €30,000 for neuromuscular disorders. The European per capita cost of disorders of the brain was €1550 on average but varied by country. The cost (in billion €PPP 2010) of the disorders of the brain included in this study was as follows: addiction: €65.7; anxiety disorders: €74.4; brain tumor: €5.2; child/adolescent disorders: €21.3; dementia: €105.2; eating disorders: €0.8; epilepsy: €13.8; headache: €43.5; mental retardation: €43.3; mood disorders: €113.4; multiple sclerosis: €14.6; neuromuscular disorders: €7.7; Parkinson's disease: €13.9; personality disorders: €27.3; psychotic disorders: €93.9; sleep disorders: €35.4; somatoform disorder: €21.2; stroke: €64.1; traumatic brain injury: €33.0. It should be noted that the revised estimate of those disorders included in the previous 2004 report constituted €477 billion, by and large confirming our previous study results after considering the inflation and population increase since 2004. Further, our results were consistent with administrative data on the health care expenditure in Europe, and comparable to previous studies on the cost of specific disorders in Europe. Our estimates were lower than comparable estimates from the US.

DISCUSSION

This study was based on the best currently available data in Europe and our model enabled extrapolation to countries where no data could be found. Still, the scarcity of data is an important source of uncertainty in our estimates and may imply over- or underestimations in some disorders and countries. Even though this review included many disorders, diagnoses, age groups and cost items that were omitted in 2004, there are still remaining disorders that could not be included due to limitations in the available data. We therefore consider our estimate of the total cost of the disorders of the brain in Europe to be conservative. In terms of the health economic burden outlined in this report, disorders of the brain likely constitute the number one economic challenge for European health care, now and in the future. Data presented in this report should be considered by all stakeholder groups, including policy makers, industry and patient advocacy groups, to reconsider the current science, research and public health agenda and define a coordinated plan of action of various levels to address the associated challenges.

RECOMMENDATIONS

Political action is required in light of the present high cost of disorders of the brain. Funding of brain research must be increased; care for patients with brain disorders as well as teaching at medical schools and other health related educations must be quantitatively and qualitatively improved, including psychological treatments. The current move of the pharmaceutical industry away from brain related indications must be halted and reversed. Continued research into the cost of the many disorders not included in the present study is warranted. It is essential that not only the EU but also the national governments forcefully support these initiatives.

Costs of care for dementia patients in community setting: an analysis for mild and moderate disease stage

OBJECTIVE

Rising life expectancy is associated with higher prevalence rates of dementia disorders. When disease progresses the patients' call on formal health care services and on social support grows which imposes increasing costs of care. The aim of this study was to investigate the costs for patients with mild and moderate dementia in community setting in Germany.

METHODS

We assessed total costs of care and individual cost components for 383 community-living dementia patients alongside a cluster-randomized trial from societal and health insurance perspective. Utilization of formal health care services was based on insurance claims data and time dedicated to informal care was assessed within caregiver interviews. We estimated costs using a two-part regression model adjusting for age, gender and cluster-effects.

RESULTS

Costs of care equal €47,747 (Euros) from societal perspective which is almost the 4.7-fold of health insurance expenditures. Valued informal care covers 80.2% of societal costs and increases disproportionally when disease progresses. In moderate dementia the corresponding amount exceeds the one in mild dementia by 69.9%, whereas costs for formal health care services differ by 14.3%.

CONCLUSION

Due to valued informal care, costs of care for community-living patients with moderate dementia are significantly higher than for patients with mild dementia. Informal care is a non-cash item saving expenditures for professional care. To relieve social security system and family caregivers as well as to allow dementia patients to stay at home as long as possible, concepts fostering community-based dementia care and support to family caregivers need to be further developed.

Does caregiver burden mediate the effects of behavioral disturbances on nursing home admission?

OBJECTIVES

The primary objective of this study was to determine whether caregiving burden mediated the relationship between specific behavior disturbances and time to nursing home admission (NHA) for persons with dementia (i.e., Alzheimer disease or a related disorder).

DESIGN

The study used secondary longitudinal data from the Medicare Alzheimer's Disease Demonstration, a Medicare-covered home care benefit and case management program for family caregivers of persons with dementia. Primary caregivers of persons with dementia were assessed via in-person and telephone interviews every 6 months over a 3-year period.

SETTING

Dementia caregivers were recruited from eight catchment areas throughout the United States.

PARTICIPANTS

The baseline sample included 5,831 dementia caregivers. Just more than 40% (43.9%; N = 2,556) of persons with dementia permanently entered a nursing home during the 3-year study period.

MEASUREMENTS

Individual behavior problems were measured with the Memory and Behavior Problem Checklist. Caregiving burden was assessed with a short version of the Zarit Burden Inventory. Key covariates, including sociodemographic background, functional status, and service utilization, were also considered.

RESULTS

Event history analyses revealed that time-varying measures of caregiver burden fully mediated the relationship between four behavioral disturbances (episodes of combativeness, property destruction, repetitive questions, and reliving the past) and NHA.

CONCLUSIONS

The findings highlight the multifaceted, complex pathway to NHA for persons with dementia and their family caregivers. The results emphasize the need for comprehensive treatment approaches that incorporate the burden of caregivers and the behavioral/psychiatric symptoms of persons with dementia simultaneously.

Assessing the cost-effectiveness of the rivastigmine transdermal patch for Alzheimer's disease in the UK using MMSE- and ADL-based models

OBJECTIVE

Assess long-term cost-effectiveness of rivastigmine patch in Alzheimer's disease (AD) management in the UK, using cognitive and functional models based on clinical trial efficacy data.

METHODS

Incremental costs and Quality Adjusted Life Years (QALYs) associated with rivastigmine patch and capsule treatment versus best supportive care (BSC) were calculated using two economic models, one based solely on Mini-Mental State Examination (MMSE) scores, and one also incorporating activities of daily living (ADL) scores. The clinical pathway was populated with data from a clinical trial of rivastigmine patch (9.5 mg/24 h) and capsules (12 mg/day) versus placebo. Costs were based on the UK health and social care costs and basic UK National Health Service (NHS) prices. Disease progression was modelled beyond the trial period over 5 years using published equations to predict natural decline in AD patients. Base case costing variables included drugs, clinical monitoring, and institutionalization.

RESULTS

The MMSE model estimated incremental costs per QALY of £10 579 for rivastigmine patch and £15 154 for capsule versus BSC. The MMSE-ADL model estimated incremental costs per QALY of £9114 for rivastigmine patch and £13 758 for capsules. The main difference between the models was a greater number of institutionalized days avoided for rivastigmine versus BSC estimated by the MMSE-ADL model.

CONCLUSIONS

Both the MMSE and MMSE-ADL models suggest that rivastigmine patch and capsules are cost-effective treatments versus BSC. Incorporating ADL evidence makes a marginal but important difference to estimates in this case. Future economic evaluations of AD treatment should include measures of both cognition and functioning.

The relation between disease severity and cost of caring for patients with Alzheimer disease in Canada

OBJECTIVES

to characterize the cost of caring for an outpatient in Canada with Alzheimer disease (AD) based on disease severity, and to describe how costs change with increases in disease severity.

METHOD

community-dwelling patients with mild-to-moderate AD were enrolled in a 3-year, naturalistic, observational study. Assessments included cognition (Mini Mental Status Examination), global ratings (Global Deterioration Scale [GDS]), and daily function (Functional Autonomy Measurement System) as part of the Canadian Outcomes Study in Dementia. Direct (medical and nonmedical) and indirect costs were collected using resource use questionnaires. Costs at baseline were compared with costs at follow-up and correlated with disease severity.

RESULTS

total costs associated with treating AD were significantly higher with greater disease severity. The mean total cost to treat patients with very mild AD (GDS = 2) was $367 per month, compared with $4063 per month for patients with severe or very severe AD (GDS = 6). From baseline to follow-up, the greatest changes in cost were observed in the group of patients with the most severe AD as measured by all scales. The largest component of total cost was indirect costs at most severity levels, though medication costs contributed the most in patients with very mild AD. Significant independent contributors to cost were being female, having more impaired activities of daily living, and exhibiting more neuropsychiatric symptoms.

CONCLUSIONS

costs for treating a patient with AD were strongly associated with disease severity, even though none of the patients were institutionalized. Delaying the progression of AD may reduce indirect costs and burden to caregivers.

The pharmacoeconomics of cognitive enhancers in moderate to severe Alzheimer's disease

Alzheimer's disease is associated with a substantial economic impact on patients, their caregivers and society. Due to the current rise in the aging population, the prevalence and impact of Alzheimer's disease are expected to increase greatly. The cost of caring for someone with Alzheimer's disease is magnified in the more severe stages of the disease. There are four cognitive enhancers commonly used for the treatment of Alzheimer's disease: three cholinesterase inhibitors (donepezil, rivastigmine and galantamine) and one NMDA receptor antagonist (memantine). Of these, donepezil and memantine have been approved in many countries as pharmacological treatments for moderate to severe Alzheimer's disease, while donepezil, rivastigmine and galantamine are approved treatments for mild to moderate Alzheimer's disease. While cost effectiveness has been well studied in mild to moderate Alzheimer's disease, the cost-benefit information for drug therapy in moderate to severe Alzheimer's disease is less clear. This article reviews the pharmacoeconomic data available on these four drugs, with a specific focus on moderate to severe Alzheimer's disease, including economic burden, cost drivers, clinical outcomes and pharmacoeconomic studies. A key driver of the cost of Alzheimer's disease is the severity of the disease, indicating that the ability to stabilize the disease state is a potential source of cost savings. Drug therapies that can limit increases in behavioural problems and cognitive and functional impairment, and postpone institutionalization without an increase in longevity may serve to reduce the economic burden on Alzheimer's disease patients. The data suggest that, while the available, approved agents offer only modest improvements in clinical outcomes, they could be cost-effective treatments for moderate to severe Alzheimer's disease when viewed from the societal perspective. For memantine and donepezil, data are available that suggest that the cost of these drugs is offset by the clinical and societal benefits provided by slowing the progression of Alzheimer's disease. While there are few head-to-head comparison trials, the similarity in costs of the treatments and efficacy against placebo suggest that cost effectiveness will not be substantially different among treatments. More studies that examine longitudinal resource utilization and its relationship to drug treatment in the moderate to severe stages are needed to clarify cost benefit in this population and possibly differentiate between individual medications.

The effects of incident and persistent behavioral problems on change in caregiver burden and nursing home admission of persons with dementia

BACKGROUND

The individual contributions of behavior problems to key and related outcomes in dementia, such as nursing home admission (NHA) or caregiver burden, remain unclear.

OBJECTIVES

This study sought to determine the ramifications of temporal change in individual behavior problems when accounting for increases in caregiver burden and time to NHA. Although burden is sometimes conceptualized as an antecedent to NHA, it has also emerged as a relevant outcome in dementia caregiving research.

METHODS

A sample of 4545 dementia caregivers who participated in the Medicare Alzheimer disease Demonstration Evaluation was selected for this secondary analysis. Various patterns of change in individual behavior problems were considered as predictors of increases in caregiver burden and time to NHA over a 3-year period via mixed effects and Cox proportional hazards models, respectively.

RESULTS

Caregivers who did not indicate a care recipient's dangerous behavior initially but did so subsequently (ie, an "incident" behavior problem) were more likely to experience increases in burden (P < 0.0026). Alternatively, the persistent occurrence of behavior disturbances (particularly memory problems) emerged as the strongest predictors of time to NHA.

DISCUSSION

The findings of this study suggest the benefit of examining temporal patterns of individual behavioral disturbances, and that incident and persistent problems account for different dementia outcomes over time. Considering the temporal ramifications and potency of specific behavior problems can facilitate the targeted and timely delivery of effective clinical interventions.

Alzheimer's disease: the strength of association of costs with different measures of disease severity

OBJECTIVE

To identify Alzheimer's disease (AD) severity measures for use in cost-effectiveness models that effectively capture the impact of AD on costs.

METHODS

A review of the literature and data abstraction from papers that present 1) mean AD costs (direct, indirect, or total) by disease severity, defined using measure of cognition, functional status, and behavior; and/or 2) the results of regression analyses that estimate the strength of the association between AD costs and disease severity.

RESULTS

All papers reviewed showed that mean total costs increase with disease severity regardless of severity-measurement method. The relative difference in mean total costs between patients with severe disease compared to those with moderate disease, or moderate disease compared to mild disease, was fairly consistent across studies, suggesting that any of the disease-severity measures may be used to broadly categorize patients by cost. However, when regression analysis included multiple disease-severity measures, independent associations with costs were noted for the different measures. Cognitive and functional status measures were consistently associated with direct costs, whereas functional status and behavioral measures were consistently associated with indirect costs and caregiver hours.

CONCLUSIONS

Either multidimensional disease-severity measures, or a single disease-severity measure, that capture the impact of cognition, functional status, and behavior on costs are needed for cost-effectiveness models.

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

OBJECTIVE

To review cost-of-illness (COI) studies of dementia from Europe and North America which report costs per patient by disease stage.

METHOD

A systematic literature search was performed in electronic databases. Studies were classified according to important determinants of costs. Results were converted into year 2006 USD-PPP, and summarized as costs for formal and informal care in mild, moderate and severe dementia.

RESULTS

28 studies were evaluated. They used a wide range of methods. Costs more than doubled from mild to severe dementia. Patterns and size of estimated costs depended primarily on study objectives (estimation of total costs-net costs), living arrangements of patients (community-dwelling-institutionalized) and inclusion of informal care.

CONCLUSION

This review is the first to have focused on costs in different stages of dementia. The stage is an important determinant of costs. However, characteristics of individual studies need to be considered, when making use of their results.

Homocysteine as a predictor of cognitive decline in Alzheimer's disease

OBJECTIVE

Moderately elevated levels of plasma total homocysteine are associated with an increased risk of developing Alzheimer's disease. We have tested whether baseline concentrations of homocysteine relate to the subsequent rate of cognitive decline in patients with established Alzheimer's disease (AD).

METHODS

In 97 patients with AD, 73 pathologically-confirmed, we analysed the decline of global cognitive test scores (CAMCOG) over time from the first assessment for at least three 6-monthly visits up to a maximum of 9.5 years (in total 689 assessments). Non-linear mixed-effects statistical models were used.

RESULTS

Baseline homocysteine levels showed a concentration-response relationship with the subsequent rate of decline in CAMCOG scores: the higher the homocysteine, the faster the decline. The relationship was significant in patients aged < 75 years who had not suffered a prior stroke. For example, in patients aged 65 years with a baseline homocysteine of 14 micromol/L, the decline from a CAMCOG score of 88 to a score of 44 occurred 19.2 (95% CI 6.8, 31.6) months earlier than in patients with a baseline homocysteine of 10 micromol/L.

CONCLUSIONS

Raised homocysteine concentrations within the normal range among the elderly strongly relate to the rate of global cognitive decline in patients with Alzheimer disease. Plasma homocysteine can readily be lowered by B-vitamin treatment and trials should be carried out to see if such treatments can slow the rate of cognitive decline in relatively young patients with Alzheimer disease.

Economic evaluation of cholinesterase inhibitor therapy for dementia: comparison of Alzheimer's disease and Dementia with Lewy bodies

OBJECTIVE

To assess the cost effectiveness of cholinesterase inhibitor (ChEI) treatment in patients with Alzheimer's disease (AD) and Dementia with Lewy bodies (DLB).

METHOD

We used 4-month open label follow-up data from routine memory clinic patients. There were 852 patients with AD and 112 with DLB. We applied three predictive models to estimate clinical and economic outcomes at five years, comparing AD and DLB patients with hypothetical untreated controls.

RESULTS

The mean improvement in MMSE in 852 AD patients was 0.57 (SD 3.4) at 4 months, and in the subgroup with baseline MMSE of 10-20 (moderate) was 1.6 (SD 3.7). Overall, the 112 DLB patients improved by 1.4 (SD 3.7). DLB patients with an MMSE 10-20 improved by 3.1 (SD 4.5) points. These efficacy data were input into the SHTAC, microsimulation and Markov models and produced estimated costs per QALY gained (CQG) for all AD of pound194,066, pound67,904 and pound123,935 respectively. In comparison, the CQGs for all DLB were pound46,794, pound2,706 and pound35,922. For the moderate subgroups only the SHTAC and microsimulation models were applicable. These gave CQG estimates for moderate AD of pound39,664 and cost saving respectively. For moderate DLB, both estimates were cost saving.

CONCLUSION

The cost per QALY gained of cholinesterase treatment of all patients with DLB (including those with MMSE outside the 10-20 range) is comparable to that of patients with moderate AD, and is probably cost saving.

A cross cultural review of the ethical issues in dementia care in Kerala, India and The Netherlands

BACKGROUND

The paper explores the diverse ethical issues in the care of persons with dementia, in the Netherlands and Kerala, India. These cross-cultural data are used to suggest newer ways for addressing the ethical issues in a mutually enhancing manner.

METHODS

A thorough review of the literature focusing on ethical aspects of the care for persons with dementia.

RESULTS

The medical paradigm is dominant in the Netherlands and awareness of dementia as an organic brain disease is low in Kerala. Institutionalized care is more common in the Netherlands and home-based care is the norm in Kerala. Institutional care is costly, whereas home-based care is stressful for caregivers. The advanced directive plays an influential role in the Netherlands, but this mechanism is yet to evolve in Kerala. The legal and social setting of the Netherlands has a strong influence on physician decision-making concerning end of life issues. In Kerala, discussion of these matters is nearly unknown.

CONCLUSION

Limited awareness of dementia in Kerala should be addressed in public forums, which can then be used to garner governmental support. The predominantly institutional model of care-giving in the Netherlands and home-based care-giving in Kerala, each have their strengths; policy makers in both societies can usefully apply the values and merits inherent in both models. A culturally appropriate implementation of the advanced directive will have beneficial medical, social, and economic impacts in Kerala. The remarkable disparity between the Netherlands and Kerala in dealing with end-of-life issues will allow more philosophically and socially informed ways of addressing the ethical questions that arise in those situations.

An economic evaluation of a perindopril-based blood pressure lowering regimen for patients who have suffered a cerebrovascular event

OBJECTIVES

Cerebrovascular disease (or stroke) is one of the main causes of long-term disability and the second leading cause of death worldwide. The economic impact of stroke is clearly seen, as it is the largest single cause of bed occupancy in hospitals in England and accounts for 6% of hospital costs. This analysis is the first to quantify the economic consequences of a blood pressure lowering regimen based on the PROGRESS study (perindopril-based regimen), for reducing future cardiovascular events.

DESIGN

A Markov decision analytical model was used to estimate the cost per quality adjusted life year (QALY) of blood pressure lowering in the treatment of patients presenting with a cerebrovascular event. The health states are based upon Barthel indices for which resource utilisation and health benefits have previously been estimated.

SETTING

The participants for the economic analysis were obtained from the PROGRESS study database. 6,105 clinical study participants were recruited through both primary and secondary care centres.

PARTICIPANTS

The mean age was 64 years; 70% were male in the original study.

INTERVENTIONS

In the PROGRESS study, blood pressure lowering by a perindopril-based regimen was compared to standard care.

MAIN OUTCOME MEASURES

Cost per quality adjusted life year for the duration of the study (4 years) and for a time span of 20 years.

RESULTS

Using only direct hospital medical costs, the cost per QALY for a perindopril based regimen is pound 6,927 for the base study period and pound 10,133 for a 20-year time period. These results are sensitive to the cost of perindopril, the cost of the stroke unit, length of stay, and to a lesser extent, the cost of indapamide.

CONCLUSIONS

This analysis demonstrates a cost-effective treatment for patients suffering a cerebrovascular event with a blood pressure lowering regimen. The findings of this study are in line with current decisions and guidance by the national institute for health and clinical excellence (NICE) in England.

The cost of dementia in Europe: a review of the evidence, and methodological considerations

Alzheimer's disease (AD) is a leading cause of disability in the elderly, leading to a high burden on caregivers and costs to society. This article describes the current level of data availability regarding the costs of AD in Europe, summarizes and compares findings from previous studies in different countries, and discusses the applicability of available data for modelling purposes. A literature review was conducted for papers in any language reporting data on costs of care for patients with diagnosed dementia or possible/probable AD. Only papers reporting patient-level data on costs were included. A total of 16 studies were identified: from the Nordic region (4), the UK (3), Spain (3), France (2), Italy (2), Belgium (1) and Germany (1). There is large variation in total cost estimates, depending on, for example, differences in study methodology, setting, type and severity of patients included, range of costs assessed and the choice of principle for valuing informal care. The median value for total annual care costs in all studies was Euro28 000 (range Euro6614-Euro64 426) [year 2005 values]. Few studies assessed aspects of disease severity other than cognitive function. The costs of AD in Europe are substantial and increase with disease severity. Methodological differences between studies make comparison across countries and healthcare systems difficult, and there is a need to standardize methods for assessing and valuing informal care. Patient-level information on resource use is required to analyse determinants of care costs and predict the impact of therapeutic interventions. More data are needed to support future economic evaluations of therapies for AD.

Modelling disease progression in Alzheimer's disease: a review of modelling methods used for cost-effectiveness analysis

The literature reporting economic evaluations related to the treatment of Alzheimer's disease (AD) has developed over the last decade. Most analyses have used economic models to estimate the cost effectiveness of drugs for the treatment of AD. This review considers the range of methods used in the published cost-effectiveness literature to model AD progression and the effect of interventions on the progression of AD. The review builds on and updates an earlier systematic review of cost-effectiveness studies on drugs for AD. Systematic and rigorous methods were used to search the literature for economic evaluations estimating the cost effectiveness of donepezil, rivastigmine, galantamine or memantine in AD. The literature search covered a wide range of electronic databases (e.g. MEDLINE, EMBASE), and included literature from the inception of databases up to the end of 2005. The search identified 22 published economic evaluations. An outline and brief critical review of the identified studies is provided, and thereafter the methods used to model disease progression were considered in more detail. The review employs recent guidance on good practice in decision-analytic modelling in HTA to critically review the modelling methods used. Using this guidance, the models are assessed against the broad criteria of model structure, data inputs and assessment of uncertainty and inconsistency. Concerns were noted over the model structure employed in all models. The reliance on cognitive scores to model AD, the progression of the disease, and the effect of treatment on costs and consequences is regarded as a serious limitation in almost all of the studies identified. There are also limitations over the data used to populate published models, especially around the failure of studies to document and establish the basis for the modelling of treatment effects. It is also clear that studies modelling AD progression, and subsequently the cost effectiveness of treatment, have not addressed uncertainty or consistency (internal and/or external) in sufficient detail. Further research is required on more appropriate methods for the modelling of AD progression. In the meantime, future economic evaluations of treatment need to be more explicit on the methods used to model AD, and the data used to populate models.

Psychotropic medication use for behavioral symptoms of dementia

Behavioral disturbances associated with dementia are common and burdensome. Although no psychotropic medications are currently approved by the US Food and Drug Administration (FDA) to treat such behavioral symptoms, a variety of drug classes are commonly used for these purposes. Atypical antipsychotic medications may be somewhat effective and are generally considered the pharmacologic treatments of choice; however "black box" warnings have recently been added to their labels by the FDA, warning of significantly increased risks of short-term mortality. Older conventional antipsychotic medications may also be somewhat effective but appear to pose risks that can be at least as great as those of the newer atypical drugs. Although antidepressants, benzodiazepines, mood stabilizers, acetylcholinesterase inhibitors, and N-methyl-D-aspartate (NMDA) receptor antagonists may be considered, particularly in patients with specific types of symptomatology, even less is known about their effectiveness and safety. Also, although various psychotropic medications used for behavioral disturbances in dementia patients may be somewhat effective, they have been increasingly associated with important safety risks.

Cognitive stimulation therapy for people with dementia: cost-effectiveness analysis

BACKGROUND

Psychological therapy groups for people with dementia are widely used, but their cost-effectiveness has not been explored.

AIMS

To investigate the cost-effectiveness of an evidence-based cognitive stimulation therapy (CST) programme for people with dementia as part of a randomised controlled trial.

METHOD

A total of 91 people with dementia, living in care homes or the community, received a CST group intervention twice weekly for 8 weeks; 70 participants with dementia received treatment as usual. Service use was recorded 8 weeks before and during the 8-week intervention and costs were calculated. A cost-effectiveness analysis was conducted with cognition as the primary outcome, and quality of life as the secondary outcome. Cost-effectiveness acceptability curves were plotted.

RESULTS

Cognitive stimulation therapy has benefits for cognition and quality of life in dementia, and costs were not different between the groups. Under reasonable assumptions, there is a high probability that CST is more cost-effective than treatment as usual, with regard to both outcome measures.

CONCLUSIONS

Cognitive stimulation therapy for people with dementia has effectiveness advantages over, and may be more cost-effective than, treatment as usual.

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

BACKGROUND

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Determinants of costs of care for patients with Alzheimer's disease

BACKGROUND

Alzheimer's disease (AD), the most common cause of dementia, is a major cause of disability and care burden in the elderly. This study aims to estimate the costs of formal and informal care and identity determinants of care costs.

MATERIALS AND METHODS

Two hundred and seventy-two (AD) patients and their caregivers were recruited among patients attending regular visits at six memory clinic in Sweden, Denmark, Norway and Finland. Patients with a diagnosis of AD and with an identifiable primary caregiver were eligible for inclusion. Data was collected by questionnaires at baseline, and at scheduled follow-up visits after 6 months and again after 12 months. Cognitive function was assessed with the Mini Mental State Examination (MMSE) and behavioural disturbances were measured using a brief version of the neuropsychiatric inventory (NPI).

RESULTS

Total annual costs were on average 172,000 SEK, ranging from 60,700 SEK in mild dementia to 375,000 SEK in severe dementia. Costs for community care (special accommodation, home help, etc.) constituted about half of total costs of care and increase sharply with increasing cognitive impairment. Informal care costs, valued at the opportunity cost of the caregiver's time, make up about a third of total costs and also increased significantly with disease severity. Medical care costs (inpatient care, outpatient care, pharmaceuticals), on the other hand, were not significantly related to disease severity. Regression analysis confirmed a strong association between costs and cognitive function, between patients as well as within patients over time. There was also a significant influence on costs from behavioural disturbances. Sensitivity analysis showed that the method chosen to value informal care can have considerable impact on results.

CONCLUSIONS

Costs of care in patient with AD are high and related to dementia severity as well as presence of behavioural disturbances. The cost estimates presented have implications for future economic evaluation of treatments for Alzheimer's disease.

A Systematic Review of the Clinical and Cost-Effectiveness of Memantine in Patients with Moderately Severe to Severe Alzheimer???s Disease

Alzheimer's disease (AD) is the most common form of dementia and is characterised by a worsening of cognition, functional ability, and behaviour and mood. The objective of this study was to review the clinical and cost-effectiveness of memantine for the treatment of patients with moderately severe to severe AD. To achieve this, a systematic search and review of the clinical and cost effectiveness literature for memantine was undertaken. The literature search covered the period from the inception of MEDLINE, Cochrane Library, EMBASE and other electronic databases until July 2004. The search included randomised controlled trials (RCTs) and full economic evaluations that assessed the use of memantine in patients with moderately severe to severe AD. Two published RCTs were included in this review; in one of these trials the participants were already being treated with donepezil. The two RCTs showed benefit for patients receiving memantine compared with placebo on the outcome measures of the Alzheimer's Disease Cooperative Study Activities of Daily Living Inventory modified for severe dementia, the Clinician's Interview-Based Impression of Change Plus Caregiver Input, and the Severe Impairment Battery, and that memantine appeared to be slightly more effective in patients already receiving a stable dose of donepezil. Five cost-effectiveness studies were included in the review. Although these studies reported cost reductions and improved outcomes with memantine, the evaluations were based on a number of assumptions. In conclusion, memantine appears to be beneficial when assessed using functional and global measurements. However, the effect of memantine on cognitive scores and behaviour and mood outcomes is less clear. Cost-effectiveness is dependent upon assumptions surrounding clinical effect and context-specific cost data.

Economic evaluation of rivastigmine in patients with Parkinson's disease dementia

BACKGROUND

The positive results of a randomised clinical trial of rivastigmine in patients with dementia associated with Parkinson's disease have been published recently. Patient-level healthcare utilisation data were also collected, and this report is the economic evaluation based on these data.

OBJECTIVE

To determine the cost effectiveness of rivastigmine 3-12 mg/day in patients in whom mild to moderate dementia developed at least 2 years after they received a clinical diagnosis of Parkinson's disease.

METHODS

A cost-effectiveness analysis was performed by applying Canadian and UK cost weights (year 2004 values) to healthcare utilisation data collected prospectively during a randomised, double-blind, multinational, 24-week trial of rivastigmine 3-12 mg/day (n = 362) versus placebo (n = 179). Patients were > or =50 years of age, had a Mini-Mental State Examination (MMSE) score of between 20 and 24 and had contact with a responsible caregiver at least 3 days a week.Quality-adjusted survival time, transformed from MMSE scores, was the measure of effectiveness. Caregiver costs included paid and unpaid time, and direct costs included concomitant medications, outpatient care, hospitalisations, long-term care and study medications. Analysis was conducted from a societal perspective with a time horizon of 24 weeks.

RESULTS

Consistent with the improvement in clinical outcomes, there was an observed increase in quality-adjusted survival time in the rivastigmine arm of 2.81 quality-adjusted life-days (two-sided p-value 0.13 [90% CI -0.243, 5.86]). Using Canadian price weights, there was an observed increase in cost in the rivastigmine arm of Can 55.76 dollars(two-sided p-value 0.98 [90% CI -3431, 3543]), with a resulting incremental cost-effectiveness ratio of Can 7429 dollars per QALY. Using UK price weights, there was an observed decrease in cost in the rivastigmine arm of pound 26.18 (two-sided p-value 0.99 [90% CI -2407, 2355]).

CONCLUSION

Although no between-treatment differences in cost were seen, the small sample size, highly variable cost distributions and short time horizon prevent us from making strong conclusions with regard to the effect of rivastigmine on total costs and, by inference, on cost effectiveness.

Cost-of-illness studies : a review of current methods

The number of cost-of-illness (COI) studies has expanded considerably over time. One outcome of this growth is that the reported COI estimates are inconsistent across studies, thereby raising concerns over the validity of the estimates and methods. Several factors have been identified in the literature as reasons for the observed variation in COI estimates. To date, the variation in the methods used to calculate costs has not been examined in great detail even though the variations in methods are a major driver of variation in COI estimates. The objective of this review was to document the variation in the methodologies employed in COI studies and to highlight the benefits and limitations of these methods. The review of COI studies was implemented following a four-step procedure: (i) a structured literature search of MEDLINE, JSTOR and EconLit; (ii) a review of abstracts using pre-defined inclusion and exclusion criteria; (iii) a full-text review using pre-defined inclusion and exclusion criteria; and (iv) classification of articles according to the methods used to calculate costs. This review identified four COI estimation methods (Sum_All Medical, Sum_Diagnosis Specific, Matched Control and Regression) that were used in categorising articles. Also, six components of direct medical costs and five components of indirect/non-medical costs were identified and used in categorising articles.365 full-length articles were reflected in the current review following the structured literature search. The top five cost components were emergency room/inpatient hospital costs, outpatient physician costs, drug costs, productivity losses and laboratory costs. The dominant method, Sum_Diagnosis Specific, was a total costing approach that restricted the summation of medical expenditures to those related to a diagnosis of the disease of interest. There was considerable variation in the methods used within disease subcategories. In several disease subcategories (e.g. asthma, dementia, diabetes mellitus), all four estimation methods were represented, and in other cases (e.g. HIV/AIDS, obesity, stroke, urinary incontinence, schizophrenia), three of the four estimation methods were represented. There was also evidence to suggest that the strengths and weaknesses of each method were considered when applying a method to a specific illness. Comparisons and assessments of COI estimates should consider the method used to estimate costs both as an important source of variation in the reported COI estimates and as a marker of the reliability of the COI estimate.

Behavioral and neuropsychiatric outcomes in Alzheimer's disease

Behavioral and psychological symptoms of dementia pose significant challenges in the management of patients with Alzheimer's disease. Neuropsychiatric symptoms are associated with cognitive decline, highly impaired activities of daily living, and frontal lobe pathology. Moreover, behavioral and psychological symptoms can diminish patient quality of life, increase caregiver distress, and accelerate nursing home placement. Although these symptoms are often associated with the later stages of Alzheimer's disease, a high percentage of individuals with mild cognitive impairment or mild Alzheimer's report symptoms as well. This article provides an overview of behavioral and neuropsychiatric symptoms associated with Alzheimer's disease and discusses nonpharmacologic and pharmacologic approaches to the management of such symptoms. For patients with severe behavioral and psychological symptoms of dementia, psychotropic agents may be warranted, whereas approved therapies for Alzheimer's, including cholinesterase inhibitors and the N-methyl-d-aspartate receptor antagonist memantine, may be appropriate in less severe cases.

Emission tomography in dementia

Dementia is a chronic brain syndrome with enormous impact on health care provision. Emission tomography (single photon emission computed tomography (SPECT) and positron emission tomography (PET)) provides a unique tool to investigate functional and neurochemical changes, both in those with established dementia and in those at risk of subsequent cognitive decline. Alzheimer's disease is characterized by bilateral temporoparietal hypoperfusion on SPECT and hypometabolism on PET, which may precede the onset of dementia as similar changes can be demonstrated in those with mild cognitive impairment and in those genetically at risk of developing Alzheimer's disease. In dementia with Lewy bodies medial parietal and occipital perfusion deficits are seen together with pre-synaptic and post-synaptic dopaminergic changes, most particularly a reduction in the striatal pre-synaptic dopamine transporter which can be visualized using appropriate ligands (e.g., (123)I-FP-CIT). Vascular dementia is associated with multiple, asymmetric, perfusion deficits in multi-infarct dementia. In contrast, subcortical vascular dementia is associated with reduced perfusion but preserved oxygen extraction fraction on PET. Fronto-temporal dementia is characterized by both hypometabolism and hypoperfusion in fronto-temporal lobes, though hypometabolism appears more extensive, affecting large areas of the cerebral hemispheres. Longitudinal studies of treatment response in Alzheimer's disease with cholinergic drugs have found changes in regional blood flow and nicotinic and muscarinic receptor function in those patients who respond to treatment. Currently, emission tomography is widely used for assisting with clinical differential diagnosis. Future developments will entail the development and application of more specific neurochemical ligands and those which bear a closer relationship to the underlying disease processes, including markers of tau, amyloid and synuclein pathology.